What is VALLEY VILLAGE CARE CENTER's CMS rating?

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

How many inspection deficiencies does VALLEY VILLAGE CARE CENTER have?

VALLEY VILLAGE CARE CENTER has 81 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at VALLEY VILLAGE CARE CENTER?

VALLEY VILLAGE CARE CENTER has a four-star staffing rating from CMS with 0.71 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 VALLEY VILLAGE CARE CENTER located?

VALLEY VILLAGE CARE CENTER is located in NORTH HOLLYWOOD, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does VALLEY VILLAGE CARE CENTER have?

VALLEY VILLAGE CARE CENTER has 99 certified beds.

Who owns VALLEY VILLAGE CARE CENTER?

VALLEY VILLAGE CARE CENTER is a for profit - limited liability company facility and is part of the ABRAHAM BAK & MENACHEM GASTWIRTH chain.

Is VALLEY VILLAGE CARE CENTER safe?

VALLEY VILLAGE CARE CENTER has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at VALLEY VILLAGE CARE CENTER stick around?

VALLEY VILLAGE CARE CENTER has average staff turnover at 34%, which is typical for the nursing home industry.

Was VALLEY VILLAGE CARE CENTER ever fined?

No, VALLEY VILLAGE CARE CENTER has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is VALLEY VILLAGE CARE CENTER on any federal watch list?

No, VALLEY VILLAGE 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 VALLEY VILLAGE CARE CENTER?

Medicare inspectors have found 81 deficiencies at VALLEY VILLAGE CARE CENTER: 80 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting VALLEY VILLAGE CARE CENTER?

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

How does VALLEY VILLAGE CARE CENTER compare to other nursing homes?

VALLEY VILLAGE CARE CENTER has a 2-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

VALLEY VILLAGE CARE CENTER

Name: VALLEY VILLAGE CARE CENTER
Address: 13000 VICTORY BLVD, NORTH HOLLYWOOD, CA, 91606, US
Telephone: (818) 985-5990
Rating: 2.0

13000 VICTORY BLVD, NORTH HOLLYWOOD, CA 91606 · (818) 985-5990

For profit - Limited Liability company 99 Beds ABRAHAM BAK & MENACHEM GASTWIRTH Data: November 2025

Trust Grade

50/100

#939 of 1155 in CA

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Last Inspection: February 2025

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

Overview

Valley Village Care Center has a Trust Grade of C, which means it is considered average and is in the middle of the pack compared to other facilities. It ranks #939 out of 1,155 nursing homes in California, placing it in the bottom half, and #254 out of 369 in Los Angeles County, indicating that only a handful of local options are better. Unfortunately, the facility is worsening, with issues increasing from 23 in 2024 to 31 in 2025. Staffing is a strong point, rated 4 out of 5 stars with a turnover rate of 34%, which is lower than the state average, indicating staff stability. While there have been no fines, which is a positive sign, the facility has faced concerns, such as failing to properly monitor insulin administration sites for residents and leaving medications unattended, which could pose safety risks.

Trust Score: C
In California: #939/1155
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 34% turnover. Near California's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for California. RNs are trained to catch health problems early.
Violations: 81 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 23 issues

2025: 31 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (34%)
14 points below California average of 48%

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

2-Star Overall Rating

Below California average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 34%

12pts below California avg (46%)

Typical for the industry

Chain: ABRAHAM BAK & MENACHEM GASTWIRTH

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 81 deficiencies on record

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure code pink (the facility's code to call when a resident is missing) was called immediately when one of three sampled residents (Resident 1) was missing per facility's undated policy and procedure titled, Missing Resident,. This deficient practice resulted in Resident 1 missing medications placing Resident 1 at risk for potential harm. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction resulting from underlying metabolic or systemic issues), muscle weakness, diabetes type 2 (high blood sugar), anemia (lack of blood), duodenal ulcer (a sore that develops on the lining of the intestine), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing a terrifying event), history of falling, polyneuropathy (nerve damage), and failure to thrive (a gradual decline in health). During a review of Resident 1's Minimum Data Set (MDS - a standardized resident assessment tool), dated 2/18/2025, the MDS indicated Resident 1 had moderately impaired cognition. Resident 1 required supervision with eating, and partial assistance with oral hygiene, toileting, and dressing. During a review of Resident 1's Progress Notes, dated 5/6/2025 at 9:15pm., the Progress Notes indicated the following: - On 5/6/2025 at 9 :15 pm, Licensed Vocational Nurse (LVN) 1 checked Resident 1's blood sugar with blood sugar of 262 with orders to call Medical Doctor if blood sugar was less than 60 or greater than 250. Family Member (FM) 1 was sitting next to Resident 1. At that time, FM 2 came in to see Resident 1. - On 5/6/2025 at 9: 20 pm, LVN 1 left Resident 1's room and went to Registered Nurse (RN) 1 to inform Resident 1's blood sugar. Per RN 1, she would inform Resident 1's Nurse Practitioner (NP). - On 5/6/2025 at 9:25 pm, RN 1 informed LVN 1 of new orders from the NP which was to give Humulin insulin (medication used to control blood sugar) 6 units times one for blood sugar greater than 250 and encourage to drink more fluids. - On 5/6/2025 at 9:30 p.m., LVN 1 went back to Resident 1's room after preparing the medication (Humulin insulin). LVN 1 unable to find Resident. LVN 1 checked the bathroom. LVN 1 checked inside the building. LVN 1 did not find Resident 1 or Family Member (FM 1). - On 5/6/2025 at 10 p.m., LVN 1 informed RN 1. RN 1 paged code pink. Staff looked for Resident 1 inside and outside the building. LVN 1 and RN 1 went to the nearest gas station. RN 1 called the Administrator and Director of Nurses (DON) to notify Resident 1 was unable to be located. RN 1 called the maintenance supervisor to check the camera. RN 1 called the police to report a missing person (Resident 1). - On 5/6/2025 at 10:30 p.m., Maintenance Supervisor checked the (main entrance) camera. Resident 1 and FM 1 were noted exiting the front lobby at around 9:51 p.m. - On 5/6/2025 at 11:15 p.m., five police officers came to the facility. Resident 1's Durable Power of Attorney (FM 3) arrived at the front lobby. - On 5/6/2025 at 11:45 p.m., LVN 1 went back to Resident 1's room and noted all of Resident 1's belongings in the room. A light blue notebook with medication list was missing. During an interview with Registered Nurse (RN 1) on 5/13/2025 at 4:07 p.m., RN 1 stated, on 5/6/2025 at around 9:20 p.m., LVN 1 reported that Resident 1's blood sugar was 262, and there was an order to call the Medical Doctor for blood sugar greater than 250. RN 1 stated, she received an order from the Nurse Practitioner (NP) to give Resident 1 an order for 6 units of insulin. RN 1 stated, she notified LVN 1 of the new order. RN 1 stated, at around 10 p.m., LVN 1 reported that Resident 1 was missing. RN 1 stated she called code pink. RN 1 stated code pink is a code used in the facility to notify the staff that a resident is missing. RN1 stated she notified the Administrator and the DON. RN 1 stated she called the police, but they were not answering so she (RN 1) called 911. RN 1 stated she tried calling FM 1 several times, and FM 1 never picked up the phone. RN 1 stated when a resident goes missing, they (facility staff) look if the missing resident is anywhere in the facility such as a bathroom, or the patio. RN 1 stated the facility needs to call code pink as soon as the facility realizes that a Resident is missing. RN 1 stated it should not have taken 30 minutes to call the code pink when Resident 1 went missing. RN 1 stated Resident 1 left the facility without getting the dose of insulin, and this resulted in Resident 1 to not get treated for the elevated blood sugar. During an interview with LVN 1 on 5/13/2025 at 4:50 p.m., LVN 1 stated when she (LVN 1) noted that Resident 1 was not in her (Resident 1) room, she (LVN 1) went around the facility, and it took her 30 minutes to look everywhere inside the building. LVN 1 stated she panicked and started looking for Resident 1 by herself. LVN 1 stated when she could not find Resident 1 that is when she told RN 1. LVN 1 stated code pink should have been called when she realized Resident 1 was missing. LVN 1 stated it should not have taken 30 minutes to call code pink when Resident 1 went missing. During an interview with the DON on 5/14/2025 at 3:30 p.m., the DON stated Resident 1 left the facility without proper authorization or notice. The DON stated the potential outcome was the uncertainty about Resident 1's safety and concerns on medication continuity. The DON stated after multiple attempts to reach FM 1, FM 1 texted back that Resident 1 was doing well, and Resident 1's blood sugar was stable (Note: The DON have not seen Resident 1 and have not seen any documented evidence of FM 1 monitoring Resident 1's blood sugar). During a review of the facility's policy and procedure titled, Elopements, dated 5/3/2022, the policy and procedure indicated, Staff shall promptly report any resident who . is suspected of being missing to the Charge Nurse, RN Supervisor or Director of Nursing. During a review of the facility's policy and procedure titled, Missing Resident, undated, the policy and procedure indicated, if a potential missing resident is identified the following actions will be implemented immediately: Immediate response to announce code pink. During a review of the facility's policy and procedure titled, Quality of Care, dated 10/2024, the policy and procedure indicated each resident shall be cared for in a manner that promotes and enhances quality care. Quality healthcare can be defined in many ways but there is growing acknowledgment that quality health services should be effective, safe, and resident-centered.

Feb 2025 28 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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Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality for one (1) of 1 sampled resident (Resident 13) reviewed for dignity when Certified Nursing Assistant 5 (CNA 5) failed to provide privacy while providing care to Resident 13. This deficient practice had the potential to affect the resident's self-esteem and self-worth. Findings: During a review of Resident 13's admission Record, the admission Record indicated the facility originally admitted the resident on 11/11/2024 and readmitted the resident on 11/112024 with diagnoses including dementia (a progressive state of decline in mental abilities), abnormalities of gait and mobility, and generalized muscle weakness. During a review of Resident 13's History and Physical (H&P), dated 11/11/2024, the H&P indicated Resident 13 can make his needs known but cannot make decisions. During a review of Resident 13's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 13 required total assistance with bathing, and lower body dressing; substantial/maximal assistance with toileting, upper body dressing, personal hygiene, sit to stand, and chair/be to chair transfers; partial/moderate assistance with all other activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident was always incontinent of bowel and bladder. During a concurrent observation and interview on 2/15/2025 at 8:43 a.m. inside Resident 13's room, observed CNA 5 providing care to Resident 13 who was turned on his side exposing the buttock while the privacy curtain was halfway closed. CNA 5 stated the Charge Nurse (CN) just came to talk to her and she forgot to fully close the curtain and continued providing care to the resident. CNA 5 stated she should have closed the curtain after talking to the CN. During a follow-up interview on 2/15/2025 at 10 a.m. with CNA 5, CNA 5 stated every time they are providing care to the residents, privacy should be maintained by fully closing the curtain. CNA 5 stated it was a dignity and privacy issue and residents could feel embarrassed if other people observe the provision of care to them (residents). During an interview on 2/15/2025 at 4:30 p.m. with the Director of Staff Development (DSD), the DSD stated during ADL care, the staff especially the CNAs should fully close the privacy curtain. The DSD stated CNA 5 should have fully closed the privacy curtain while providing care to Resident 13 to preserve the resident's dignity, self-esteem, and self-worth. During an interview on 2/17/2025 at 4:32 p.m. with the Director of Nursing (DON), the DON stated when providing care to the residents, the staff should provide privacy by fully closing the privacy curtain after introducing themselves and explaining to the resident what they will de doing. The DON stated CNA 5 should have fully closed the privacy curtain while providing care to Resident 13 so the resident would feel respected and not embarrassed. The DON stated it was a dignity issue. During a review of the facility's policy and procedure (P&P) titled, Quality of Care-Dignity, last reviewed on 1/2025, the P&P indicated: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. - Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain written verification of informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for two of five sampled residents (Resident 32 and 76), or resident representative by failing to: 1. Ensure Resident 32's choice to consent (give permission) or not to consent for the use of bupropion (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]) was documented in the informed consent. 2. Ensure Resident 76's choice to consent or not to consent for the use of venlafaxine (medication used to treat depression) was documented in the informed consent. These deficient practices violated the residents' and responsible representatives' rights to make an informed decision. Findings: a. During a record review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 on 5/17/2021, with diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), generalized muscle weakness and depression. During a record review of Resident 32's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings,) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a record review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 32's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 32 was on an antidepressant (medications used to treat symptoms of depression). During a record review of Resident 32's Physician Order, dated 10/14/2024, the Physician Order indicated bupropion hydrochloride extended release, give 150 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) by mouth one time a day for depression manifested by lack of motivation with activities of daily living. During a record review of Resident 32's Informed Consent, dated 10/14/2024, the Informed Consent did not indicate if Resident 32's Representative agreed on bupropion administration. During a record review of Resident 32's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 10/2024 and 11/2024, the MAR indicated Resident 32 received bupropion on 10/15/2024, 10/17/2024 to 11/25/2024. During a concurrent interview and record review, on 2/16/2025, at 2:34 p.m., with the Assistant Director of Nursing (ADON), Resident 32's Physician Order, dated 1/14/2024, and Informed Consent for bupropion, dated 10/14/2024, was reviewed. The ADON stated the Informed Consent, dated 10/14/2024, did not indicate if Resident 32's Representative consented or did not consent for bupropion administration. The ADON stated nurses should fill the Informed Consent completely. The ADON stated the importance of completed Informed Consent was to indicate if the nurses can give the ordered medication and its Resident Representatives right to be informed. b. During a record review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 10/17/2023, with diagnoses that included unspecified (unconfirmed) noninfective (something is not able to be caught or spread from one person to another) gastroenteritis (an inflammation of the stomach and intestines that causes diarrhea, vomiting, and abdominal pain) and colitis (inflammation of the colon, or large intestine), depression and generalized weakness. During a record review of Resident 76's H&P, dated 12/17/2024, the H&P indicated Resident 76 had the capacity to understand and make decisions. During a record review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 76 was on an antidepressant. During a record review of Resident 76's Physician Order, dated 12/16/2024, the Physician Order indicated venlafaxine hydrochloride extended-release oral tablet 75 mg, give 75 mg by mouth one time a day for depression manifested by verbalization of sadness. During a record review of Resident 76's Informed Consent, dated 12/16/2024, the Informed Consent did not indicate if Resident 76 agreed to receive venlafaxine. During a record review of Resident 76's MAR, dated 12/2024, the MAR indicated Resident 76 received venlafaxine on 12/17/2024 to 12/19/2024 for depression. During a concurrent interview and record review, on 2/17/2025, at 7:37 a.m., with Registered Nurse (RN) 3, Resident 76's Informed Consent for venlafaxine, dated 12/16/2024, was reviewed. RN 3 stated Resident 76's Informed Consent did not indicate if Resident 76 consented or not to the use of venlafaxine. RN 3 stated RN 4 should have completed the Informed Consent before medication administration. During an interview, on 2/17/2025, at 8:09 a.m., with the ADON, the ADON stated RN 4 did not complete Resident 76's Informed Consent for venlafaxine. The ADON stated medication should not be started since Informed Consent did not indicate if Resident 76 agreed to the use of venlafaxine. During an interview, on 2/17/2025, at 5:13 p.m., with the Director of Nursing (DON), the DON stated Informed Consent should be complete and if incomplete, it is not valid. The DON stated medication should not be administer if informed consent was not complete. During a record review of facility's policy and procedure (P&P) titled, Verification of Informed Consent for Psychotherapeutic Medications (a class of medications used to treat mental health conditions), dated 6/2024, last reviewed on 1/14/2025, the P&P indicated, Each resident has the right to be free from psychotherapeutic drugs and to provide informed consent before treatment with psychotherapeutic drugs. The facility will obtain a written informed consent for treatment using psychotherapeutic drugs and consent renewal every six months. Before prescribing psychotherapeutic drugs, the Physician must personally examine the resident and obtain informed written consent signed by the resident or the resident representative along with the signature of the health care professional declaring the required material information has been provided. Signed written consent will be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures.

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 provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for two (2) of three (3) sampled residents (Residents 1 and 77) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 11/14/2014 and readmitted the resident on 10/10/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), abnormalities of gait and mobility, and generalized muscle weakness. During a review of Resident 1's History and Physical (H&P) dated 11/4/2024, the H&P indicated Resident 1 can understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 12/2/2024, the MDS indicated Resident 1 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with sit to stand and total assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 1's fall risk assessment dated [DATE], 9/3/2024, and 12/6/2024, the fall risk assessments indicated the resident was a high risk for falls. During a review of Resident 1's care plan (CP) on at risk for falls related to aging, multiple medical problems, impaired mobility and weakness initiated on 12/1/2014 and last revised on 2/3/2025, the CP indicated to ensure the resident's call light is within reach and encourage to use for assistance as needed as one of the interventions to prevent falls. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated a physician's order dated 11/27/2024 for call light placed within reach. During a concurrent observation and interview on 2/14/2025 at 9:35 a.m. inside Resident 1's room with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1's call light was not clipped to the bed and was on the floor and not within Resident 1's reach. LVN 1 stated before to leaving the room, the staff should make sure all residents' call light should be within reach. LVN 1 stated Resident 1's call light should have been clipped to the sheet and within the resident's reach so Resident 1 can call for assistance when needed and her needs attended promptly. During a concurrent interview and record review on 2/17/2025 at 4:55 p.m. reviewed Resident 1's Order Summary Report, care plans, and fall risk assessments with the Assistant Director of Nursing (ADON). The ADON stated Resident 1's physician's order and care plan indicated to place call light reach and the fall risk assessments indicated Resident 1 was a high risk for falls. The ADON stated the staff should ensure all residents' call light is within reach prior to leaving the room so the residents can call for assistance and the staff can attend to their needs. The ADON stated Resident 1's call light should have been clipped to the sheet and within the resident's reach so the staff can attend and meet Resident 1's needs timely. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 1/14/2025, the P&P indicated the following: - When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. - Answer the resident's call as soon as possible. b. During a review of Resident 77's admission Record, the admission Record indicated the facility admitted the resident on 4/1/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), history of falling, and generalized muscle weakness. During a review of Resident 77's H&P dated 4/4/2024, the H&P indicated Resident 77 did not have the capacity to understand and make decisions. During a review of Resident 77's MDS dated [DATE], the MDS indicated Resident 77 had severely impaired cognition and required substantial/maximal assistance with eating and total assistance from staff with all ADLs. During a review of Resident 77's fall risk assessments dated 7/10/2024, 10/9/2024, and 1/10/2025, the fall risk assessments indicated Resident 77 was a high risk for falls. During a review of Resident 77's care plan (CP) on at risk for falls related to gait or balance problems and incontinence initiated on 4/2/2024 and last revised on 4/13/2024, the CP indicated to be sure the resident's call light is within reach and encourage the resident to use for assistance as needed and the resident needs prompt response to all requests for assistance. During a review of Resident 77's Order Summary Report, the Order Summary Report indicated a physician's order dated 11/27/2024 for call light placed within reach. During a concurrent observation and interview on 2/14/2025 at 9:15 a.m. inside Resident 77's room with LVN 1, LVN 1 stated Resident 77's pad call light (a sensitive call light that enables patients with have difficulty activating standard call light to summon help easily) was placed on the upper left side of the bed and not within Resident 77's reach. LVN 1 stated before to leaving the room, the staff should make sure all residents' call light should be within reach. LVN 1 stated Resident 77 had limited movement of the upper extremities and unable to reach for the call light or move her head towards the call light to activate. LVN 1 stated Resident 77's call light should have been within reach so Resident 1 can call for assistance when needed and her needs attended promptly. During a concurrent interview and record review on 2/17/2025 at 4:55 p.m. reviewed Resident 77's Order Summary Report, care plans, and fall risk assessments with the ADON. The ADON stated Resident 77's physician's order and care plan indicated to place call light reach and the fall risk assessments indicated Resident 77 was a high risk for falls. The ADON stated the staff should ensure all residents' call light is within reach prior to leaving the room so the residents can call for assistance and the staff can attend to their needs. The ADON stated Resident 77's call light should have been clipped to the sheet and within the resident's reach so the staff can attend and meet Resident 77's needs timely. During a review of the facility's P&P titled, Answering the Call Light, last reviewed on 1/14/2025, the P&P indicated the following: - When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. - Answer the resident's call as soon as possible.

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** b. During a review of Resident 84's admission Record, the admission Record indicated the facility admitted Resident 84 on 11/30/2024 and readmitted the resident on 12/23/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following a cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) affecting the right dominant side, encephalopathy (brain damage or disease that affects the brain's structure or function), and aphasia (a language disorder that makes it difficult to communicate). The admission Record indicated Resident 84 had a Resident Representative. During a review of Resident 84's History of Present Illness (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 12/24/24, indicated Resident 84 could make needs known but cannot make medical decisions. During a review of Resident 84's Minimum Data Set (MDS - a resident assessment tool), dated 12/30/2024 indicated Resident 84 rarely had the ability to understand and rarely had the ability to be understood. The MDS indicated Resident 84 was dependent (helper does all the effort) on oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a record review on 2/16/2025 at 8:25 a.m. of Resident 84's medical records (a history of someone's health), the medical records indicated there was no advance directive and/or advance directive acknowledgment noted in Resident 84's medical record. During a concurrent record review and interview on 2/16/2025 at 8:30 a.m. with Health Information Director (HID), Resident 84's chart was reviewed. The HID stated there was no documented evidence there was an Advance Directive Acknowledgment in the chart but would verify with Social Services Director (SSD). During an interview on 2/16/2025 at 8:42 a.m., the SSD stated upon admission residents are asked about Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) and advance directive. The SSD stated there is no advance directive acknowledgment or any documentation to indicate Resident 84's responsible party was informed of formulating an advance directive. The SSD should be offering advance directives to residents as it is their right to have an advance directive and know what their wishes are. The SSD stated an advance directive is a paper form of the resident's after-life wishes. The SSD stated advance directives acknowledgment form has not been offered to Resident 84 and/or his responsible party with a risk for Resident 84's right not to be respected. During an interview on 2/17/2025 at 4:05 p.m., the Director of Nursing (DON) stated Resident 84 has been in the facility since November of last year. The DON stated that if advance directive information is not in the chart it means the SSD did not communicate and did not offer. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, last reviewed 1/14/2025, the P&P indicated advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Based on interview and record review, the facility failed to inform and provide the resident/representative the option to formulate an advance directive (legal documents that provide instructions for medical care and only go into effect if the resident cannot communicate their wishes) for two of three sampled residents (Resident 20 and Resident 84) reviewed for Advance Directive care area. This deficient practice violated Resident 20 and Resident 84's rights and/or representatives' right to be fully informed of the option to formulate an advance directive. Findings: a. During a review of Resident 20's admission Record, the admission record indicated the facility originally admitted the resident on 8/22/2023 and readmitted on [DATE] with diagnoses including cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and generalized muscle weakness. During a review of Resident 20's Internal Medicine Initial Evaluation, dated 1/24/2025, the evaluation indicated the resident had the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool), dated 1/26/2025, indicated the resident had adequate hearing and clear speech, had the ability to make self understand and understand others. The MDS indicated Resident 20 was dependent on staff for shower/bathe self and required substantial/maximal assistance with upper and lower body dressing and putting on/taking off footwear. The MDS indicated Resident 20 was dependent on staff with mobility including sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer. During a concurrent interview and record review on 2/16/2025 at 1:29 p.m. with Social Services Director (SSD), Resident 20's Social Service Assessment, dated 1/23/2025, was reviewed. The Social Service Assessment indicated, under Advance Directive section, as not applicable. The SSD stated she did not offer and provide information to Resident 20 if they would like to formulate an advance directive or not. The SSD stated this is completed at the time of admission. The SSD stated when Resident 20 is not offered and provided an option to formulate an Advance Directive or not could affect his overall medical decisions and not follow his wishes and his after-life care. During an interview on 2/17/2025 at 5:55 p.m., the Director of Nursing (DON) stated the admission department starts the conversation with the Advance Directives. The DON stated then the SSD will do the assessment advance directive and quarterly and annually can be reviewed. The DON stated at the time of readmission the SSD and the admitting nurse will have to ask and validate if the resident/representative had executed an Advance Directive. The DON stated if they would like to formulate it then they will assist and discuss during the interdisciplinary meeting. The DON stated the resident's wishes would not be known unless it is in writing because it serves as a document to help the resident. The DON stated wishes can change in advance and it will help the providers navigate the resident's care and knows what the resident's wishes are. During a review of the facility's policy and procedure (P&P) titled, Advance Directives last reviewed on 1/14/2025, the P&P indicated Upon admission, the resident will be provided with written information concerning the right to refuse to accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do . If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advances directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.

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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Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Change in a Resident's Condition or Status (COC), for one of two sampled residents (Resident 50) by not promptly informing Resident 50's resident representative when on 1/23/2025 Resident 50 had a laboratory result of low iron level (a condition where your body has too few iron stores). This deficient practice resulted to violation of Resident 50 or the resident representative's right to be notified. Findings: During a review of Resident 50's admission Record, the admission Record indicated the facility admitted Resident 50 on 1/10/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following a cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) affecting the left dominant side, epilepsy (a chronic brain disorder that causes seizures, which are abnormal electrical discharges in the brain), and essential (primary) hypertension (HTN - high blood pressure). The admission Record indicated Resident 50's family member was the resident representative. During a review of Resident 50's History and Physical (H&P) Note, dated 1/11/2025, the H&P indicated Resident 50 had fluctuating capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 50 had the ability to understand and had the ability to be understood. The MDS indicated Resident 50 was dependent (helper does all the effort) with toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 50's Lab Result Report, dated 1/23/2025, the report indicated an iron level of 49 micrograms per deciliter (ug/dL - a unit of measurement, normal range of 65 to 175 ug/dL). The result indicated Resident 50's iron level was low. During a review of Resident 50's Progress Notes, dated 1/23/2025 at 2:07 p.m., the notes indicated labs were relayed to Nurse Practitioner (NP- a registered nurse with advanced training who provides patient care). During a review of Resident 50's Order Summary Report, dated 1/23/2025, the report indicated an order for ferrous sulfate (a type of iron that treats and prevents iron deficiency anemia) 325 milligrams (mg- a unit of measurement), to give one tablet by mouth three times a day for supplement with meals to prevent stomach upset. During a concurrent record review and interview on 2/16/2025 at 3:07 p.m. with the Health Information Director (HID), Resident 50's Situational Background Assessment and Recommendation (SBAR - a structured way to share information between people, especially in healthcare setting), was reviewed. The HID stated there were no SBARs done on 1/23/2025 for Resident 50. During a concurrent record review and interview on 2/17/2025 at 11:37 a.m. with Minimum Data Set Coordinator Nurse (MDSC), Resident 50's medical records (a history of someone's health) were reviewed. The MDSC stated a SBAR is for any change in a resident's condition, it can be for a decline or improvement for all aspects of care mental and physical. The MDSC stated an abnormal laboratory would require a SBAR to be done. The MDSC reviewed Resident 50's labs on 1/23/2025 and stated Resident 50's iron is low. The MDSC stated there should be a SBAR for the low iron labs but does not see a SBAR for the low iron result. The MDSC stated the purpose of a SBAR is to have interventions, must call the doctor, there needs to be monitoring, care planning and contact the family and/or resident representative. The MDSC stated did not see any specific monitoring or care plan for the low iron for Resident 50. The MDSC stated monitoring would include to observe for tarry stools, skin color, and bleeding. The MDSC stated the risk of not doing a SBAR is failing to notify the family of the COC since it is their right to know so that they can be informed and make regarding Resident 50's care. The MDSC stated also a risk for no interventions for monitoring a potential risk for internal bleeding and distress. The MDSC stated since there was no SBAR created, there was no care plan created to monitor sign and symptoms of anemia, because the care plans are to establish interventions and monitoring for effectiveness. During a concurrent record review and interview on 2/17/2025 at 4:17 p.m. with the Director of Nursing (DON), Resident 50's medical records were reviewed. The DON stated a SBAR is used to do an assessment to identify the change in a resident, must notify the doctor to review the plan of care and revised accordingly. The DON stated an SBAR is for any changes in residents that are off baseline. The DON reviewed Resident 50's labs on 1/23/2025 and stated iron level of 49 ug/dL was low reflecting a change in Resident 50's labs and would require for the nurse to do an SBAR. The DON stated with a SBAR staff will ask additional questions, and will include monitoring, and the doctor may order follow up labs. The DON stated there was no follow up order for labs after low iron results. The DON stated Resident 50 would require a care plan for low iron level. The DON stated Resident 50 must have a care plan to have a direction of treatment and how to address the situation. The DON stated the low iron level was not relayed to family. The DON stated it may have violated the family member's right to be informed of the COC. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed 1/14/2025, the P&P indicated our facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical and or mental conditions and or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical and mental condition or status. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident condition will be conducted as required by current OBRA regulation governing resident assessments and as outline in the MDS RAI instruction Manual.

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, facility failed to maintain privacy of confidential information when Licensed Vocational Nurse 4 (LVN 4) left the electronic health record (EHR- a digital version of a patient's paper chart) opened, unattended and out of view for one of one sampled resident (Resident 92) during a random observation. This deficient practice violated Resident 92's right to privacy and confidentiality of their medical records. Findings: During a review of Resident 92's admission Record, the admission Record indicated the facility admitted Resident 92 on 1/30/2025 with diagnoses including personal history of transient ischemic attack (TIA- a temporary disruption of blood flow to the brain), essential (primary) hypertension (HTN-high blood pressure), and hyperlipidemia (high levels of fat, or lipids, in the blood). During a review of Resident 92's Minimum Data Set (MDS - a resident assessment tool) dated 2/3/2025, the MDS indicated Resident 92 had the ability to understand and be understood. During an observation on 2/15/2025 at 10:02 a.m. observed LVN 4 standing outside of Resident 92 room with EHR opened to Resident 92's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). Observed LVN 4 then walk away to Nurse Station 2 away from the computer leaving Resident 92's EHR open. During an interview on 2/15/2025 at 10:08 a.m. with LVN 4, LVN 4 stated she left Resident 92's EHR opened and unattended. LVN 4 stated she should have closed the computer as there is a risk for someone to have access to Resident 92's personal information that they should not have access to. During an interview on 2/17/2025 at 4:28 p.m. with the Director of Nursing (DON), the DON stated staff must minimize the computer screen when walking away from the computer to protect resident information. The DON stated there is a potential for someone to pass by and other people to see resident information who should not have access to the residents' records. During a review of the facility's policy and procedures (P&P) titled, Confidentiality of Information and Personal Privacy, last reviewed 1/14/2025, the P&P indicated the facility will protect and safeguard resident confidentiality and personal privacy. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. Access to resident personal and medical records will be limited to authorized staff and business associates.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one (1) of three (3) sampled residents (Resident 32) reviewed under Environmental Task by failing to ensure Resident 32's right floor mat was not torn off on the right lower corner. This deficient practice had the potential to negatively affect the resident's quality of life. Findings: During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2025 with diagnoses including muscle wasting and atrophy (loss of muscle mass and strength), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 32's History and Physical (H&P) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 32 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 32's Order Summary Report, the Order Summary Report indicated a physician's order dated 11/26/2024 for floor mat (landing mat) on the right side of the bed and monitor every shift for proper positioning and placement. During a review of Resident 32's care plan (CP) on risk for falls and injuries initiated on 5/18/2021 and last revised on 2/3/2025, the CP indicated floor mat (landing mat) on the right side of the bed and monitor for proper positioning and placement every shift as one of the interventions to prevent falls. During a concurrent observation and interview on 2/15/2025 at 9:18 a.m. inside Resident 32's room with Treatment Nurse 1 (TN 1), TN 1 stated Resident 32's right floor mat had the right lower corner torn off. TN 1 stated the maintenance department will be notified to change the floor mat. TN 1 stated the staff are responsible to notify the maintenance department if a resident equipment needs to be changed in the room. TN 1 stated Resident 32's torn floor mat was not providing a homelike environment for the resident. TN 1 stated the facility is considered Resident 32's home already and had to be provided a clean, safe, and functioning equipment in the room. During an interview on 2/17/2025 at 4:55 p.m. with the Assistant Director of Nursing (ADON), the ADON stated if staff observed any equipment, devices, or furnishing in the room that is in disrepair such as the floor mat that is torn, the maintenance department should be notified immediately to change the device, equipment, or furnishings. The ADON stated residents are provided with a safe, clean, functioning equipment, furnishings while residing in the facility as the facility is already their home. The ADON stated Resident 32's floor mat should have been changed as soon as observed with the torn off right lower corner to provide a homelike environment for the resident as it can affect Resident 32's wellbeing while in the facility. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, last reviewed 6/27/2024, the P&P indicated: - Residents are provided with a safe, clean, comfortable and homelike environment. - The facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a personalized, homelike setting such as a clean, safe, sanitary and orderly/clutter free environment.

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of one sampled resident (Resident 20) reviewed for physical restraints care area by failing to ensure Resident 20 had an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and a care plan for restraint bed placed against the wall. These deficient practices had the potential to result in the restriction of resident's freedom of movement, a decline in physical functioning, psychosocial harm, and physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from). Findings: During a review of Resident 20's admission Record, the admission Record indicated the facility originally admitted the resident on 8/22/2023 and readmitted the resident on 1/22/2025 with diagnoses including cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness. During a review of Resident 20's Internal Medicine Initial Evaluation, dated 1/24/2025, the Internal Medicine Initial Evaluation indicated the resident has the capacity to understand and make decisions. During a review of Resident 20's physician's order dated 2/13/2025, the physician's order indicated devices: left one fourth (¼) side rail (bar or barrier that attaches to the side of a bed) and right side of bed towards the wall for enabler and resident's preference. During a review of Resident 20's Minimum Data Set (MDS-a resident assessment tool), dated 1/26/2025, the MDS indicated the resident had adequate hearing and clear speech, had the ability to make self understood and understand others. The MDS indicated the resident was dependent on staff for shower/bathe self and required substantial/maximal assistance with upper and lower body dressing and putting on/taking off footwear. The MDS indicated the resident was dependent on staff with mobility including sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. During an observation on 2/15/2025 at 10:07 a.m., Resident 20 was lying asleep on a low bed. The right side of Resident 20's bed was up against the wall. During an interview on 2/15/2025 at 12:45 p.m. with Resident 20, Resident 20 stated his right side of his bed had been up against the wall for a long time since he was admitted and readmitted . Resident 20 stated he does not know why his right side of the bed was up against the wall and would prefer his bed not to be that close to the wall. During a concurrent observation and interview on 2/16/2025 at 2:37 p.m. with Certified Nursing Assistant (CNA 6) inside Resident 20's room, Resident 20's right side of bed was up against the wall. CNA 6 stated Resident 20 was asleep on bed. CNA 6 stated since Resident 20 had been admitted , the resident's bed had always been up against the wall. CNA 6 stated he (CNA 6) assumes it was because the resident was high risk for falls, but he was unsure of the exact reason. CNA 6 stated if Resident 20 needed to transfer out of bed, he (CNA 6) would assist the resident on the left side of the bed. During a concurrent observation and interview on 2/16/2025 at 2:44 p.m. with Licensed Vocational Nurse (LVN 7), Resident 20's right side of his bed was up against the wall. Resident 20 was asleep on the bed. LVN 7 stated she did not know why the resident's bed was up against the wall. During an interview on 2/16/2025 at 3:26 p.m. with the MDS Coordinator (MDSC), the MDSC stated restraint assessment, informed consent, interdisciplinary meeting, physician orders, and care plan are done on admission or when it (restraint) is used and reviewed at least quarterly. The MDSC stated restraints prohibit the movement of the resident. During a concurrent interview and record review on 2/16/2025 at 3:36 p.m. with the MDSC, reviewed Resident 20's physician orders, assessments, informed consent, and care plans. The MDSC stated there was no restraint assessment, no informed consent, and no care plan on the use of restraint bed placed against the wall. The MDSC stated it is important to have all the requirements in place to ensure the restraint was safe to be used and for the staff to know what interventions to implement for the resident. The MDSC stated at a minimum, restraint use should be evaluated quarterly. During an interview on 2/17/2025 at 6:04 p.m. with the Director of Nursing (DON), the DON stated there is a physician's order for Resident 20's preference of having the right side of bed up against the wall. The DON stated that the freedom of movement includes being able to get out of bed on the right side of the bed. The DON stated Resident 20 is unable to move the bed away from the wall. The DON stated they will reassess all residents whose bed is up against the wall using their facility's policy and procedure (P&P) titled, Use of Restraints. During a review of the facility's P&P titled, Use of Restraints last reviewed on 1/14/2025, the P&P indicated Restraints shall only used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. The P&P indicated 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device . or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The deficient of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back fown, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint . Residents and/or surrogate/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use . Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use.

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 interview and record review, the facility: 1. Failed develop a comprehensive person-centered care plan (CP-a document outlining a detailed approach to care customized to an individual resident's needs) timely for one of one sampled resident (Resident 2) reviewed for anticoagulant (blood thinner - prevents blood clots or keep an existing clot from getting worse) when Resident 2's care plan addressing the use of heparin (anticoagulant) was developed 25 days after readmission. 2. Failed to develop a comprehensive person-centered care plan for one of two sampled residents (Resident 50) reviewed for Change of Condition (COC) care area when Resident 50 had a COC of low iron laboratory results (too low may be a sign of anemia [lack of oxygen-rich blood which can cause fatigue, weakness, and dizziness]) on 1/23/2025. These deficient practices had the potential for a delay in providing the necessary care and treatments to Residents 2 and 50. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 2/8/2021 and readmitted the resident on 12/27/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 1/18/2025, the MDS indicated Resident 2 had severely impaired cognition (having the ability to think, learn, and remember clearly) and required total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident received anticoagulant. During a re view of Resident 2's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/27/2024 for heparin sodium (porcine) injection solution 5000 units per milliliter (units/ml - a unit of measurement) **dispense as written ([NAME])** 5000 units hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) two (2) times a day for blood clot prevention. During a review of Resident 2' care plan (CP) on risk for bleeding or bruising related to use of heparin, the CP indicated it was initiated on 1/21/2025. During a concurrent interview and record review on 2/16/2025 at 2:45 p.m., reviewed Resident 2's physician's order and CP with Registered Nurse 1 (RN 1). RN 1 stated Resident 2 had a physician's order for heparin dated 12/27/2024 and the care plan was initiated on 1/21/2025. RN 1 stated care plans are supposed to be initiated as soon as a physician's order was received. RN 1 stated Resident 2's care plan addressing the use of heparin should have been initiated timely on 12/27/2025 so everyone involved in Resident 2's care would be aware of the proper interventions needed to prevent delay in providing the necessary care and treatment Resident 2 needed. During a concurrent interview and record review on 2/17/2025 at 4:19 p.m., reviewed Resident 2's physician's order and care plan with the Assistant Director of Nursing (ADON). The ADON stated care plans, especially new medication orders, should be initiated by the nurse who received the order. The ADON stated Resident 2 had a physician's order dated 12/27/2025 for heparin and the care plan addressing the use of heparin was developed and implemented on 1/21/2025. The ADON stated Resident 2's care plan addressing the use of heparin was not developed and implemented timely. The ADON stated Resident 2's care plan for the heparin should have been developed and implemented timely on 12/27/2025 so the other disciplines involved in the care of Resident 2 would be aware of the interventions to prevent delay in providing care and treatment for the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, last reviewed on 1/2025, the P&P indicated: - A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident - The comprehensive person-centered care plan is developed within seven (7 ) days of completion of the required comprehensive assessment (MDS). - The comp person-centered care plan will: a. include measurable objectives and timeframes. b. describe the services that are to be furnished to attain or maintain the resident's highest practicable, mental, and psychosocial well-being. b. During a review of Resident 50's admission Record, the admission Record indicated the facility admitted Resident 50 on 1/10/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following a cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) affecting the left dominant side, epilepsy (a chronic brain disorder that causes seizures, which are abnormal electrical discharges in the brain), and essential (primary) hypertension (HTN-high blood pressure). During a review of Resident 50's History and Physical (H&P) Note dated 1/11/2025, the H&P Note indicated Resident 50 had fluctuating capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 50 was able to make self understood and understand others. The MDS indicated Resident 50 was dependent (helper does all the effort) with toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 50's Laboratory Result Report dated 1/23/2025, the Laboratory Result Report indicated an iron level of 49 micrograms per deciliter (ug/dL-a unit of measurement, normal range 65-175 ug/dL); the result indicated the iron level was low. During a review of Resident 50's Progress Notes dated 1/23/2025 at 2:07 p.m., the Progress Notes indicated the laboratory results were relayed to the Nurse Practitioner (NP- a registered nurse with advanced training who provides patient care) with new orders carried out. During a review of Resident 50's Order Summary Report dated 1/23/2025, the Order Summary Report indicated a physician's order for ferrous sulfate (a type of iron that treats and prevents iron deficiency anemia) 325 milligrams (mg- a unit of measurement) give 1 tablet by mouth three times a day for supplement with meals to prevent stomach upset. During a concurrent record review and interview on 2/17/2025 at 11:37 a.m. with the Minimum Data Set Coordinator Nurse (MDSC) of Resident 50's medical records (a history of someone's health), the MDSC stated she did not see a care plan for Resident 50's low iron. The MDSC stated no care plan was created to indicate monitoring for signs and symptoms of anemia. The MDSC stated care plans are used to establish interventions which included monitoring for effectiveness as there is also a risk for constipation when taking iron. During a concurrent record review and interview on 2/17/2025 at 4:17 p.m. of Resident 50's medical records with the Director of Nursing (DON), the DON stated Resident 50 would require a care plan for low iron. The DON stated having a care plan provides the direction of treatment and how to address the situation. During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive Person-Centered, last reviewed on 1/2025, the P&P indicated: - A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident - The comprehensive person-centered care plan is developed within seven (7 ) days of completion of the required comprehensive assessment (MDS). - The comp person-centered care plan will: a. include measurable objectives and timeframes. b. describe the services that are to be furnished to attain or maintain the resident's highest practicable, mental, and psychosocial well-being.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to revise the comprehensive care plan for one of five sampled residents (Resident 32) reviewed for unnecessary medications by failing: 1. To revise (update) Resident 32's care plan on the use of bupropion (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]) after the physician increased the dose of the medication on 12/19/2024. 2. To ensure care plans reflect the updated interventions provided to Resident 32. These deficient practices had the potential for delayed provision of necessary care and services. Findings: During a record review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 on 5/17/2021, with diagnoses that included including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), generalized muscle weakness, and dementia (a progressive state of decline in mental abilities). During a record review of Resident 32's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a record review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 32's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 32 required supervision or touching assistance with eating and total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 32 was on antidepressant (medications used to treat symptoms of depression) and insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). A. During a record review of Resident 32's Physician Order, dated 12/19/2024, the Physician Order indicated the following order: 1. Bupropion hydrochloride extended release, give 150 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) by mouth one time a day for depression manifested by lack of motivation with activities of daily living. 2. Discontinue bupropion hydrochloride extended release, 100 mg by mouth one time a day for depression manifested by lack of motivation with activities of daily living. During a concurrent interview and record review on 2/16/2025, at 2:34 p.m., with the Assistant Director of Nursing (ADON), Resident 32's Care Plan on bupropion use, dated 9/27/2023, was reviewed. The ADON stated the facility last updated the care plan for bupropion use on 9/27/2023 and the facility did not revise the comprehensive care plan on 12/19/2024 when the physician increased the dose of the medication from 100 mg to 150 mg. The ADON stated Resident 32's care plan should have been updated when medication is increased. The ADON stated the importance of updating or revising the care plan was to guide nurses on medication administration. During an interview on 2/17/2025 at 1:49 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 32's care plan should have been updated for any medication increase or any medication change. During an interview on 2/17/2025, at 4:17 p.m. with the Minimum Data Set Nurse (MDSC), the MDSC stated the MDS nurses updates and revises the care plan quarterly (every three months). The MDSC stated if medication was increase, the staff who received the order should revise the care plan. The MDSC stated Licensed Vocational Nurses (LVNs) should have revised the care plan on Resident 32's use of bupropion. The MDSC stated the importance of revising Resident 32's care plan was to guide nurses on the latest order and intervention for the resident. During an interview on 2/17/2025, at 5:13 p.m. with the Director of Nursing (DON), the DON stated Resident 32's care plan should have been revised with any medication changes and if medication dose was increased to give an actual presentation of what the intervention so staff can monitor the effect of the medication. During a record review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, and last reviewed on 1/14/2025, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implement for each resident. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents condition change. The interdisciplinary team must review and update the care plan . b. when the desired outcome is not met. B. During a review of Resident 32's Order Summary Report, the Order Summary Report indicated the following physician's orders: 1. 2/12/2024: Lantus solution (a long-acting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication])100 unit per milliliter (unit/ml - a unit of measurement) inject 34 units subcutaneously (beneath the skin) at bedtime related to DM 2. Hold if blood sugar (BS) is less than (<) 100. 2. 1/24/2025: Novolog solution (a short acting insulin)100 unit/ml (insulin aspart) inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): <60, hypoglycemic protocol and inform physician (MD); if 60 - 149 = 0 unit;150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; 400 plus = 12 unit; more than (>) 400, 12 units and inform MD subcutaneously with meals for DM. During a review of Resident 32's care plan (CP) on DM initiated in 5/23/2021 and last revised on 2/9/2023, the CP indicated the following interventions: 1. Humalog solution 100 unit/ml (Insulin Lispro - a short acting insulin) inject as per sliding scale: if 60 - 149 = 0 Unit < 60, hypoglycemic protocol and inform MD.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; 400 plus = 12 Units; if > 400, 12 Units and inform MD., subcutaneously before meals and at bedtime 2. Diabetes medications (insulin lispro, glargine) as ordered by doctor. Monitor/document for side effects and effectiveness. 3. Humalog Solution 100 unit/ml (insulin lispro) inject four (4) units subcutaneously three times a day 4. Lantus solution 100 unit/ml (insulin glargine) inject 20 units subcutaneously at bedtime. During a concurrent interview and record review on 2/17/2025 at 4:20 p.m., Resident 32's CP on DM 2 was reviewed with the Assistant Director of Nursing (ADON). The ADON stated Resident 32's CP interventions for the insulin were not updated to reflect the current dose the physician ordered. The ADON stated care plans are updated during the quarterly or annual MDS assessments and as needed when a new order is received. The ADON stated Resident 32's should have been updated when the order was changed to reflect the current type of insulin and dosage ordered by the physician so everyone would be aware of Resident 32's current plan of care to prevent delay in the delivery of necessary services the resident needed. During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, last reviewed on 1/14/2025, the P&P indicated care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. The P&P further indicated: - Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. - When goals and objective are not achieved, the resident's clinical record will be documented why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly. - Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are achieved. - Goals and objectives are reviewed and/or revised: a. When there has been a change in the resident's condition. b. When the desired outcome has not been achieved.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 67) reviewed for nutrition care area was provided with the care and services to maintain good nutrition by failing to provide Resident 67 with assistance with all meals as the physician has ordered. This deficient practice had the potential for Resident 67 to lose weight and/or be malnourished (not getting enough of the right nutrients from food). Findings: During a review of Resident 67's admission Record, the admission Record indicated the facility admitted Resident 67 on 3/22/2024 and readmitted the resident on 12/6/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following a cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) affecting the left dominant side, muscle weakness, moderate protein calorie malnutrition (a nutritional condition that occurs when someone doesn't get enough protein and calories), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 67's Nutritional assessment dated [DATE], the Nutritional Assessment indicated Resident 67 was on puree diet texture upon readmission, recently upgraded per Speech Therapy; resident needs assistance with meals; and oral (PO) intake were mostly 25-75 percent (%). During a review of Resident 67's Order Summary Review, the Order Summary Review indicated the following physician's orders dated 12/6/2024: - Regular diet mechanical soft texture. Regular liquid consistency, fortified meals, four ounces (oz-unit of measurement), high protein nourishment (HPN) with meals. - Provide feeding assistance at all times. During a review of Resident 67's Nutritional assessment dated [DATE], the Nutritional Assessment indicated resident needs assistance with meals with PO intakes mostly 25-75%. During a review of Resident 67's Minimum Data Set (MDS - a resident assessment tool), dated 12/12/2024, the MDS indicated Resident 67 had the ability to understand and be understood. The MDS indicated Resident 67 was dependent (helper does all the effort) with toileting, showering, lower body dressing, putting on and taking off shoes, and required partial assistance (helper does less than half the effort) oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 67's care plan created on 1/17/2025 for nutritional and dehydration (the body doesn't have enough water in it to function properly), the care plan indicated interventions that included to assist resident as needed with feeding and to monitor for signs of malnutrition. During a review of Resident 67's Speech Therapy Evaluation and Plan of Treatment dated 2/13/2025, the Speech Therapy Evaluation and Plan of Treatment indicated Resident 67 requires supervision and/or assistance with meals 91-100% of the time due to swallow safety. During a review of Resident 67's progress notes dated 2/15/2025 at 3:24 p.m., the progress notes indicated Resident 67 refused to eat breakfast. The progress notes also indicated Resident 67 consumed 50% of lunch when his family assisted Resident 67 with feeding. During a review of the facility's Nursing Staffing Assignment and Sign-in Sheet dated 2/16/2025 for the 7-3 shift and 3-11 shift, the Nursing Staffing Assignment and Sign-in Sheet indicated Resident 67 was not listed as a resident that required assistance with meals. During an interview on 2/15/2025 at 2:30 p.m. with Resident 67's Family Member 1 (FM 1), FM 1 stated Resident 67 would benefit from someone assisting the resident with meals as Resident 67 was not able to feed himself and staff do not help him toeat. During a concurrent observation and interview on 2/15/2025 at 6:38 p.m. with the Director of Rehab (DOR), observed Resident 67 sitting up on bed with the bedside table in front of him. Observed the resident's food tray on the bedside table that contained a cup of spilled water. The DOR stated Resident 67 eats independently but after seeing Resident 67's tray, the DOR asked Resident 67 if he needed assistance with feeding. During an observation and interview on 2/15/2025 at 6:55 p.m., observed Certified Nursing Assistant 7 (CNA 7) sitting on a chair next to Resident 67 assisting the resident with his meal. CNA 7 stated Resident 67 is requiring a lot of assistance and cueing. During an observation on 2/16/2025 at 7:22 a.m., observed Resident 67 sitting up with tray in front of him. There was no staff assisting Resident 67 with his meal. During a concurrent observation and interview on 2/16/2025 at 7:54 a.m. with Treatment Nurse 1 (TN 1) of Resident 67's breakfast tray, TN 1 stated Resident 67 may have eaten two bites of his breakfast. During an interview on 2/16/2025 at 4:46 p.m. with CNA 2, CNA 2 stated there is a list on their work assignments that indicate which residents require assistance with their meals. During an interview on 02/17/25 at 10:02 a.m. with CNA 3, CNA 3 stated she has been assisting Resident 67 with meals because the resident has not been eating by himself. CNA 3 stated Resident 67 used to eat on his own, but he needs encouragement. CNA 3 stated now, staff must assist Resident 67 with feeding himself. CNA 3 stated Resident 67 consumed 90% of breakfast that day because the resident had assistance with feeding himself. CNA 3 stated the list of residents who require assistance with meals is indicated in their assignment. CNA 3 stated Resident 67's name was not indicated on the list. During an interview on 02/17/25 at 10:16 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 67 needs assistance with meals and the assignment will reflect the resident's name. LVN 4 stated Resident 67 requires assistance with eating, if CNAs are not assisting Resident 67 with meals, he will not eat and will have his tray in front of him untouched. During an interview on 2/17/2025 at 5:12 p.m. with the Director of Nursing (DON), the DON stated the charge nurses (LVNs) are the ones who inform the CNAs on who are the residents requiring assistance with meals. The DON stated the Occupational Therapist (OT) should be able to communicate to staff that Resident 67 requires more assistance. The DON stated Resident 67 required verbal cues and the resident was able to follow commands. The DON stated the physician's order indicated to provide feeding assistance to Resident 67 at all times. The DON stated this means staff should be assisting the resident with all meals. The DON stated if Resident 67 is not provided assistance with feeding, the resident might not eat which can place the resident at risk for weight loss and weakness. During a review of the facility's policy and procedures (P&P) titled, Activities of Daily living (ADLs), Supporting, last reviewed 1/14/2025, the P&P indicated residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility's P&P titled, Dining and or Assistance with Meals, last reviewed 1/14/2025, the P&P indicated resident shall receive assistance with meals in a manner that meets the individual needs of each resident.

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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Based on interview and record review, the facility failed to ensure that one of two residents (Resident 50) reviewed for Change of Condition (COC) care area received treatment and care in accordance with professional standards of practice when a Situational, Background, Assessment, and Recommendation (SBAR-a structured way to share information between people, especially in healthcare setting) was not created for Resident 50 when the resident had a COC of low iron laboratory results (too low may be a sign of anemia [lack of oxygen-rich blood which can cause fatigue, weakness, and dizziness]) on 1/23/2025. This deficient practice had the potential for Resident 50 to go unmonitored for low iron resulting in the potential for fatigue, weakness, and dizziness. Findings: During a review of Resident 50's admission Record, the admission Record indicated the facility admitted Resident 50 on 1/10/2025 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following a cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) affecting the left dominant side, epilepsy (a chronic brain disorder that causes seizures, which are abnormal electrical discharges in the brain), and essential (primary) hypertension (HTN-high blood pressure). During a review of Resident 50's History and Physical (H&P) Note dated 1/11/2025, the H&P Note indicated Resident 50 had fluctuating capacity to understand and make decisions. During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool), dated 1/17/2025, the MDS indicated Resident 50 was able to make self understood and understand others. The MDS indicated Resident 50 was dependent (helper does all the effort) with toileting, showering, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 50's Laboratory Result Report dated 1/23/2025, the Laboratory Result Report indicated an iron level of 49 micrograms per deciliter (ug/dL-a unit of measurement, normal range 65-175 ug/dL); the result indicated the iron level was low. During a review of Resident 50's Progress Notes dated 1/23/2025 at 2:07 p.m., the Progress Notes indicated the laboratory results were relayed to the Nurse Practitioner (NP- a registered nurse with advanced training who provides patient care) with new orders carried out. During a review of Resident 50's Order Summary Report dated 1/23/2025, the Order Summary Report indicated a physician's order for ferrous sulfate (a type of iron that treats and prevents iron deficiency anemia) 325 milligrams (mg- a unit of measurement) give 1 tablet by mouth three times a day for supplement with meals to prevent stomach upset. During a concurrent record review and interview on 2/16/2025 at 3:07 p.m. with the Health Information Director (HID) of Resident 50's SBAR, the HID stated there was no SBAR created on 1/23/2025 for Resident 50. During a concurrent record review and interview on 2/17/2025 at 11:37 a.m. with the Minimum Data Set Coordinator Nurse (MDSC) of Resident 50's medical records (a history of someone's health), the MDSD stated an SBAR is intended for any change in a resident's condition which can be either a decline or improvement in all aspects of care. The MDSC stated an abnormal laboratory result would require an SBAR to be done. The MDSC reviewed Resident 50's laboratory result on 1/23/2025 and stated Resident 50's iron was low. The MDSC stated there should be an SBAR created addressing Resident 50's low iron level. The MDSC stated the purpose of an SBAR is to have interventions like informing the doctor, monitoring the resident, and contacting the family and/or resident representative. The MDSC stated Resident 50's monitoring would include observing for tarry stools, skin color, and bleeding. During a concurrent record review and interview on 2/17/2025 at 4:17 p.m. of Resident 50's medical records with the Director of Nursing (DON), the DON stated an SBAR is used to do an assessment to identify the change of condition in a resident and to allow the facility to notify the doctor. The DON reviewed Resident 50's laboratory result on 1/23/2025 and stated the resident's iron level of 49 ug/dL was low and would require for the nurse to do an SBAR. The DON stated having an SBAR will guide the nurse to ask additional questions and will include monitoring the resident. The DON stated if Resident 50 was diagnosed with anemia, the facility would do monitoring for fatigue. During a review of the facility's policy and procedures (P&P) titled, Quality of Care, last reviewed 1/14/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of care. Resident-centered care can be provided that responds to individual preference, needs, and values. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed 1/14/2025, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representatives of changes in the resident's medical and/or mental conditions and/or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical and mental condition or status.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide acceptable parameter of nutrition for one of two sampled residents (Resident 67) reviewed under nutrition when: 1. Resident 67's medical doctor (MD) was not informed when the resident ate less than 50% for two consecutive meals on: - 2/10/2025 for lunch and dinner - 2/13/2025 for lunch and dinner - 2/14/2025 refused breakfast and has less than 50% of lunch 2. Resident 67 was not provided assistance with meals on: - 2/15/2025 dinner and - 2/16/2025 breakfast and lunch . These deficient practices had the potential for Resident 67 to lose weight and/or be malnourished (not enough of the right nutrients from food). Findings: During a review of Resident 67's admission Record, the admission Record indicated the facility admitted Resident 67 on 3/22/2024 and readmitted the resident on 12/6/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following a cerebral infarction (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) affecting the left dominant side, muscle weakness, moderate protein calorie malnutrition (a nutritional condition that occurs when someone doesn't get enough protein and calories), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 67's Nutritional assessment dated [DATE], the Nutritional Assessment indicated Resident 67 was on puree diet texture upon readmission, recently upgraded per Speech Therapy; resident needs assistance with meals; and oral (PO) intake were mostly 25-75 percent (%). During a review of Resident 67's Order Summary Review, the Order Summary Review indicated the following physician's orders dated 12/6/2024: - Regular diet mechanical soft texture. Regular liquid consistency, fortified meals, four ounces (oz-unit of measurement), high protein nourishment (HPN) with meals. - Provide feeding assistance at all times. During a review of Resident 67's Nutritional assessment dated [DATE], the Nutritional Assessment indicated resident needs assistance with meals with PO intakes mostly 25-75%. During a review of Resident 67's Minimum Data Set (MDS - a resident assessment tool), dated 12/12/2024, the MS indicated Resident 67 had the ability to understand and be understood. The MDS indicated Resident 67 was dependent (helper does all the effort) with toileting, showering, lower body dressing, putting on and taking off shoes, and required partial assistance (helper does less than half the effort) oral hygiene, upper body dressing, and personal hygiene and required set-up assistance (helper sets up or cleans up) with eating. During a review of Resident 67's care plan created on 1/17/2025 for nutritional and dehydration (the body doesn't have enough water in it to function properly), the care plan indicated interventions that included to assist resident as needed with feeding and to monitor for signs of malnutrition. During a review of Resident 67's care plan created on 2/4/2025, the care plan indicated resident has potential nutritional problem and dehydration risk related to recent poor PO intake less than 50%. The care plan interventions included to provide/serve diet as ordered, record intake per meal, report intake below 50%. During a review of Resident 67's Situational Background Assessment and Request (SBAR- a communication framework that helps people share information in a structured way) dated 2/12/2025 at 1:55 p.m., the SBAR indicated Resident 67 was noted with cough during drinking liquids. During lunch, resident was noted with coughing during fluid intake. There were no choking or excessive coughing noted at that time. During a review of Resident 67's Speech Therapy Evaluation and Plan of Treatment dated 2/13/2025, the Speech Therapy Evaluation and Plan of Treatment indicated Resident 67 requires supervision and/or assistance with meals 91-100% of the time due to swallow safety. During a review of Resident 67's progress notes dated 2/15/2025 at 3:24 p.m., the progress notes indicated Resident 67 refused to eat breakfast. The progress notes also indicated Resident 67 consumed 50% of lunch when his family assisted Resident 67 with feeding. During a review of the facility's Nursing Staffing Assignment and Sign-in Sheet dated 2/16/2025 for the 7-3 shift and 3-11 shift, the Nursing Staffing Assignment and Sign-in Sheet indicated Resident 67 was not listed as a resident that required assistance with meals. During an interview on 2/15/2025 at 2:30 p.m. with Resident 67's Family Member 1 (FM 1), FM 1 stated Resident 67 would benefit from someone assisting the resident with meals as Resident 67 was not able to feed himself and staff do not help him to eat. During an observation and interview on 2/15/2025 at 6:55 p.m., observed Certified Nursing Assistant 7 (CNA 7) sitting on a chair next to Resident 67 assisting the resident with his meal. CNA 7 stated Resident 67 is requiring a lot of assistance and cueing. During an observation on 2/16/2025 at 7:22 a.m., observed Resident 67 sitting up with tray in front of him. There was no staff assisting Resident 67 with his meal. During a concurrent observation and interview on 2/16/2025 at 7:54 a.m. with Treatment Nurse 1 (TN 1) of Resident 67's breakfast tray, TN 1 stated Resident 67 may have eaten two bites of his breakfast. During an interview on 2/16/2025 at 4:46 p.m. with CNA 2, CNA 2 stated there is a list on their work assignments that indicate which residents require assistance with their meals. During an interview on 02/17/25 at 10:02 a.m. with CNA 3, CNA 3 stated she has been assisting Resident 67 with meals because the resident has not been eating by himself. CNA 3 stated Resident 67 used to eat on his own, but he needs encouragement. CNA 3 stated now, staff must assist Resident 67 with feeding himself. CNA 3 stated Resident 67 consumed 90% of breakfast that day because the resident had assistance with feeding himself. CNA 3 stated the list of residents who require assistance with meals is indicated in their assignment. CNA 3 stated Resident 67's name was not indicated on the list. CNA 3 stated if a resident refuses to eat, they (CNAs) were told to try and offer meal three times, and if the resident still refused, they (CNAs) notify the charge nurse. During a concurrent record review of Resident 67's Care Plan for the potential for nutritional problem and dehydration risk related to recent poor PO intake less than 50% and Amount Eaten for February 2025 and interview on 02/17/25 at 10:16 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated if a resident refuses to eat, they (staff) will offer nourishment or nutritional supplements ordered. LVN 4 stated if the resident refuses again, they must do an SBAR, start monitoring the resident, call the resident's MD, and inform the resident's family. LVN 4 stated Resident 67 needs assistance with meals and the assignment will reflect the resident's name. LVN 4 stated if a resident has had more than two meal refusals, they inform the resident's MD. LVN 4 reviewed Resident 67' Care Plan for potential nutritional problem and dehydration risk related to recent poor PO intake less than 50%, LVN 4 stated Resident 67's care plan indicated to report when Resident 67 eats less than 50%. LVN 4 stated the intervention should have been more specific to indicate how many meals are less than 50%. LVN 4 stated the intervention should have indicated to notify MD when resident eats less than 50% for two consecutive meals. LVN 4 reviewed Resident 67's Amount Eaten for February, LVN 4 stated Resident 67's meal consumption of less than 50% on consecutive meals for 2/10/2025, 2/13/2025, and 2/14/2025 should have been reported to the MD. LVN 4 stated those should have been reported to the MD so the MD can provide orders like laboratory tests, fluids, diet change, and/or medications. LVN 4 stated if the MD is not notified, there can be a risk for Resident 67 to lose weight and to be malnourished which can affect the resident's skin, hydration, and level of consciousness. During an interview on 2/17/2025 at 5:12 p.m. with the Director of Nursing (DON), the DON stated the LVNs should have reported Resident 67's meal consumption of less than 50% on consecutive meals for 2/10/2025, 2/13/2025, and 2/14/2025 to the MD for orders as there can be a risk for delay in care. The DON also stated if residents are eating less than usual, the CNAs communicate to the charge nurses. The DON stated Resident 67's consumption of two consecutive meals of 50% less would be concerning. During a review of the facility's policy and procedures (P&P) titled, Activities of Daily living (ADLs), Supporting, last reviewed 1/14/2025, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. During a review of the facility's P&P titled, Dining and or Assistance with Meals, last reviewed 1/14/2025, the P&P indicated resident shall receive assistance with meals in a manner that meets the individual needs of each resident.

CONCERN (D)

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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide necessary behavioral health care and services for one of five sampled residents (Resident 78) when the facility failed to conduct a behavioral interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) meeting on the use of Seroquel (an antipsychotic medication used to treat several kinds of mental health conditions) and escitalopram (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]). This deficient practice had the potential to negatively affect the delivery of services. Findings: During a record review of Resident 78's admission Record, the admission Record indicated the facility admitted Resident 78 on 3/29/2024, with diagnoses that included other toxic encephalopathy (a condition where the brain becomes damaged due to the presence of toxins), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and depression. During a record review of Resident 78's Care Plan about use of antidepressant (medication used to treat depression), dated 3/29/2024, the Care Plan indicated an intervention to discuss with the Physician, family, the ongoing need for use of medication. During a record review of Resident 78's Care Plan about use of psychotropic medications (medications used to treat mental health conditions), dated 3/29/2024, the Care Plan indicated an intervention to discuss with the Physician, family the ongoing need for use of medication. During a record review of Resident 78's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/30/2024, the H&P indicated, Resident 78 can make needs known but cannot make medical decisions. During a record review of Resident 78's Psychoactive Summary Sheet dated 12/1/2024 to 1/31/2024, for Seroquel, the Psychoactive Summary Sheet indicated from 12/1/2024 to 12/31/2024, Resident 78 had six behavioral episodes from 7:00 a.m. to 3:00 p.m. and six behavioral episodes from 11:00 p.m. to 7:00 a.m. The Psychoactive Summary Sheet indicated from 1/1/2025 to 1/31/2025, Resident 78 had two behavioral episode from 7:00 a.m. to 3:00 p.m. and two episodes from 11:00 p.m. to 7:00 a.m. During a record review of Resident 78's Minimum Data Set (MDS - a resident assessment tool), dated 1/6/2025, the MDS indicated Resident 78's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a record review of Resident 78's Physician Order, dated 1/23/2025, the Physician Order indicated the following: 1. Seroquel tablet, give 25 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) by mouth in the evening for psychotic disorder secondary to post traumatic stress disease (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) manifested by striking out, resisting care and continuous screaming. 2. Escitalopram oxalate tablet 10 mg, give one tablet by mouth in the afternoon for depression manifested by social isolation (lack of social connection or support from others). During a record review of Resident 78's Behavior Management Meeting (a gathering to discuss and plan how to address a resident's behavior), dated 12/2/2024 and 2/3/2025, the Behavior Management Meeting did not indicate if Resident 78's use of antidepressant and psychotropic medication was discussed. During an interview, on 2/16/2025, at 6:46 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the facility just started Behavioral IDT for residents on psychotropic medications on 12/2024 and not all residents on psychotropic medications was reviewed. During a concurrent interview and record review, on 2/17/2025, at 8:09 a.m., with the ADON, the ADON stated Resident 78's IDT was reviewed. The ADON stated the facility lacked documentation of Behavior Management Meeting (IDT) with Resident 78's Psychiatrist. The ADON stated the importance of an IDT with the Psychiatrist was to discuss if Resident 78 had increasing or decreasing behavior, so the Psychiatrist can adjust the medication to make sure Resident 78 is getting the correct dosage of the medication. During an interview, on 2/17/2025, at 1:43 p.m., with the Director of Staff Development (DSD), the DSD stated Behavioral IDT is important so the facility and the Psychiatrist can determine if resident needed medication adjustment or discontinuation. During an interview, on 2/17/2025, at 2:43 p.m., with the Director of Nursing (DON), the DON stated the Psychiatrist comes and visit every two months. The DON stated the ADON was in charge of the Behavioral IDT with the Psychiatrist. During an interview, on 2/17/2025, at 5:13 p.m., with the DON, the DON stated Behavioral IDT is a tool to monitor the effectiveness of the medication under the supervision of the clinician. During a record review of facility's policy and procedure (P&P) titled, Psychotropic/Antipsychotic Medications and Gradual Drug Dose Reduction, dated 4/2024 and last reviewed on 1/14/2025, the P&P indicated, Residents who use antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Periodically, the staff and practitioner will review the continued relevance of each residents' medications. The attending Physician and staff will identify target symptoms for which a resident is receiving various medications. The staff will monitor for improvement in those target symptoms and provide the Physician with that information. During a record review of facility's policy and procedure (P&P) titled, Behavioral Health Services, dated 2/2019 and last reviewed on 1/14/2025, the P&P indicated, Behavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care.

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: 1. Failed to act upon the recommendations of the consultant pharmacist for one of five sampled residents (Resident 20) reviewed for Unnecessary Medications, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medications, and Medication Regimen Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) care area by failing to follow-up with Resident 20's physician regarding the consultant pharmacist's MRR recommendation for a thyroid stimulating hormone (TSH- a blood test that measures this hormone) blood draw due to the resident's use of amiodarone (medication used to treat life-threatening heart rhythm problems). This deficient practice had the potential to place Resident 20 at risk for ineffective treatment or adverse effects. 2. Failed to identify and report irregularities in the drug regimen with the attending physician for one of one sampled resident (Resident 2) reviewed for Anticoagulant (commonly called blood thinner, that increase the time it takes for blood to clot) use. This deficient practice had the potential to cause Resident 2 to receive suboptimal (less than the highest standard or quality) care due to unintended complications related to the side effects (unwanted, unpleasant results of a medication) of anticoagulant use such as bleeding or bruising if not administered correctly which may lead to hospitalization or even death. Findings: 1. During a review of Resident 20's admission Record, the admission Record indicated the facility originally admitted the resident on 8/22/2023 and readmitted the resident on 1/22/2025 with diagnoses including cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and generalized muscle weakness. During a review of Resident 20's Internal Medicine Initial Evaluation, dated 1/24/2025, the Internal Medicine Initial Evaluation indicated the resident has the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS-a resident assessment tool), dated 1/26/2025, the MDS indicated the resident had adequate hearing and clear speech, had the ability to make self understood and understand others. The MDS indicated the resident was dependent on staff for shower/bathe self and required substantial/maximal assistance with upper and lower body dressing and putting on/taking off footwear. The MDS indicated the resident was dependent on staff with mobility including sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. During a review of Resident 20's physician's order, dated 5/27/2024, the physician's order indicated amiodarone hydrochloride oral (by mouth) tablet, give 200 milligrams (mg-a unit of measurement) one time a day related to unspecified atrial fibrillation (a. fib.- irregular and often very rapid heart rhythm). Hold (do not administer) if apical (heartbeat felt at the bottom of the heart) pulse less than 60. During a review of Resident 20's MRR dated 12/4/2024, the MRR indicated resident takes amiodarone and to consider doing (checking) TSH. During a concurrent interview and record review on 2/16/2025 at 3:13 p.m. with the MDS Coordinator (MDSC), Resident 20's physician orders and laboratory results from 12/2024 to 2/16/2025 were reviewed. The MDSC stated there was no TSH blood draw ordered from 12/1/2024 to 2/16/2025. The MDSC stated there was also no baseline TSH blood draw done at the time of the resident's original admission. During a concurrent interview and record review on 2/16/2025 at 3:21 p.m., with the MDSC, Resident 20's nursing progress notes from 12/3/2024 to 1/10/2025 were reviewed. The MDSC stated there were no notes that Resident's MRR was relayed to the resident's physician for TSH blood draw. The MDSC stated the MRR should have been relayed to the resident's physician and should been documented if the physician would have the TSH blood draw done or not. During an interview on 2/17/2025 at 6 p.m., with the Director of Nursing (DON), the DON stated when the consultant pharmacist reviews a resident's medication regimen, the pharmacist provides a report to the physician. The DON further stated the licensed nurses (LN) inform the resident's physician via fax or phone call. The DON stated the LNs then receive a telephone order, whether the physician agrees or disagrees with the pharmacist's recommendation. The DON stated the consultant pharmacist would conduct another MRR the next month to review the residents' medications against the active medications. The DON stated the pharmacist is part of the health team and has a perspective of the effects of medications to the residents. The DON stated Resident 20's MRR for TSH blood draw would allow for monitoring the therapeutic levels of amiodarone to determine amiodarone's potency (strength or effectiveness) to the resident. During a review of the facility-provided undated drug guide titled, Amiodarone Generic, the drug guide indicated monitoring parameters include Thyroid Function Tests (TFTs- used for diagnosis and to monitor treatment of common thyroid gland disorders which includes TSH and thyroid hormones T3 and T4 blood tests) at baseline, then periodically. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews (MRR) last reviewed on 1/14/2025, the P&P indicated the goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication . Within 24 hours of the MRR, the consultant pharmacist provides a written report to the attending physicians for each resident identified as having non-life-threatening medication irregularity. The report contains: a. the resident's name; b. the name of the medication; c. the identified irregularity; and d. the pharmacist's recommendation. An 'irregularity' refers to the use of medications that is inconsistent with accepted pharmaceutical services standards of practice; is not support by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. 2. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 2/8/2021 and readmitted the resident on 12/27/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (having the ability to think, learn, and remember clearly) and required total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident received anticoagulant. During a review of Resident 2's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/27/2024 for heparin sodium (porcine) injection solution 5000 units per milliliter (units/ml - a unit of measurement), dispense as written ([NAME])** 5000 units hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) two (2) times a day for blood clot prevention. During a review of Resident 2's heparin label attached to the heparin box, the label indicated Resident 2's name, heparin 5000 unit per ml subcutaneously (the insertion of medications beneath the skin) every 12 hours for deep vein thrombosis prophylaxis (measures taken to prevent the formation of blood clots in the deep veins, typically in the legs). During a concurrent interview and record review on 2/16/2025 at 2:45 p.m., reviewed Resident 2's physician's order, MAR from 12/2024 to 2/2025, interim Medication Regimen Review (iMRR - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication done upon admission by the dispensing pharmacy) form, and a photograph of the heparin label with Registered Nurse 1. RN 1 stated the physician's order and MAR did not match the heparin label. RN 1 stated the MAR indicated Resident 2 received the heparin 2 times a day. RN 1 stated the medication should have been held and clarified with the physician prior to administration. RN 1 stated the Charge Nurse (CN) should have checked with the pharmacy that the label did not match the physician's order. RN 1 stated the pharmacy will call the facility if there was a discrepancy with the order and will not dispense the medication if not clarified. During a concurrent interview and record review on 2/16/2025 at 4:28 p.m., reviewed Resident 2's physician's order, MAR, iMRR, and the photograph of the heparin label with Registered Nurse 2 (RN 2). RN 2 stated Resident 2 was not on hemodialysis and the physician's order and MAR did not match the heparin label. RN 2 stated it was an order entry error when she (RN 2) chose the wrong order in the electronic health record (EHR). RN 2 stated she did not know what [NAME] meant and that the heparin order did not indicate the route of administration. RN 2 stated the iMRR indicated there were no recommendations and she did not receive a call from the pharmacy to clarify the heparin order. RN 2 stated the five (5) rights of medication administration includes the right route. RN 2 stated the medication should have been held and the physician should have been called to clarify the order. During an interview on 2/17/2025 at 2:42 p.m. with Pharmacy Consultant 1 (Pharm 1), discussed Resident 2's physician's order with Pharm 1. Pharm 1 stated Resident 2's heparin order should have been clarified with the physician prior to administration of the medication. Pharm 1 stated MRRs are completed within the first week of each month and provide the report to the Director of Nursing (DON). Pharm 1 stated iMRR for new admissions are completed by the pharmacy dispensing the medications for the residents. Pharm 1 stated he completes the MRRs for all residents in the facility whether they are new admits or not. Pharm 1 stated during the 1/2025 MRR, he did not have any recommendation for Resident 2 including the route of administration for the heparin. Pharm 1 stated he missed that the order was missing the route of administration. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, last reviewed on 1/14/2025, the P&P indicated: - The consultant pharmacist reviews the medication regimen of each resident at least monthly. - Medication regimen reviews are done upon admission and at least monthly thereafter, or more frequently if indicated. - The goal of MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. - The MRR involves a thorough review of the resident's medical record to prevent, identify, and report and resolve medication related problems, medication errors, and other irregularities such as incorrect medications, administration time or dosage forms. - An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure informed consent was obtained for one of five sampled residents (Resident 32) when Resident 32's bupropion (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities once enjoyed]) dosage was increased. This deficient practice had the potential to place the residents at risk for receiving unnecessary medication. Findings: During a record review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 on 5/17/2021, with diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), generalized muscle weakness and depression. During a record review of Resident 32's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a record review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 32's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 32 was on antidepressant (medications used to treat symptoms of depression). During a record review of Resident 32's Physician Order, dated 12/19/2024, the Physician Order indicated the following order: 1. bupropion hydrochloride extended release, give 150 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) by mouth one time a day for depression manifested by lack of motivation with activities of daily living. 2. discontinue bupropion hydrochloride extended release, 100 mg by mouth one time a day for depression manifested by lack of motivation with activities of daily living. During a record review of Resident 32's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/2024, the MAR indicated from 12/1/2024 to 12/18/2024, Resident 32 received bupropion 100 mg tablet daily and on 12/19/2024, bupropion 150mg daily was started for Resident 32. During a record review of Resident 32's Psychoactive Summary Sheet, dated 11/2024, for bupropion, the Psychoactive Summary Sheet indicated Resident 32 had eight behavioral episodes from 7:00 a.m. to 3:00 p.m. During a concurrent interview and record review, on 2/16/2025, at 2:34 p.m. with the Assistant Director of Nursing (ADON), Resident 32's Gradual Dose Reduction and Informed Consent for bupropion was reviewed. The ADON stated on 10/16/2024, Resident 32's bupropion was decreased from 150 mg to 100 mg. The ADON stated on 12/19/2024, Resident 32's bupropion was increased from 100 mg to 150 mg. The ADON stated the facility obtains new informed consent if psychotropic medications are increased. The ADON stated there was no informed consent obtained from Resident 32 for the increase of bupropion on 12/19/2024. The ADON stated the importance of obtaining new informed consent was for resident's rights and without the consent, bupropion 150 mg should have not been administered to Resident 32. During an interview, on 2/17/2025, at 1:49 p.m., with the Director of Staff Development (DSD), the DSD stated informed consent should have been obtained with any newly ordered psychotropic medication and with dose increase. During an interview, on 2/17/2025, at 5:13 p.m., with the Director of Nursing (DON), the DON stated a new informed consent should have been obtained with any increase of psychotropic medications. The DON stated it is residents' rights and without the signed informed consent, bupropion should have not been administered after the physician increase the dose. The DON stated Resident 32 received bupropion even without the signed informed consent. During a record review of facility's policy and procedure (P&P) titled, Verification of Informed Consent for Psychotherapeutic Medications, dated 6/2024 and last reviewed on 1/14/2025, the P&P indicated, The facility will obtain a written informed consent for treatment using psychotherapeutic drugs and consent renewal every six months. Signed written consent will be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures.

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 that its medication error rate was less than five percent (% - unit of measurement) when two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting two of four residents observed for medication administration (Residents 58 and 2) by: 1. Failing to ensure Licensed Vocational Nurse (LVN) 3 administered Resident 58's potassium chloride (medication used in the management and treatment of hypokalemia [low potassium level in the blood]) with a full glass of water as per physician's order. 2. Failing to ensure LVN 6 clarified Resident 2's heparin (an anticoagulant medication used to prevent and treat blood clots) order before medication administration. These deficient practices had the potential to result in residents experiencing medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and medication error. Findings: a. During a record review of Resident 58's admission Record, the admission Record indicated the facility admitted Resident 58 on 2/25/2022, with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hypokalemia and essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause). During a record review of Resident 58's Minimum Data Set (MDS - a resident assessment tool), dated 12/3/2024, the MDS indicated Resident 58's cognitive skills for daily decisions was intact. During a record review of Resident 58's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/3/2025, the H&P indicated Resident 58 did not have the capacity to understand and make decisions. During a record review of Resident 58's Order Summary Report, dated 2/26/2024, the Order Summary Report indicated potassium chloride extended release 20 milliequivalent (meq - unit of measurement), give one tablet by mouth one time a day for supplement. Take with food and full glass of water or juice of four ounces. During a medication administration observation, on 2/15/2025, at 8:57 a.m., with LVN 3, at Resident 58's bedside LVN 3 administered a potassium tablet to Resident 58 with two ounces of water. During a concurrent observation and interview, on 2/15/2025, at 9:06 a.m., with LVN 3, LVN 3 measured two ounces of water and stated the physician order for potassium administration was to give with full glass of water. LVN 3 stated two ounces is not full glass of water. LVN 3 stated she should have followed the physician's order. During an interview, on 2/17/2025, at 1:49 p.m., with the Director of Staff Development (DSD), the DSD stated LVN 3 should follow the physicians order for potassium administration with full glass of water. During an interview, on 2/17/2025, at 5:13 p.m., with the Director of Nursing (DON), the DON stated a full glass of water is four to eight ounces of water. The DON stated taking potassium with a full glass of water helps lessen upsetting the stomach. The DON stated two ounces is not a full glass. The DON stated it is the facility's policy to follow physician's order. During a record review of facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber's order, including any required time frame. b. During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/8/2021, with diagnoses that included unspecified (unconfirmed) encephalopathy (a change in your brain function due to injury or disease), complete atrioventricular block (a problem with your heartbeat signal moving from the upper to lower part of your heart causing irregular heartbeat) and unspecified dementia (a progressive state of decline in mental abilities). During a record review of Resident 2's H&P, dated 12/30/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 was on anticoagulant (medication used to prevent blood clot). During a record review of Resident 2's Physician Order, dated 12/27/2024, the Physician Order indicated heparin sodium injection (the act of putting a liquid, especially a drug, into a person's body using a needle and a syringe) solution 5,000 unit per milliliter (ml - unit of measurement), dispense as written ([NAME] - means that a doctor is instructing a pharmacist to provide the exact medication prescribed, without substituting a generic version, even if a cheaper alternative is available) 5000-unit hemodialysis (a medical procedure that filters waste products and excess fluid from the blood when the kidneys are no longer functioning properly) two times a day for blood clot prevention. During a record review of Resident 2's heparin label attached to the heparin box, the label indicated Resident 2's name, heparin 5000 unit per ml subcutaneously (the insertion of medications beneath the skin) every 12 hours for deep vein thrombosis prophylaxis (measures taken to prevent the formation of blood clots in the deep veins, typically in the legs). During a concurrent observation and interview, on 2/16/2025, at 5:12 p.m., with LVN 6, outside of Resident 2's room LVN 6 read and compared the physician order for heparin, dated 12/27/2024, to the label attached to the heparin box. LVN 6 administered heparin to Resident 2's right lower quadrant of the abdomen. LVN 6 stated the physician order did not match the heparin label. LVN 6 stated the physician's order should match the medication label. LVN 6 stated she should have notified Registered Nurse (RN) 2 before heparin administration. During a concurrent interview and record review, on 2/17/2025, at 8:09 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Physician Order, dated 12/27/2024, was reviewed. The ADON stated [NAME] in Resident 2's Physician Order for heparin means dispense as written. The DON stated the Physician Order did not indicate a route of administration. The ADON stated Resident 2 was not on hemodialysis. The ADON stated LVNs who administered the medication should have clarified the order first with the physician. The ADON stated LVNs should follow the physician order than the medication label. The ADON stated LVN 6 made a significant medication error. The ADON stated the five rights of medication administration includes the right route. The ADON stated the route was not followed as it was not indicated in the physician order. During an interview, on 2/17/2025, at 1:49 p.m., with the DSD, the DSD stated LVN 6 should clarify the heparin order before medication administration. During an interview, on 2/17/2025, at 5:13 p.m., with the DON, the DON stated nurses should follow the procedure of medication administration that includes the right resident, right medication, right order and reconcile on what's on the medication label. The DON stated LVN 6 should have called the physician and clarify the route. The DON stated Resident 2 can have an adverse effect from the medication. During a record review of facility's P&P titled, Administering Medications, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, Medications are administered in a safe, timely manner and as prescribed. Medications are administered in accordance with prescribers' orders, including any required time frame. If a dosage if believed to be inappropriate or excessive for a resident, or a medication had been identified as having potential adverse consequences for the residents or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of one of three sampled residents (Resident 38) reviewed under the kitchen care area. This deficient practice had the potential to result in decreased food and nutrient intake which may result in unintended (not planned) weight loss. Findings: During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted on [DATE] with diagnoses including muscle weakness (generalized), adult failure to thrive (decline in health that can occur in older people), and essential (primary) hypertension (HTN- high blood pressure). During a review of Resident 38 Care Plan dated 10/5/2024, the Care Plan indicated the resident is at nutritional risk secondary to failure to thrive. Interventions included diet as ordered, provide and honor food preferences. During a review of Resident 38's Order Summary dated 10/10/2024, the Order Summary indicated a physician's order for no added salt diet, regular texture, and regular liquid consistency. During a review of Resident 38's Minimum Data Set (MDS - a resident assessment tool) dated 1/7/2025, the MDS indicated the resident had the ability to understand and be understood. During a review of the facility's menu titled, Good for your Health Menus, for 2/10/2025 to 2/16/2025, the menu indicated the dinner menu for 2/15/2025 was: - Baked ziti - Green beans with onions and red peppers - Garlic bread - Butterscotch pears During a concurrent observation of the tray line and interview with the Dietary Supervisor (DS) on 2/15/2025 at 4:37 p.m., the DS stated they substituted spinach for the green beans because there was an issue with the delivery of the green beans. During a concurrent observation and interview on 2/15/2025 at 6:51 p.m. with Resident 38, observed Resident 38 sitting up on bed with the food tray in front of her. Resident 38 stated corn was served instead of green beans that was on the menu. Resident 38 stated she does not like corn and refuses to eat the corn. During an interview on 2/16/2025 at 2:18 p.m. with the DS, the DS stated she is the one in charge of ordering food. The DS stated the dinner menu on 2/15/2025 needed to be green beans but a wrong item (spinach) was sent. The DS stated when the menu is changed, they need to make a substitute for a vegetable to vegetable and to be approved by the Registered Dietitian (RD). The DS stated they ran out of spinach and so they substituted it with corn. The DS stated she was not aware that Resident 38 did not want to eat the corn. The DS stated residents may get upset and frustrated because they did not get green beans. The DS stated residents should have offered food substitute as they might be disappointed with the menu pairing. During an interview on 2/16/2025 at 2:26 p.m. with the RD, the RD stated she was aware corn was substituted for spinach. The RD stated she approved the substitution. The RD stated since Resident 38 did not eat the corn, the resident's intake can be affected. During a review of the facility's policies and procedures (P&P) titled Menus, dated 1/14/2025, the P&P indicated menus shall meet the nutritional needs of resident, be prepared in advance and be followed. Deviation from menus that have already been posted will be noted in the kitchen and/or in the record book used solely for recording such changes. During a review of the facility's policies and procedures (P&P) titled Substitutions, dated 1/22/2025, the P&P indicated, residents' likes and dislikes will be considered when making substitutions.

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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Based on interview and record review the facility failed to maintain accurate and complete medical records for one of four sampled residents (Resident 20). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation. Findings: During a record review of Resident 20's admission Record, the admission Record indicated the facility admitted Resident 20 on 8/22/2023, with diagnoses that included metabolic encephalopathy (change in how your brain works due to an underlying condition), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) and unspecified (unconfirmed) cardiomyopathy (a group of heart muscle diseases that weaken the heart's ability to pump blood effectively throughout the body). During a record review of Resident 20's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 1/24/2025, the H&P indicated Resident 20 had the capacity to understand and make decisions. During a record review of Resident 20's Minimum Data Set (MDS - a resident assessment too), dated 11/20/2024, the MDS indicated Resident 20's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a record review of Resident 20's Physician Order, dated 1/22/2025, the Physician Order indicated Sacubitril-Valsartan ( a combination of two medication used to treat chronic heart failure [a condition where the heart muscle is weakened and cannot pump blood effectively]) oral tablet 24-26 milligram (mg - metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth two times a day for dilated cardiomyopathy (a type of heart muscle disease that causes the heart chambers to thin and stretch, growing larger). Hold for systolic blood pressure (sbp - pressure in the arteries when the heart beats) less than 110. During a record review of Resident 20's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 1/2025, the MAR indicated, on 1/3/2025, at 5:00 p.m., Licensed Vocational Nurse (LVN) 2 administered Sacubitril-Valsartan with a documented blood pressure of 18/62. During a concurrent interview and record review, on 2/15/2025, at 2:43 p.m., with LVN 2, Resident 20's MAR, dated 1/2025, was reviewed. LVN 2 stated he meant to document 118/62 and not 18/62. LVN 2 stated it was inaccurate documentation. During an interview, on 2/17/2025, at 1:49 p.m., with the Director of Staff development (DSD), the DSD stated LVN 2 should have rechecked the blood pressure if it was low and document correctly. During an interview, on 2/17/2025, at 5:13 p.m., with the Director of Nursing (DON), the DON stated LVN 2 should have corrected his documentation. The DON stated the importance of accurate documentation was to make sure treatment and medication is given according to what the physician order. The DON stated if documented blood pressure was 18/62, medication should have been held. During a record review of facility's policy and procedure titled, Charting and Documentation, dated 7/2017 and last reviewed on 1/14/2025, the P&P indicated, Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

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 necessary care was provided consistently for one of one sampled resident (Resident 39) reviewed for hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to ensure there was documented evidence that the resident and/or resident representative was involved during the initial interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meeting for admission to discuss the hospice plan of care. This deficient practice had the potential to negatively affect Resident 39's physical comfort and psychosocial well-being resulting in the delay or lack of necessary hospice care and services. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and readmitted the resident on 4/27/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 39's History and Physical (H&P) dated 4/28/2024, the H&P indicated Resident 39 did not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 1/30/2025, the MDS indicated Resident 39 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with eating and bed mobility; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 39 received hospice services. During a review of Resident 39's Order Summary Report, the Order Summary Report indicated a physician's order dated 1/21/2025 to admit Resident 39 to Hospice Provider 1 (HP 1) under routine level of care with a diagnosis of Parkinson's disease. During a review of Resident 39's Current Treatment/Medication/Durable Medical Equipment (DME) list form provided by HP 1 to the facility dated 1/23/2025, the Current/Medication/DME list form indicated IDT to review patient's status every 14 days and as needed to evaluate changes in condition. During a review of Resident 39's IDT Progress Note form dated 1/20/2025, the IDT Progress Note indicated the participants were the Social Services Director (SSD), Director of Rehabilitation (DOR) Department, and the Case Manager (CM). During a concurrent interview and record review on 2/17 2025 at 8:27 a.m., reviewed Resident 39's IDT Progress Note dated 1/20/2025 with the SSD. The SSD stated the IDT Progress Note indicated only facility staff was present during the IDT addressing hospice care and services to be provided to the resident. The SSD stated IDT meetings are conducted with the resident and/or resident representative on admission, quarterly, and with as needed with any changes in condition either in person or thru the telephone. The SSD stated Resident 39's IDT Progress Note did not indicate Resident 39 and/or resident representative were present in any portion of the IDT meeting. The SSD stated the progress note should have indicated Resident 39 and/or the family was present during the IDT meeting to ensure Resident 39 and/or the family are aware of and involved in the development of Resident 39's plan of care and prevent potential delay in providing the hospice services. During a concurrent interview and record review on 2/17/2025 at 11:23 a.m., reviewed Resident 39's IDT Progress Note dated 1/20/2025 with the Assistant Director of Nursing (ADON). The ADON stated the IDT Progress Note did not indicate that Resident 39 and/or his representative were present in any portion of the IDT meeting. The ADON stated Resident 39 and/or his representative should have been present thru the phone or in person to ensure that they were aware of and involved in the plan of care and the hospice services Resident 39 will receive. The ADON stated if Resident 39 and/or the representative was not involved in the development of the plan of care there could be potential delay in providing the necessary hospice care and services Resident 39 needed. During a review of the facility's policy and procedure (P&P) titled, Hospice Program, last reviewed on 1/14/2025, the P&P indicated: - Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the car and services provided by the facility to maintain the resident's highest practicable physical, mental, and psychosocial well-being. - The coordinated care plan will reflect the resident's goals, and wishes, and during ongoing communication with the resident or representative, including goals and objectives, interventions, and medical treatment and diagnostic tests. During a review of the facility's P&P titled Care Planning - Interdisciplinary Team, last reviewed on 1/14/2025, the P&P indicated: - The facility's care planning/IDT is responsible for the development of an individualized comprehensive care plan for each resident. - The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. - The mechanics of how the IDT meets its responsibilities in the development of the interdisciplinary care plan, such as face-to-face, teleconference, written communication, etc., is at the discretion of the care planning committee.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 20) was monitored for the use of vancomycin (medication used to treat infection). This deficient practice had the potential to result in Resident 20's unidentified side effects (an unwanted or unexpected result of a drug) of vancomycin use. Findings: During a record review of Resident 20's admission Record, the admission Record indicated the facility admitted Resident 20 on 8/22/2023, with diagnoses that included metabolic encephalopathy (change in how your brain works due to an underlying condition), pneumonia (lung infection) and unspecified (unconfirmed) cardiomyopathy (a group of heart muscle diseases that weaken the heart's ability to pump blood effectively throughout the body). During a record review of Resident 20's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings) dated 1/24/2025, the H&P indicated Resident 20 had the capacity to understand and make decisions. During a record review of Resident 20's Minimum Data Set (MDS- a resident assessment tool) dated 11/20/2024, the MDS indicated Resident 20's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. During a record review of Resident 20's Physician Order dated 1/22/2025, the Physician Order indicated vancomycin hydrochloride intravenous (a medical procedure that involves inserting a needle or tube into a vein to deliver fluids, medications, or nutrient) solution, use 1000 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) intravenously every 12 hours for pneumonia until 1/25/2025. During a record review of Resident 20's Intravenous Record (IV Record-a daily documentation record used by a licensed nurse to document medications given to a resident intravenously while on antibiotic [medications used to treat bacterial infections]) dated 1/2025, the IV Record indicated from 1/23/2025 to 1/25/2025, vancomycin was administered to Resident 20 twice a day at 9 a.m. and 9 p.m. During a record review of Resident 20's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/2025, the MAR indicated no documented monitoring for the use and side effect of vancomycin. During a record review of Resident 20's Progress Notes dated 1/23/2025 to 1/25/2025, the Progress Notes indicated no documented monitoring for the use and side effect of vancomycin on 1/23/2025 from 3 p.m. to 11 p.m. and 1/24/2025 from 7 a.m. to 3 p.m. During a record review of Resident 20's Daily Skilled Medicare Charting dated 1/23/2025, timed at 9:54 p.m., the Daily Skilled Medicare Charting indicated no vancomycin adverse side effect monitoring. During a concurrent interview and record review on 2/15/2025, at 11:30 a.m., with the Infection Preventionist (IP), Resident 20's Physician order dated 1/22/2025, Intravenous Record dated 1/2025, MAR dated 1/2025, and Progress Notes dated 1/23/2025 to 1/25/2025 were reviewed. The IP stated antibiotic monitoring for the use and side effect should be documented every shift in the Progress Notes. The IP stated there was no documented vancomycin monitoring on 1/24/2025 from 7 a.m. to 3 p.m. The IP stated the importance of monitoring for use of antibiotic was to monitor resident so the physician could be notified if resident had worsening condition. During an interview on 2/17/2025 at 1:49 p.m., with the DSD, the DSD stated residents on antibiotic are monitored for side effects and effectiveness of the medication. The DSD stated resident are monitored every shift for the first 72 hours. The DSD stated the monitoring should be documented in the Progress Notes. During an interview on 2/17/2025 at 5:13 p.m. with the DON, the DON stated monitoring for antibiotic is every shift and should be documented in the IV Record and in Daily Skilled Medicare Charting. The DON stated IP should also check the therapeutic effect (response after a treatment of any kind). The DON stated the importance of antibiotic monitoring was to check if resident was having any side effect like gastrointestinal symptoms and to inform the physician so medication can be stop or changed as needed. During a record review of facility's P&P titled, Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes dated 12/2016 and last reviewed on 1/14/2025, the P&P indicated, All resident antibiotic regimen will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: . k. outcome and l. adverse (unwanted undesirable effects that are possibly related to a drug) events. During a record review of facility's P&P titled, Surveillance for Infections dated 9/2023 and last reviewed on 1/14/2025, the P&P indicated, Documentation tools for the surveillance program . b. infection control worksheet (surveillance date sheet), nurse notes, or other related documentation.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one (1) of three (3) sampled residents (Resident 32) reviewed under the Environmental Task when Resident 32's bed controller (device used to change the height and angle of the bed) cable was observed with chipped part at the base with the crews exposed. This deficient practice had the potential to place Resident 32 at risk for injury. Findings: During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2025 with diagnoses including muscle wasting and atrophy (loss of muscle mass and strength), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 32's History and Physical (H&P) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 32 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a concurrent observation and interview on 2/15/2025 at 9:18 a.m. inside Resident 32's room with Treatment Nurse 1 (TN 1), TN 1 stated the base of Resident 32's bed control box was chipped with the screws exposed on both sides. TN 1 stated the maintenance department was responsible in rounding and changing any resident device or equipment that is in disrepair. TN 1 stated he was not sure when the maintenance department makes rounds and checks the rooms. TN 1 stated the staff was responsible to notify the maintenance for any equipment or device that is in disrepair. TN 1 stated the maintenance department will be notified to change Resident 32's bed control. TN 1 stated Resident 32's bed control should have been changed for the resident's safety as Resident 32 can get injured from the chipped base of the bed control box and the exposed screws. During an interview on 2/17/2025 at 4:55 p.m. with the Assistant Director of Nursing (ADON), the ADON stated if staff observed any equipment, devices, or furnishing in the room that is in disrepair such as broken, the maintenance department should be notified immediately to change the device, equipment, or furnishings. The ADON stated residents are provided with a safe, clean, functioning equipment, furnishings while residing in the facility as the facility is already their home. During an interview on 2/17/2025 at 5 p.m. with the Maintenance Supervisor (MS), the MS stated the maintenance department makes regular rounds of rooms and checks if all the call lights and bed controls are working and in good condition. The MS stated the maintenance department repairs and replaces them (call lights and bed controls) as needed if not working and/or broken. The MS stated the staff were supposed to notify him if a bed control is broken or the call light is not working so they can replace the equipment as soon as possible. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, last reviewed 1/14/2025, the P&P indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The P&P further indicated the functions of maintenance personnel include maintaining the building in good repair and free from hazard. During a review of the facility's P&P titled, Homelike Environment, last reviewed 1/14/2025, the P&P indicated: - Residents are provided with a safe, clean, comfortable and homelike environment. - The facility staff and management maximizes, to the extent possible the characteristics of the facility that reflect a personalized, homelike setting such as a clean, safe, sanitary and orderly/clutter free environment.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in accordance with professional standards: 1. For one of one sampled resident (Resident 32) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) the insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). 2. For one of one sampled resident (Resident 2) reviewed for anticoagulant (commonly called blood thinner, that increase the time it takes for blood to clot) by failing to ensure there was monitoring in place for signs and symptoms of bleeding for the use of heparin (an anticoagulant). This deficient practice had the potential to cause Resident 2 unintended complications related to the side effects (unwanted, unpleasant results of a medication) of anticoagulant use such as bleeding or bruising if not monitored routinely which may lead to hospitalization or even death. Cross Reference F760 (Resident 32) and F755 (Resident 2) Findings: a. During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2025 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 32's History and Physical (H&P) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), dated 12/15/2025, the MDS indicated Resident 32 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 32 received insulin. During a review of Resident 32's Order Summary Report, the Order Summary Report indicated the following physician's orders dated: - 2/12/2024: Lantus solution (a long-acting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication])100 unit per milliliter (unit/ml - a unit of measurement) inject 34 units subcutaneously (beneath the skin) at bedtime related to DM 2. Hold (do not administer) if blood sugar (BS) is less than (<) 100. - 1/7/2025: Lantus solution 100 unit/ml (insulin glargine) inject 26 units subcutaneously at bedtime related to DM 2. Hold if BS <100. - 12/8/2024: Lantus solution 100 unit/ml (insulin glargine) inject 26 units subcutaneously at bedtime related to DM 2. - 10/14/2024 to 1/24/2025: Novolog solution (a short acting insulin)100 unit/ml (insulin aspart) inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): <60, hypoglycemic (low blood sugar) protocol and inform physician (MD); if 60 - 149 = 0 unit;150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; 400 plus = 12 unit; more than (>) 400, 12 units and inform MD subcutaneously before meals and at bedtime for DM 2. - 1/24/2025: Novolog solution 100 unit/ml (insulin aspart) inject as per sliding scale: <60, hypoglycemic protocol and inform physician (MD); if 60 - 149 = 0 unit;150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; 400 plus = 12 unit; > 400, 12 units and inform MD subcutaneously with meals for DM 2. During a concurrent interview and record review on 2/16/2025 at 2:22 p.m., reviewed Resident 32's physician's orders, Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident) Location of Administration Report for 1/2025 and 2/2025 with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated Resident 32 had a physician's order for Novolog and Lantus and were administered as follows: - Lantus solution 100 unit/ml: 1/13/25 10:45 p.m. subcutaneously Abdomen - left upper quadrant (LUQ) 1/14/25 9:14 p.m. subcutaneously Abdomen - LUQ 2/12/25 9:40 p.m. subcutaneously Abdomen - right upper quadrant (RUQ) 2/13/25 9:11 p.m. subcutaneously Abdomen - RUQ - Novolog solution 100 unit/ml: 1/02/25 9:00 p.m. subcutaneously Abdomen - left lower quadrant (LLQ) 1/03/25 5:45 a.m. subcutaneously Abdomen - LLQ 1/15/25 8:55 p.m. subcutaneously Abdomen - LUQ 1/16/25 6:27 a.m. subcutaneously Abdomen - LUQ 1/16/25 11:53 a.m. subcutaneously Abdomen - RUQ 2/03/25 8:55 p.m. subcutaneously Abdomen - RUQ 2/04/25 9:01 p.m. subcutaneously Abdomen - RUQ 2/11/25 9:02 p.m. subcutaneously Abdomen - LUQ 2/12/25 9:40 p.m. subcutaneously Abdomen - LUQ 2/13/25 9:13 p.m. subcutaneously Abdomen - LUQ 2/14/25 8:29 p.m. subcutaneously Abdomen - LUQ 2/07/25 4:21 p.m. subcutaneously Abdomen - right lower quadrant (RLQ) 2/08/25 8:42 a.m. subcutaneously Abdomen - RLQ 2/08/25 1:15 p.m. subcutaneously Abdomen - RLQ 2/15/25 7:47 a.m. subcutaneously Abdomen - LUQ 2/15/25 12:10 p.m. subcutaneously Abdomen - LUQ 2/16/25 7:39 a.m. subcutaneously Abdomen - LUQ 2/16/25 11:26 a.m. subcutaneously Abdomen - LUQ LVN 1 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 1 stated the last three (3) administration sites for insulin was shown every time the staff opens the MAR. LVN 1 stated Resident 32's MAR indicated the insulin administration sites were not rotated. LVN 1 stated Resident 32's insulin administration sites should have been rotated per standards of practice to prevent pain, redness, irritation, bruising, and pits on the resident's skin. During a concurrent interview and record review on 2/17/2025 at 4:30 p.m., reviewed Resident 32's physician's orders, MAR Location of Administration Report for 1/2025 and 2/2025 with the Assistant Director of Nursing (ADON). The ADON stated the locations of administration sites for Resident 32's insulin were not rotated. The ADON stated the charge nurses (CN) are supposed to rotate insulin administration sites according to standards of practice and as indicated in the manufacturer's guideline and the CN can see the last 3 administration sites of insulin in the MAR. The ADON stated Resident 32's administration sites for insulin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. During a review of the facility-provided manufacturer's guideline on Lantus insulin glargine injection 100 unit/ml, undated, the manufacturer's guideline indicated: - Change (rotate) the injection sites within the area chosen with each dose to reduce the risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis skin with lumps) at the injection sites. - Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, or damaged. During a review of the facility-provided manufacturer's guideline on Insulin aspart (vials) (Novolog), undated, the manufacturer's guideline indicated: - Move site where you give the shot each time. - It is given as a shot into the fatty part of the skin in the upper arm, buttocks, or stomach area. - A side effect include thick skin pits, or lumps where the injection was given. - Do not give into skin that is thickened, or has pits, or has lumps. - Do not into skin that is irritated, tender, bruised, red, scaly, hard, scarred. During a review of the facility policy and procedure (P&P) titled, Insulin administration, last reviewed on 1/14/2025, the P&P indicated: - Select an injection site: a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately two (2) inches above the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). b. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 2/8/2021 and readmitted the resident on 12/27/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (having the ability to think, learn, and remember clearly) and required total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident received anticoagulant. During a re view of Resident 2's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/27/2024 for heparin sodium (porcine) injection solution 5000 units per milliliter (units/ml - a unit of measurement) **dispense as written ([NAME])** 5000 units hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) two (2) times a day for blood clot prevention. During a review of Resident 2's care plan (CP) on anticoagulant therapy (heparin) initiated on 1/21/2025, the CP indicated the following interventions to prevent adverse reactions related to anticoagulant use: - Daily skin inspection. Report abnormalities to the nurse. - Monitor/document/report as needed adverse reaction of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, bruising, significant or sudden changes in vital signs. During a concurrent interview and record review on 2/16/2025 at 2:45 p.m., reviewed Resident 2's physician's orders and MAR with Registered Nurse 1 (RN 1). RN 1 stated Resident 2 did not have a physician's order to monitor for bleeding every shift for the use of anticoagulant heparin. RN 1 stated residents should have a physician's order to monitor residents for signs and symptoms of bleeding due to use of anticoagulant. RN 1 stated there should have been a physician's order to monitor Resident 2 for signs and symptoms of bleeding as it placed Resident 32 at risk for untoward cardiac (pertaining to the heart) events and hospitalization. During a concurrent interview and record review on 2/17/2025 at 4:19 p.m., reviewed Resident 2's physician's order and MAR with the Assistant Director of Nursing (ADON). The ADON stated Resident 2 did not have a physician's order to monitor the resident for signs of symptoms of bleeding and there was no monitoring for bleeding in the MAR. The ADON stated the licensed nurse (LN) should also obtain a physician's order for monitoring for signs and symptoms of bleeding every shift along with the order for anticoagulant per facility protocol. The ADON stated the LN should have obtained an order for monitoring for signs and symptoms of bleeding addressing Resident 2's use of heparin to prevent complications related to not monitoring the symptoms of bleeding which may lead to hospitalization. During a review of the facility's policy and procedure (P&P titled, Anticoagulant - Clinical Protocol, last reviewed 1/14/2025, the P&P indicated: - Assess for any signs and symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. - Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug) for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding. - The nurse shall assess and document or report the current anticoagulant therapy, including drug and current dosage. - Long-term subcutaneous administration of heparin in chronically bed-bound individuals is not indicated or of proven benefit for long-term deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis. - The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose. During a review of the facility's P&P titled, Standards of Clinical Practice, last reviewed 1/14/2025, the P&P indicated a policy statement that services provided to the residents are performed in accordance with current acceptable standards of clinical practice.

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** Based on observation, interview and record review, the facility failed to ensure five of six sampled residents (Resident 23, Resident 92, Resident 95, Resident 297, and Resident 32) reviewed for accident care area were free of accidents when: 1. Resident 23's pathway to the bathroom (restroom/toilet) was obstructed with his roommate's wheelchair. This deficient practice had the potential for Resident 23 to fall while waiting to get into the bathroom. 2. Resident 92's acetaminophen (pain medication) two tablets and enoxaparin (treats and prevents blood clots) were left on top of the medication cart unattended and out of the sight of Licensed Vocational Nurse 4 (LVN 4). This deficient practice had the potential for Resident 92's medications to be taken by another resident or other person. 3. The facility failed to accurately document Resident 95's Fall Risk Assessment after Resident 95 had a fall. This deficient practice had the potential for Resident 95 to have inaccurate assessment of fall that can affect nursing interventions. 4. The facility failed to ensure Resident 297's and 32's floor mat (a cushioned mat that reduces the risk of injury from a fall) did not have a furniture or equipment on top of them. This deficient practice increased the risk of injury when the residents slip, trip, and fall by hitting the hard surface of the equipment or furniture on top of the floor mat. Findings: a. During a review of Resident 23's admission Record, the admission Record indicated the facility admitted Resident 23 on 8/14/2024 and readmitted the resident on 9/16/2024 with diagnoses that included acquired absence of right below the knee, muscle wasting and atrophy (decrease in size or wasting away of a body part or tissue) multiple sites, and muscle weakness. During a review of Resident 23's Care Plan created on 8/14/2025 for risk for fall and injuries, the care plan indicated interventions that included assess and anticipate resident's needs and ensure personal items within resident reach. During a review of Resident 23's Bowel (the long, tube-shaped organ in the abdomen that completes the process of digestion) and Bladder (a hollow, stretchy organ in the lower part of your abdomen that stores urine before it leaves your body through your urethra) assessment dated [DATE], the Bowel and Bladder Assessment indicated Resident 23 was continent (the ability to control your bladder and bowel) with both bowel and bladder. During a review of Resident 23's Care Plan created 8/23/2024, the Care Plan indicated Resident 23 was at risk for incontinency due to aging process and medical conditions with limited mobility. The interventions included to ensure the resident has unobstructed path to the bathroom. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool), dated 11/18/2024, the MDS indicated Resident 23 had the ability to understand and be understood. The MDS indicated Resident 23 required partial assistance (helper does less than half the effort) with toileting, lower body dressing, and putting on and taking off footwear. During a review of Resident 23's Quarterly Risk assessment dated [DATE], the Quarterly Risk Assessment indicated Resident 23 had a fall risk score of 10 (a total score of 10 or above represents high risk for fall). During an interview on 2/15/2025 at 9:33 a.m. with Resident 23, Resident 23 stated staff place his roommate's wheelchair locked and blocking the bathroom door making him unable to use the bathroom. During a concurrent observation and interview on 2/16/2025 at 11:18 a.m. with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated a wheelchair was blocking the bathroom. LVN 4 stated because Resident 23 is independent with using the bathroom, the front door to the bathroom should be clear to allow for Resident 23 to safely use the restroom. LVN 4 stated Resident 23 may have a fall trying to get to the restroom. LVN 4 moved the wheelchair to the side of the roommate's bed to clear the entrance to the restroom. During a concurrent observation and interview on 2/17/2025 at 7:31 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 23's roommate's wheelchair left by the night shift staff was blocking the bathroom door. CNA 4 stated the area leading to the bathroom should be clear for Resident 23 to be able to use the restroom and the resident can fall trying to get into the bathroom. During an interview on 2/17/2025 at 4:48 p.m. with the Director of Nursing (DON), the DON stated staff must move all obstruction (including the wheelchair) to allow Resident 23 to safely get in and out of the bathroom. During a review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Residents, last reviewed 1/14/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled, Homelike environment, last reviewed 1/14/2025, the P&P indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belonging to the extent possible. During a review of the facility's P&P titled, Accommodation of Needs, last reviewed 1/14/2025, the P&P indicated the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and or achieving a safe independent functioning, dignity and well-being. f. moving furniture or large items in rooms and common areas that may obstruct the path of a resident. b. During a review of Resident 92's admission Record, the admission Record indicated the facility admitted Resident 92 on 1/30/2025 with diagnoses including personal history of transient ischemic attack (TIA- a temporary disruption of blood flow to the brain), essential (primary) hypertension (HTN-high blood pressure), and hyperlipidemia (high levels of fat, or lipids, in the blood). During a review of Resident 92's MDS dated [DATE], the MDS indicated Resident 92 had the ability to understand and be understood. During a review of Resident 92's Order Summary dated 1/30/2025, the Order Summary indicated the following physician's orders: - Acetaminophen tablet 325 milligram (mg- a unit of measurement) give two tablets by mouth every six hours as need for mild pain (rated 1 to 3 out of 10 [with 10 as severe pain]) not to exceed 3 grams (gm- a unit of measurement) in 24 hours. - Enoxaparin sodium injection solution 40 mg/4 milliliters (ml- a unit of measurement) inject 40 mg subcutaneously (beneath or under the skin) one time a day for deep vein thrombosis (DVT- is a blood clot that forms in a deep vein, usually in the leg, thigh, or pelvis) prevention. During a review of Resident 92's Care Plan created on 2/5/2025, the Care Plan indicated the use of enoxaparin with interventions to monitor for signs and symptoms of neurological impairment, and if neurological compromise is noted, urgent treatment is necessary. During a review of Resident 92's Care Plan created on 2/5/2025, the Care Plan indicated a risk for bleeding and/or bruising related to the use of lovenox (enoxaparin) with interventions to administer medication per doctor's order. During an observation on 2/15/2025 at 10:02 a.m., observed LVN 4 standing outside of Resident 92's room with enoxaparin and a medication cup containing two pills on top of the medication cart. Observed LVN 4 walking away from the medication cart with enoxaparin and two pills on top medication cart left unattended while LVN 4 went to Nurses Station 2. During an interview on 2/15/2025 at 10:08 a.m. with LVN 4, LVN 4 stated she left Resident 92's medication that included two acetaminophen tablets and enoxaparin on top of the medication cart unattended and out of her sight. LVN 4 stated should not be leaving medications unattended as there can be a potential for someone to take the medications. During an interview on 2/17/2025 at 4:54 p.m. with the DON, the DON stated medications should not be left on top of the medication cart and out of the sight of the nurse. The DON stated but there is always a potential for a resident to grab the medications. The DON stated the best practice is to lock medications when leaving the medication cart. During a review of the facility's P&P titled, Administering Medications, last reviewed 1/14/2025, the P&P indicated during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personal administering medications, and all outward side must be inaccessible to residents or others passing by. c. During a review of Resident 95's admission Record, the admission Record indicated the facility admitted the resident on 12/11/2024 with diagnoses that included muscle weakness (generalized), reduced mobility, lack of coordination, and acquired absence of left leg above knee. During a review of Resident 95's MDS dated [DATE], the MDS indicated Resident 95 usually understands and was usually understood. The MDS indicated Resident was dependent (helper does all the effort) with toileting, showering, lower body dressing and putting on and taking off footwear and required substantial assistance (helper does more than half the effort) with eating, oral hygiene, upper body dressing, and personal hygiene. During a review of Resident 95's admission and readmission Initial assessment dated [DATE], the admission and readmission Initial Assessment indicated a fall risk score of 10 (a total score of 10 or above represents high risk for fall). During a review of Resident 95's Care Plan created on 12/12/2024, the Care Plan indicated the resident was at risk for falls and injuries related to balance problems, gait abnormality, poor trunk control, and bowel and bladder incontinence. The Care Plan interventions included the resident needs activities that minimize the potential for falls while providing diversion and distraction. During a review of Resident 95's Situational Background Assessment and Request (SBAR- a structured way to share information between people, especially in healthcare setting) dated 12/28/2024 at 7:49 p.m., the SBAR indicated Resident 95 was noted on the floor by his bed, on his right side of the body. Resident 95 stated he was turning in his bed and then he fell. During a review of Resident 95's Care Plan created on 12/28/2024 for actual unwitnessed fall with no injury, the Care Plan interventions included to assess and anticipate resident's needs and continue the at-risk plan. During a review of Resident 95's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated a score of 8 (not a high risk for a fall). During an interview on 2/17/2025 at 12:01 p.m. with the Minimum Data Set Nurse Coordinator (MDSC), the MDSC stated Resident 95's initial fall risk score was 10 indicating Resident 95 was a high risk for a fall. The MDSC stated on 12/28/2024, Resident 95's fall risk indicated a score of 8 (lower risk for falls). The MDS stated the fall risk assessment should have indicated a higher score (or the same score but not lower) after Resident 95's falls. The MDSC stated proper interventions and precautions may not be done as a result of the inaccurate fall risk assessment. The MDSC stated Resident 95 continued to have intermittent confusion and should not have been documented as alert. The MDSC stated Resident 95's fall risk score should have been an 11. d. During a review of Resident 297's admission Record, the admission Record indicated the facility originally admitted Resident 297 on 5/7/2024 and readmitted in the facility on 2/12/2025, with diagnoses including congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), and generalized weakness. During a review of Resident 297's History and Physical, dated 2/13/2025, the H&P indicated the resident can make his needs known but unable to make medical decisions. During a review of Resident 297's Admission/readmission Initial Assessment form dated 2/12/2025, the Admission/readmission Initial Assessment form indicated Resident 297 required supervision/touching assistance with eating; partial/moderate assistance with bed mobility; substantial/maximal assistance with toileting hygiene; all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) were not tested due to safety concerns. During a review of Resident 297's fall risk assessment dated [DATE], the fall risk assessment indicated the resident was not a high risk for falls. During a concurrent observation and interview on 2/15/2025 at 8:45 a.m., inside Resident 297's room with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated Resident 297's overbed table was placed on top of the right floor mat for unknown amount of time. CNA 5 stated the overbed table wheels left an indentation on the floor mat and was unstable when she tried to move it (overbed table). CNA 5 stated the overbed table can fall on Resident 297 and cause injury to the resident. CNA 5 further stated Resident 297 can hit the table, loose balance, and cause injury upon getting out of bed. CNA 5 stated the overbed table should not have been left on top of the floor mat as it placed Resident 297 at risk for getting hurt during a fall. During an interview on 2/17/2025 at 4:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated there should be no heavy equipment or any furniture on top of the floor mat as it can affect the integrity of the floor mat which could affect the impact of a fall incident. The ADON stated placing any equipment or furniture on top of the floor mat can cause injury when the resident get up and hit the table due to unstable balance, or the overbed table can be unstable and fall on the resident when moved. The ADON stated Resident 297's overbed table should not have been placed on top of the floor mat as it placed Resident 297 at risk for incurring injury in case of a fall. During a review of the facility's recent P&P titled Safety and Supervision of Residents last reviewed on 1/14/2025, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; quality assurance and performance improvement (QAPI, a data driven and proactive approach to quality improvement of care) reviews of safety and incident/accident data; and facility-wide commitment to safety. During a review of the facility-provided user instruction for Floor Mat 1 (FM 1), undated, the user instruction indicated in addition to low height beds that have been found to help reduce the incidence of falls; impact reduction fall mats placed alongside the bed have become a cost-effective means to help reduce the incidence of patient trauma and severity of injury by providing a cushioned, slide resistant surface. e. During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2025 with diagnoses including muscle wasting and atrophy (loss of muscle mass and strength), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 32's History and Physical (H&P) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 32's fall risk assessments dated 6/17/2024, 9/20/2024, and 12/18/2024, the fall risk assessments indicated the resident was a high risk for falls. During a review of Resident 32's care plan (CP) on risk for falls and injuries related to gait/balance problems and dementia initiated on 5/18/2021 and last revised on 2/3/2025, the CP indicated floor mat (landing mat) on the right side of the bed and monitor for proper positioning and placement every shift as one of the interventions to prevent falls. During a concurrent observation and interview on 2/15/2025 at 9:18 a.m. inside Resident 32's room with Treatment Nurse 1 (TN 1), TN 1 stated Resident 32's overbed table was placed on top of the right floor mat and was unstable when moved and the wheels left an indentation on the floor mat. TN 1 stated the overbed table can be unstable and fall on Resident 32 when moved or the resident can hit the table when Resident 32 accidentally rolls out of the beds and cause injury. TN 1 stated the overbed table should not have been placed on top of the floor mat as it placed Resident 32 at risk for injuries during a fall or any incident. During an interview on 2/17/2025, at 4:30 p.m., with the ADON, the ADON stated there should be no heavy equipment or any furniture on top of the floor mat as it can affect the integrity if the floor mat which could affect the impact of a fall or incident. The ADON placing any equipment or furniture on top of the floor mat can cause injury when the residents get up and hit the table due to unstable balance or the overbed table can be unstable and fall on the resident when moved. The ADON stated Resident 32's overbed table should not have been placed on top of the floor mat as it placed Resident 32 at risk for incurring injury in case of a fall. During a review of the facility's recent P&P) titled Safety and Supervision of Residents last reviewed on 1/14/2025, the P&P indicated safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and facility-wide commitment to safety. During a review of the facility-provided user instruction for Floor Mat 1 (FM 1), undated, the user instruction indicated in addition to low height beds that have been found to help reduce the incidence of falls; impact reduction fall mats placed alongside the bed have become a cost-effective means to help reduce the incidence of patient trauma and severity of injury by providing a cushioned, slide resistant surface.

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 (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for five of nine sampled residents (Residents 25, 32, 41, 58, and 2) by failing: 1. To ensure Resident 25's Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD-a chronic lung disease causing difficulty in breathing] and asthma [a chronic lung disease that makes breathing difficult in adult]) and two over-the-counter multidose medications were labeled with dates the medications were opened for two of four medication carts reviewed. 2. To ensure Resident 32's physician order was followed. On 2/16/2025 at 7:43 a.m., LVN 1 administered Norco (medication used to treat pain) to Resident 32 with a pain level of zero. 3. To accurately document Resident 41's Medication Count Sheet for clonazepam (a medication that treats seizures and can also treat a panic disorder). 4. To ensure Resident 58's physician order was followed for potassium (a mineral that your body needs to work properly) administration. 5. To ensure there was monitoring in place for Resident 2 for signs and symptoms of bleeding for the use of heparin (an anticoagulant that prevent blood clots or keep an existing clot from getting worse). These deficient practices had the potential for medication errors and to not give the necessary care and services to the affected residents. Findings: a. During a concurrent medication administration observation and interview on 2/15/2025, at 8:16 a.m., with Licensed Vocational Nurse 3 (LVN 3), outside Resident 25's room. Observed Resident 25's Trelegy inhaler with written open date of 2/3 and stool softener 100 milligram (mg- metric unit of measurement, used for medication dosage and/or amount) with written open date of 2/13. LVN 3 stated Trelegy and stool softener medication did not indicate the year medication was opened. During a medication administration observation on 2/15/2025, at 8:39 a.m., with LVN 3, outside of Resident 58's room. Observed prostat (a ready-to-drink concentrated liquid protein) bottle with written open date of 2/13. During an interview on 2/15/2025, at 8:57 a.m., LVN 3 stated prostat bottle did not indicate the year the medication was opened. During an interview on 2/17/2025, at 1:49 p.m., with the Director of Staff Development (DSD), the DSD stated multidose medications should have a written date including the year it was opened. The DSD stated the importance of writing the complete date was to maintain efficacy of the medication and to prevent medication errors. During an interview on 2/17/2025, at 5:13 p.m., with the Director of Nursing (DON), the DON stated nurses should write in the bottle, the date the medication was opened. The DON stated date includes the year it was opened. The DON stated it is the best practice. The DON stated the importance of writing the date with the year the medication was opened to know when to stop using the medication. The DON stated the facility's policy and procedure on labelling medication includes writing the complete date the medication was opened. During a record review of the facility's policy and procedure (P&P) titled, Labelling of Medication Containers, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. During a record review of the facility's P&P, titled, Administering Medications, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, The expiration or beyond use date on the medication label is checked prior to administering. When opening a multidose container, the date opened is recorded on the container. b. During a record review of Resident 32's admission Record, the admission Record indicated the facility admitted Resident 32 on 5/17/2021, with diagnoses that included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic imbalance), generalized muscle weakness, and unspecified (unconfirmed) low back pain. During a record review of Resident 32's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a record review of Resident 32's Minimum Data Set (MDS - a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 32's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 32 was on opioid (medication used to treat moderate to severe pain). During a record review of Resident 32's Physician Order, dated 10/14/2024, the Physician Order indicated Norco tablet 10-325 mg, give one tablet by mouth every six hours as needed for severe breakthrough (a sudden increase in pain that may occur in patients who already have chronic pain) with a pain level of seven to ten. During a record review of Resident 32 Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 2/16/2025, timed at 7:43 a.m., the MAR indicated LVN 1 administered Norco to Resident 32's pain level of zero. During an interview on 2/17/2025, at 1:49 p.m., with the DSD, the DSD stated Norco should not be given to Resident 32 when pain level is zero. The DSD stated zero means Resident 32 had no pain. During an interview on 2/17/2025, at 5:13 p.m., with the DON, the DON stated LVN 1 should check Resident 32's pain level before administering the pain medication. The DON stated the facility's policy for medication administration was to follow the physician order. During a record review of facility's policy and procedure (P&P) titled, Pain-Clinical Protocol, dated 3/2018 and last reviewed on 1/14/2025, the P&P indicated, The physician will order appropriate non-pharmacologic (treatments or therapies that do not involve the use of medications) and medication interventions to address the individual's pain. Pain medications should be selected based on pertinent treatment guidelines. Generally, and to the extent possible, an analgesics (medication used to treat pain) regimen should utilize the simplest regimen and lowest risk medications before using more problematic or higher risk approaches. During a record review of facility's P&P titled, Administering Medications, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, Medications are administered in accordance with prescribers' orders, including any required time frame. c. During a record review of Resident 41's admission Record, the admission Record indicated the facility admitted Resident 41 on 1/17/2020, with diagnoses that included paroxysmal atrial fibrillation (a type of irregular heartbeat that occurs intermittently and typically resolves on its own), unspecified anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life) and other lack of coordination. During a record review of Resident 41's H&P, dated 10/29/2024, the H&P indicated Resident 41 did not have the capacity to understand and make decisions. During a record review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 41 was on antianxiety medications (medications used to help reduce anxiety). During a record review of Resident 41's Physician Order, dated 2/12/2025, the Physician Order indicated clonazepam (medication used to treat anxiety) 0.5 mg tablet, give 0.25 mg by mouth every 12 hours for anxiety manifested by repetitive calling out of staff. During a concurrent interview and record review on 2/15/2025, at 12:52 p.m., with the Assistant Director of Nursing (DON), Resident 41's Medication Count Sheet for clonazepam indicated 62 and 60 tablets were circled. The ADON counted the clonazepam medication pack, and the actual number of clonazepam left in the medication pack was 62 tablets. During an interview on 2/15/2025, at 1:11 p.m., with the ADON, the ADON stated it is important to document accurately in the Medication Count Sheet. During an interview on 2/17/2025 at 1:49 p.m., with the DSD, the DSD stated once medication is delivered, the medication in the medication pack is counted and the number is documented in the Medication Count Sheet. The DSD stated if nurse made two different entries, the nurse should cross out one and leave the right number of medications. During an interview on 2/17/2025, at 5:13 p.m., with the DON, the DON stated nurses should document in the Medication Count Sheet the number of medications received. The DON stated if a nurse made an error, they should cross it out and write the initial of their name. The DON stated accurate documentation is important for controlled medication (a substance that is regulated by the government due to its potential for abuse and addiction) and it is the facility's policy to count and document accurately. During a record review of facility's P&P titled, Controlled Substances, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, The facility complies with all laws, regulations and other requirement related to handling, storage, disposal and documentation of controlled medications. Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift. Upon receipt, the nurse receiving the medication and the individual delivering the medication verify the name, dose and quantity of each controlled substances being delivered. An individual resident-controlled substance record is made for each resident who is receiving a controlled substance. The record contains: 1. Name of resident. 2. Name and strength of the medication 3. Quantity received. 4. Number on hand. d. During a record review of Resident 58's admission Record, the admission Record indicated the facility admitted Resident 58 on 2/25/2022, with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hypokalemia (a condition where the potassium levels in the blood are lower than normal. Potassium is an essential electrolyte that plays a vital role in muscle function, nerve signaling, and heart health) and essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause). During a record review of Resident 58's MDS, dated [DATE], the MDS indicated Resident 58's cognitive skills for daily decisions were intact. During a record review of Resident 58's H&P, dated 1/3/2025, the H&P indicated Resident 58 did not have the capacity to understand and make decisions. During a record review of Resident 58's Order Summary Report, dated 2/26/2024, the Order Summary Report indicated potassium chloride (medication used in the management and treatment of hypokalemia) extended release 20 milliequivalent (meq - unit of measurement), give one tablet by mouth one time a day for supplement. Take with food and full glass of water or juice of four ounces. During a medication administration observation on 2/15/2025, at 8:57 a.m. with LVN 3, at Resident 58's bedside. Observed LVN 3 administer potassium tablet to Resident 58 with two ounces of water. During a concurrent observation and interview on 2/15/2025, at 9:06 a.m., with LVN 3, LVN 3 measured two ounces of water and stated the physician order for potassium administration was to give with full glass of water. LVN 3 stated two ounces is not a full glass of water. LVN 3 stated she (LVN 3) should have followed the physician's order. During an interview on 2/17/2025, at 1:49 p.m. with the DSD, the DSD stated LVN 3 should follow the physician's order for potassium administration with full glass of water. During an interview on 2/1/2025, at 5:13 p.m. with the DON, the DON stated full glass of water is four to eight ounces of water. The DON stated taking potassium with full glass of water helps lessen a stomach upset. The DON stated two ounces is not a full glass. The DON stated it is the facility's policy to follow the physician's order. During a record review of facility's P&P titled, Administering Medications, dated 4/2019 and last reviewed on 1/14/2025, the P&P indicated, Medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber's order, including any required time frame. e. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted the Resident 2 on 2/8/2021and readmitted in the facility on 12/27/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (having the ability to think, learn, and remember clearly) and required total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident received an anticoagulant. During a re view of Resident 2's H&P, dated 12/30/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/27/2024 for heparin sodium (porcine) injection solution 5000 units per milliliter (units/ml - a unit of measurement) **dispense as written ([NAME])** 5000 units hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) two (2) times a day for blood clot prevention. During a review of Resident 2' care plan (CP) on risk for bleeding or bruising related to use of heparin initiated on 1/21/2025 indicated the following interventions to prevent bleeding or bruising: - Administer medication per physician's order. - Observe for signs and symptoms of bleeding such as tarry stools, blood in urine, bruising, petechiae (red or purple spots underneath the skin that occur as a result of tiny bleeding, which do not blanch on pressure. During a concurrent interview and record review on 2/16/2025 at 2:45 p.m., reviewed Resident 2's physician's order, and MAR with Registered Nurse 1 (RN 1). RN 1 stated Resident 2 did not have a physician's order to monitor for bleeding every shift for the use of anticoagulant heparin. RN 1 stated residents should have a physician's order to monitor residents for signs and symptoms of bleeding due to the use of an anticoagulant. RN 1 stated there should have been a physician's order to monitor Resident 2 for signs and symptoms of bleeding as it placed Resident 32 at risk for untoward cardiac events and hospitalization. During a concurrent interview and record review on 2/17/2025 at 4:19 p.m., reviewed Resident 2's physician's order and MAR with the Assistant Director of Nursing (ADON). The ADON stated Resident 2 did not have a physician's order to monitor the resident for signs of symptoms of bleeding and there was no monitoring for bleeding in the MAR. The ADON stated the licensed nurse (LN) should also obtain a physician's order for monitoring for signs and symptoms of bleeding every shift along with the order for anticoagulant per facility protocol. The ADON stated the LN should have obtained an order for monitoring for signs and symptoms of bleeding addressing Resident 2's use of heparin to prevent complications related to not monitoring the symptoms of bleeding which may lead to hospitalization. During a review of the facility's policy and procedure (P&P titled, Anticoagulant - Clinical Protocol, last reviewed 1/14/2025, the P&P indicated: - Assess for any signs and symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. - Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug) for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding. - The nurse shall assess and document or report the current anticoagulant therapy, including drug and current dosage. - Long-term subcutaneous administration of heparin in chronically bed-bound individuals is not indicated or of proven benefit for long-term deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis. - The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose. During a review of the facility's P&P titled, Standards of Clinical Practice, last reviewed 1/14/2025, the P&P indicated a policy statement that services provided to the residents are performed in accordance with current acceptable standards of clinical practice.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards): 1. For one of one sampled resident (Resident 32) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) the insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). 2. For one of one sampled resident (Resident 2) reviewed for anticoagulant (commonly called blood thinner, that increase the time it takes for blood to clot) use by: a. Failing to clarify that Resident 2's physician's order for heparin (an anticoagulant) did not indicate the route of administration and the correct indication. b. Failing clarify the pharmacy label on the heparin did not match the physician's order and Medication Administration Record (MAR - a daily documentation record used by a LN to document medications and treatments given to a resident) prior to administration of the medication. These deficient practices had the potential to cause Resident 2 to receive suboptimal (less than the highest standard or quality) care due to unintended complications related to the side effects (unwanted, unpleasant results of a medication) of anticoagulant use such as bleeding or bruising if not administered correctly which may lead to hospitalization or even death. Findings: a. During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted the resident on 1/24/2025 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities), and generalized muscle weakness. During a review of Resident 32's History and Physical (H&P) dated 10/16/2024, the H&P indicated Resident 32 did not have the capacity to understand and make decisions. During a review of Resident 32's Minimum Data Set (MDS, a resident assessment tool), tool), dated 12/15/2025, the MDS indicated Resident 32 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision or touching assistance with eating; total assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS further indicated Resident 32 received insulin. During a review of Resident 32's Order Summary Report, the Order Summary Report indicated the following physician's orders dated: - 2/12/2024: Lantus solution (a long-acting insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication])100 unit per milliliter (unit/ml - a unit of measurement) inject 34 units subcutaneously (beneath the skin) at bedtime related to DM 2. Hold if blood sugar (BS) is less than (<) 100. - 1/7/2025: Lantus solution 100 unit/ml (insulin glargine) inject 26 units subcutaneously at bedtime related to DM 2. Hold if BS <100. - 12/8/2024: Lantus solution 100 unit/ml (insulin glargine) inject 26 units subcutaneously at bedtime related to DM 2. - 10/14/2024 to 1/24/2025: Novolog solution (a short acting insulin)100 unit/ml (insulin aspart) inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): <60, hypoglycemic protocol and inform physician (MD); if 60 - 149 = 0 unit;150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; 400 plus = 12 unit; more than (>) 400, 12 units and inform MD subcutaneously before meals and at bedtime for DM 2. - 1/24/2025: Novolog solution 100 unit/ml (insulin aspart) inject as per sliding scale: <60, hypoglycemic protocol and inform physician (MD); if 60 - 149 = 0 unit;150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 399 = 10 units; 400 plus = 12 unit; > 400, 12 units and inform MD subcutaneously with meals for DM 2. During a concurrent interview and record review on 2/16/2025 at 2:22 p.m., reviewed Resident 32's physician's orders, MAR Location of Administration Report for 1/2025 and 2/2025 with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated Resident 32 had a physician's order for Novolog and Lantus and were administered as follows: - Lantus solution 100 unit/ml: 1/13/25 10:45 p.m. subcutaneously Abdomen - left upper quadrant (LUQ) 1/14/25 9:14 p.m. subcutaneously Abdomen - LUQ 2/12/25 9:40 p.m. subcutaneously Abdomen - right upper quadrant (RUQ) 2/13/25 9:11 p.m. subcutaneously Abdomen - RUQ - Novolog solution 100 unit/ml: 1/02/25 9:00 p.m. subcutaneously Abdomen - left lower quadrant (LLQ) 1/03/25 5:45 a.m. subcutaneously Abdomen - LLQ 1/15/25 8:55 p.m. subcutaneously Abdomen - LUQ 1/16/25 6:27 a.m. subcutaneously Abdomen - LUQ 1/16/25 11:53 a.m. subcutaneously Abdomen - RUQ 2/03/25 8:55 p.m. subcutaneously Abdomen - RUQ 2/04/25 9:01 p.m. subcutaneously Abdomen - RUQ 2/11/25 9:02 p.m. subcutaneously Abdomen - LUQ 2/12/25 9:40 p.m. subcutaneously Abdomen - LUQ 2/13/25 9:13 p.m. subcutaneously Abdomen - LUQ 2/14/25 8:29 p.m. subcutaneously Abdomen - LUQ 2/07/25 4:21 p.m. subcutaneously Abdomen - right lower quadrant (RLQ) 2/08/25 8:42 a.m. subcutaneously Abdomen - RLQ 2/08/25 1:15 p.m. subcutaneously Abdomen - RLQ 2/15/25 7:47 a.m. subcutaneously Abdomen - LUQ 2/15/25 12:10 p.m. subcutaneously Abdomen - LUQ 2/16/25 7:39 a.m. subcutaneously Abdomen - LUQ 2/16/25 11:26 a.m. subcutaneously Abdomen - LUQ LVN 1 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 1 stated the last three (3) administration sites for insulin was shown every time the staff opens the MAR. LVN 1 stated Resident 32's MAR indicated the insulin administration sites were not rotated. LVN 1 stated Resident 32's insulin administration sites should have been rotated per standards of practice to prevent pain, redness, irritation, bruising, and pits on the resident's skin. During a concurrent interview and record review on 2/17/2025 at 4:30 p.m., reviewed Resident 32's physician's orders, MAR Location of Administration Report for 1/2025 and 2/2025 with the Assistant Director of Nursing (ADON). The ADON stated the locations of administration sites for Resident 32's insulin were not rotated. The ADON stated the charge nurses (CN) are supposed to rotate insulin administration sites according to standards of practice and as indicated in the manufacturer's guideline and the CN can see the last 3 administration sites of insulin in the MAR. The ADON stated Resident 32's administration sites for insulin should have been rotated to prevent adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin. The ADON not rotating the insulin administration sites can be considered a medication error due to the CN not following professional standards of practice and manufacturer's guideline or recommendation. During a review of the facility-provided manufacturer's guideline on Lantus insulin glargine injection 100 unit/ml, undated, the manufacturer's guideline indicated: - Change (rotate) the injection sites within the area chosen with each dose to reduce the risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis 9skin with lumps) at the injection sites. - Do not use the same spot for each injection or inject where the skin is pitted, thickened, lumpy, tender, bruised, scaly, hard, or damaged. During a review of the facility-provided manufacturer's guideline on Insulin aspart (vials) (Novolog), undated, the manufacturer's guideline indicated: - Move site where you give the shot each time. - It is given as a shot into the fatty part of the skin in the upper arm, buttocks, or stomach area. - A side effect include thick skin pits, or lumps where the injection was given. - Do not give into skin that is thickened, or has pits, or has lumps. - Do not into skin that is irritated, tender, bruised, red, scaly, hard, scarred. During a review of the facility policy and procedures (P&P) titled, Insulin administration, last reviewed on 1/14/2025, the P&P indicated: - Select an injection site: a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately two (2) inches above the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility's P&P, titled, Adverse Consequences and Med Errors, last reviewed on 1/14/2025, the P&P indicated: - A medication error is defined as preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer's specifications or accepted professional standards and principles of the professionals providing the services. b. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 2/8/2021 and readmitted the resident on 12/27/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of muscle on multiple sites, and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition (having the ability to think, learn, and remember clearly) and required total assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident received anticoagulant. During a re view of Resident 2's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 22 did not have the capacity to understand and make decisions. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated a physician's order dated 12/27/2024 for heparin sodium (porcine) injection solution 5000 units per milliliter (units/ml - a unit of measurement) **dispense as written ([NAME])** 5000 units hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) two (2) times a day for blood clot prevention. During a concurrent observation, interview and record review on 2/16/2025 at 2:42 p.m., reviewed Resident 2's physician's order and MAR for 2/2025 with LVN 1. LVN 1 stated Resident 2 was not on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney/s have failed). LVN 1 stated Resident 2's physician's order for heparin dated 12/27/2024 and the MAR did not indicate the route of administration. Medication Cart 2 (MC 2) was checked with LVN 1 and LVN 1 stated the label on the heparin indicated the administration route was to administer the medication subcutaneously for deep vein thrombosis (DVT - a blood clot that forms in the veins located deep within a limb, usually the lower leg or thigh) prophylaxis (refers to measures taken to prevent diseases or infections before they occur). LVN 1 stated the physician's order, MAR, and medication label did not match. LVN 1 stated the nurses are supposed to compare the medication label with the MAR, and if there was discrepancy then the order must be checked, hold (do not administer) the medication and clarify the order with the physician. LVN 1 stated Resident 2 received the heparin since 12/28/2024. LVN 1 stated Resident 2's heparin should have been held and clarified with the physician prior to administering the medication. During a concurrent interview and record review on 2/16/2025 at 2:45 p.m., reviewed Resident 2's physician's order, MAR from 12/2024 to 2/2025, interim Medication Regimen Review (iMRR - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication done upon admission by the dispensing pharmacy) form, and a photograph of the heparin label with Registered Nurse 1. RN 1 stated the physician's order and MAR did not match the heparin label. RN 1 stated the physician's order and MAR indicated the route of administration. RN1 stated the MAR indicated Resident 2 received the heparin two times a day. RN 1 stated the medication should have been held and clarified with the physician prior to administration. RN 1 stated the CN should have checked with the pharmacy that the label did not match the physician's order. RN 1 stated the pharmacy will call the facility if there was a discrepancy with the order and will not dispense the medication if not clarified. During a concurrent observation, interview, and record review on 2/16/2025 at 4:07 p.m., reviewed Resident 2's physician's order, MAR, and heparin label with Licensed Vocational Nurse 6 (LVN 6). LVN 6 stated the physician's order and MAR did not indicate the route of administration. LVN 6 stated the physician's order should match the medication label. LVN 6 stated the CN should have held the medication and notify the RN supervisor of clarify the order with the physician. During a concurrent interview and record review on 2/16/2025 at 4:28 p.m., reviewed Resident 2's physician's order, MAR, iMRR, and the photograph of the heparin label with Registered Nurse 2 (RN 2). RN 2 stated Resident 2 was not on hemodialysis and the physician's order and MAR did not match the heparin label. RN 2 stated it was an order entry error when she (RN 2) chose the wrong order in the electronic health record (EHR). RN 2 stated she did not know what [NAME] meant and the heparin order did not indicate the route of administration. RN 2 stated the iMRR indicated there were no recommendations and she did not receive a call from the pharmacy to clarify the heparin order. RN 2 stated the five (5) rights of medication administration includes the right route. RN 2 stated the medication should have been held and call the physician to clarify the order. During a concurrent interview and record review on 2/17/2025 at 8:09 a.m., with the Assistant Director of Nursing (ADON), Resident 2's Physician Order dated 12/27/2024 was reviewed. The ADON stated [NAME] in Resident 2's Physician Order for heparin means dispense as written. The DON stated the Physician Order did not indicate route of administration. The ADON stated Resident 2 was not on hemodialysis. The ADON stated CN who administered the medication should have clarify the order first with the physician. The ADON stated CN should follow the physician order instead of the medication label. The ADON stated LVN 6 made a significant medication error. The ADON stated the five rights of medication administration includes the right route. The ADON stated route was not followed as it was not indicated in the physician order. During a follow up concurrent interview and record review on 2/17/2025 at 4:19 p.m. reviewed Resident 2's MAR from 1/2024 to 2/2025 with the ADON, the ADON stated the heparin was administered two times a day for a total of 102 instances. The ADON stated administering the heparin without the route of administration was considered a medication error as the route was not indicated in the physician's order. During an interview on 2/17/2025 at 5:13 p.m., with the DON, the DON stated nurses should follow the procedure of medication administration that includes the right resident, right medication, right order, right route, and right indication, and reconcile on what's on the medication label. The DON stated the CNs should have held the medication and called the physician and clarify the route of administration. The DON stated Resident 2 can have an adverse effect from receiving the medication without the route of administration. The DON stated administering the heparin to Resident 2 without the route of administration from 12/28/2024 to 2/16/2025 for a total of 102 instances was considered a significant medication error. During a record review of facility's policy and procedure (P&P) titled, Administering Medications last reviewed on 1/14/2025, the P&P indicated: - Medications are administered in a safe, timely manner and as prescribed. - Medications are administered in accordance with prescribers' orders, including any required time frame. - If a dosage if believed to be inappropriate or excessive for a resident, or a medication had been identified as having potential adverse consequences for the residents or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the residents attending physician or the facility's medical director to discuss the concerns. - The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the facility's P&P titled, Adverse Consequences and Med Errors, last reviewed on 1/14/2025, the P&P indicated: - A medication error is defined as preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer's specifications or accepted professional standards and principles of the professionals providing services. - Example of medication error include wrong route of administration. - An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include adverse drug/medication reaction and side effect. - An adverse drug reaction is any unintended response to a drug and occurs in doses for prophylaxis, diagnosis or therapy. - When a resident receives a new medication, the medication order is evaluated for the dose, route of administration, duration, and monitoring that are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Temperatures were not checked on 2/13, 2/14 and 2/15 for the dry storage room. 2. The following food items were not discarded: - Corn flakes with use by date of 2/8/25 - Breadcrumbs with use by date of 1/10/25 - Beans with use by date of 2/10/25 - [NAME] cheese with use by date of 2/14/25 3. Food items were not properly labeled with either missing received date, open date and/or use by date for: - Lentils - Lays chips - Soy sauce These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in medically compromised residents who received food from the kitchen. Findings: During an initial observation tour of the kitchen on 2/15/2025 at 7:06 a.m. in the dry storage room, observed Storage Room Temperature Log, for the month of February 2025 indicating no temperatures for: - 2/13/2025 p.m. - 2/14/2025 a.m. and p.m. - 2/15/2025 a.m. During an initial observation tour of the kitchen on 2/16/2025 at 7:16 a.m., in the dry storage room, observed: - Corn flakes with use by date of 2/8/25 - Breadcrumbs with use by date of 1/10/25 - Beans with use by date of 2/10/25 - Lentils in clear container with no received date, open date, or use by date - Lays chips with a date of 1/8/2025 - Soy sauce with no received date, open date and/or use by date. During an initial observation tour of the kitchen on 2/16/2025 at 7:29 a.m. of the kitchen refrigerator, observed Monterey cheese labeled with date of 2/7/2025 and use by date of 2/14/2025. During a concurrent observation of the kitchen and interview with [NAME] 1 (C 1), on 2/16/2025 at 8:09 a.m., C 1 stated all foods should be labeled with received date, open date, and use by date. C 1 stated food items need to be properly labeled to ensure items are not expired. C 1 reviewed the Monterey cheese and stated based on use by date, the cheese is expired, it should not be in the refrigerator, and it needs to be discarded. C 1 stated having expired food items in the refrigerator can be a risk for residents to consume and the residents to get sick. During an interview on 2/16/2025 at 1:57 p.m. with the Dietary Supervisor (DS), the DS stated the cooks sign off (check and record) the temperatures of the dry storage room two times a day. The DS stated it is important to track the temperatures to keep the temperatures within range for food safety. The DS stated if food is not safe, bacteria can grow rapidly, and residents can get sick if they consume food. During an interview on 2/16/2025 at 2:01 p.m. with the DS, the DS stated all foods should be labeled with received date, open date, and use by date. The DS stated labeling should be done to ensure they have a used by date for residents to consume safely. The DS stated the Monterey cheese should be discarded as they were unable to tell when it is expired but based on the use by date, the cheese should have been discarded. During a review of the facility's policy and procedures (P&P) titled, Labeling and Dating of Foods, last reviewed on 1/14/2025, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Food delivered to facility needs to be marked with a received date. Newly opened food items will need to be closed and labeled with an open date and use by the date follows the various storage guideline. During a review of the facility's P&P titled, Corrective action when food in the storeroom reaches above 85 Fahrenheit (F), last reviewed on 1/14/2025, the P&P indicated when temperature within the emergency or food storage room becomes higher than 85 F, corrective action must take place to ensure food has not become compromised. 2. The Dry Food Storage Temperature Log will be started to monitor storage unit temperature

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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Based on interview and record review, the facility failed to implement infection control measures by failing to ensure: 1. Prostat (supplement for dietary management of wounds and other conditions requiring increased protein) bottle was kept in a clean and in sanitary condition before and after use for two of four sampled medication carts (Medication Carts 1 and 4). 2. The Maintenance Director (MS) and the Infection Preventionist (IP) were able to identify signs of legionella (a severe form of pneumonia - lung inflammation usually caused by infection) as indicated in the legionella water management program. These deficient practices had the potential to result in unidentified cases of legionella and the spread of infection in the facility as well as prostat bottle contamination (the process of making something dirty). Findings: 1. During a concurrent medication administration observation and interview, on 2/15/2025, at 9:11 a.m., with Licensed Vocational Nurse (LVN) 5, outside of Resident 12's room LVN 5 pulled a Prostat bottle from the bottom fourth (4th) drawer of Medication Cart number 1. The Prostat bottle had light brown drippings on the side of the bottle. LVN 5 poured 30 milliliter (ml - unit of measurement) of Prostat in a medication cup and closed the cover. LVN 5 held the Prostat bottle and stated the Prostat bottle was sticky. LVN 5 returned the Prostat bottle in the bottom cart of the medication cart without cleaning the bottle. During a concurrent observation and interview, on 2/16/2025, at 9:15 a.m., with LVN 3, LVN 3 pulled a Prostat bottle from the bottom 4th drawer of Medication Cart Number 1. The Prostat bottle had dried light brown drippings on the side. LVN 3 stated the Prostat bottle is a little sticky to touch. LVN 3 stated nurses should have cleaned the bottle after every use to prevent cross contamination. During a concurrent observation and interview, on 2/16/2025, at 9:21 a.m., with LVN 4, LVN 4 pulled a Prostat bottle from the bottom 4th drawer of Medication Cart Number 4. The Prostat bottle had dried light brown drippings on the side. LVN 4 stated the Prostat bottle was dirty and sticky. LVN 4 stated she did not clean the Prostat bottle this morning. LVN 4 stated the importance of cleaning the Prostat bottle was for infection control. During an interview, on 2/17/2025, at 1:49 p.m., with the Director of Staff Development (DSD), the DSD stated if a medication bottle is sticky, staff should wipe it off and clean it. During an interview, on 2/17/2025, at 5:13 p.m., with the Director of Nursing (DON), the DON stated staff needs to check their supplies in their medication carts and clean it before and after medication administration for infection control. During a record review of facility's policy and procedure (P&P) titled, Surveillance of Infections, dated 9/2023, and last reviewed on 1/14/2025, the P&P indicated, Ensures that reusable equipment is appropriate cleaned or disinfected after each use and only single-use vials are used. Staff follows established facility infection control procedures (handwashing, antiseptic technique [a set of practices that help prevent the spread of infection], gloves, isolation precautions [steps taken to prevent the spread of germs in hospitals and other settings]) for the administration of medication, as applicable. 2. During a concurrent interview and record review on 2/15/2025 at 2:55 p.m., with the Maintenance Director (MS), the facility's policy and procedure (P&P) titled, Legionella Water management Program dated 9/2022 was reviewed. The P&P indicated, the identification of situations that can lead to legionella growth, such as .4.the presence of biofilm, scale or sediment. The MS stated he (MS) checks the facility for stagnant (not flowing) water and randomly (chosen by chance rather than according to a plan) selects water sample to be send out for legionella testing once a year. The MS stated he (MS) did not know the signs of legionella in the water. The MS stated he did not know what biofilm was. The MS stated it is important to know what biofilm was so if he (MS) sees any presence of biofilm in the water in the facility, he (MS) can collect the sample and send out for legionella testing without waiting for another year. During a concurrent interview and record review on 2/15/2025 at 3:16 p.m. with the IP, the facility's Lesson Plan for Legionella Water Management Program dated 2/3/2025 was reviewed. The Lesson Plan indicated, The identification of situations that can lead to legionella growth, such as .4.the presence of biofilm, scale or sediment. The IP stated the MS was in-charge of checking the facility for stagnant water. The IP stated she (IP) provided the in-service (education) for the legionella to the MS. The IP stated she did not know what biofilm was. During an interview on 2/17/2025 at 1:49 p.m., with the DSD, the DSD stated the MS assigned to inspect the facility should know possible signs of legionella in the stagnant water. During an interview on 2/17/2025 at 3:10 p.m. with the Administrator (ADM), the ADM stated the MS should know what to look for possible signs of legionella in the water. The ADM stated the MS was the one that randomly selects the sample of water to be tested for legionella. The ADM stated the importance of identifying signs of legionella in the water was to prevent any cases and spread among residents. During a record review of facility P&P titled, Legionella Water Management Program dated 9/2022 and last reviewed on 1/14/2025, the P&P indicated, Our facility is committed to the prevention, detection and control of water -borne contaminants, including legionella. As part of the infection prevention and control program. Our facility has a water management program, which is overseen by the water management team. The purpose of the water management program is to identify areas in the water system where legionella bacteria can grow and spread and to reduce the risk of Legionnaires Disease The identification of situations that can lead to legionella growth, such as .4.the presence of biofilm, scale or sediment.

Jan 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to report allegation of staff-to-resident abuse within two hours to the State Survey Agency (SSA) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), as per its policies on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/18/2021, with diagnoses that included unspecified (unconfirmed) atrial fibrillation (irregular heartbeat), essential hypertension (a type of high blood pressure that develops gradually and has no clear cause) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 1's History and Physical (H&P), dated 5/26/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent to staff for all activities of daily living (ADL-eating, toileting, dressing and personal hygiene). During a record review of Resident 1's Situation Background Assessment Review (SBAR-a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 1/7/2025, the SBAR indicated Resident 1 had minor bruising and minor swelling on the left hand near the knuckles of the second and third finger. The SBAR indicated the Physician was notified on 1/7/2025 a 6 p.m. During a record review of Resident 1's Progress Notes (PN), dated 1/7/2025, timed at 10 pm., the PN indicated Registered Nurse 1 (RN 1) called Family Member 1 (FM 1) and FM 1 notified RN 1 that FM 1 believed that either Home Health Aide (HHA) or Certified Nursing Assistant 4 (CNA 4) mishandled Resident 1 during care. The PN indicated RN 1 notified FM 1 that she (RN 1) would investigate the incident. During an interview on 1/9/2025, at 2:02 p.m., with Caregiver (CG) and translated by the Activity Director (AD), CG stated on 1/7/2025, at 11 a.m., in the dining room, Resident 1 reported to CG the redness on Resident 1's left hand. CG stated she (CG) reported to CNA 3 on 1/7/2025, between 3 p.m., to 4 p.m., and Licensed Vocational Nurse 2 (LVN 2) came to check Resident 1 between 4 p.m., to 5 p.m. During an interview on 1/9/2025, at 3:09 p.m., the Director of Nursing (DON) stated bruising and redness was observed on 1/7/2025, at 6 p.m. The DON stated she (DON) was not notified of the change in condition on 1/7/2025. The DON stated any staff can report allegation of abuse to Administrator (ADM) and the facility's policy was to report allegation of abuse within two hours. During an interview on 1/9/2025, at 3:45 p.m., the ADM stated FM 1 reported Resident 1's allegation of abuse on 1/8/2025, at 9:45 a.m. The ADM stated she (ADM) called SSA on 1/8/2025 at 10:36 a.m. to report the allegation of abuse. During an interview on 1/9/2025, at 4:11 p.m., CNA 3 stated on 1/7/2025, at 5:30 p.m., CG informed and showed her (CNA 3) Resident 1's redness on the left hand. CNA 3 instructed CG to call LVN 2 while she (CNA 3) stayed with Resident 1. CNA 3 stated LVN 2 came and looked at Resident 1's hand. During an interview on 1/14/2025, at 11:17 a.m., LVN 2 stated on 1/7/2025 between 6:30 p.m., to 7 p.m., FM 1 called and spoke to LVN 2, FM 1 reported to LVN 2 that somebody hurt Resident 1. LVN 2 stated she (LVN 2) reported to RN 1 that FM 1 was upset and claimed somebody hurt Resident 1. LVN 2 stated she (LVN 2) should have reported to the ADM within two hours after FM 1 notified her (LVN 2) that somebody hurt Resident 1. During a record review of facility's policy and procedure (PP) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating dated 4/2021 and last reviewed on 1/2025, the PP indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft, misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing or certification agency responsible for surveying or licensing the facility. b. The local or state ombudsman. c. The resident's representative. d. Adult protective services (where state law provides jurisdiction in long-term care). e. Law enforcement officials. f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. During a record review of facility's policy and procedure (PP) titled, Abuse, Neglect, exploitation and Misappropriation Prevention dated 4/2021 and last reviewed on 1/2025, the PP indicated, Investigate and report any allegations within timeframes required by federal requirements.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1 receiving too much pain medication causing overdose (happens when a toxic amount of a drug, or combination of drugs overwhelms the body). Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 5/18/2021, with diagnoses that included unspecified (unconfirmed) atrial fibrillation (irregular heartbeat), essential hypertension (a type of high blood pressure that develops gradually and has no clear cause) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 1's History and Physical (H&P), dated 5/26/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a record review of Resident 1's Care Plan on at risk for alteration in comfort, dated 5/27/2024, the Care Plan indicated an intervention to administer pain medication as ordered. During a record review of Resident 1's Order Summary Report, dated 7/16/2024, the Order Summary Report indicated ibuprofen (medication used to treat pain) 600 milligrams (mg- metric unit of measurement, used for medication dosage and or amount), give one tablet by mouth every six hours as needed for moderate pain level of four to six. During a record review of Resident 1's Order Summary Report, dated 12/20/2024, the Order Summary Report indicated hydrocodone-acetaminophen (medication used to treat pain) 5-325 mg, give two tablets by mouth every six hours as need for severe pain level of eight to ten. During a record review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/25/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 was dependent to staff for all activities of daily living (ADL-eating, toileting, dressing and personal hygiene). During a concurrent interview and record review on 1/9/2025, at 3:09 p.m., with the Director of Nursing (DON), Resident 1's Order Summary Report dated 7/16/2024, 12/20/2024, and Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/2025, was reviewed. The MAR dated 1/6/2025, indicated at 9:34 a.m., Licensed Vocational Nurse 3 (LVN 3) gave two tablets of hydrocodone-acetaminophen to Resident 1 with a pain level of seven. The DON stated Resident 1 should have been given ibuprofen instead of hydrocodone-acetaminophen. The DON stated LVN 3 did not follow the physician's order. During a record review of facility's policy and procedure (PP) titled, Administering Medications, dated 12/2012, and last reviewed on 1/2025, the PP indicated, Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. During a record review facility's PP titled, Pain Assessment and Management, dated 3/2020, and last reviewed on 1/2025, the PP indicated, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.

Nov 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received services with reasonable accommodation of the resident needs for two of three sampled residents (Residents 2 and Resident 3). Resident 2 and Resident 3, who were at risk for falls, did not have the call light (an alerting device for residents to call for assistance) within the resident ' s reach. This deficient practice had the potential for not meeting Residents 2 and 3's needs for assistance. Findings: During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 7/10/2024 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). During a record review of Resident 3 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/1/2024, the MDS indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills was severely impaired. During a record review of Resident 3 ' s Fall Risk Assessment, dated 10/27/2024, the Fall Risk Assessment indicated the resident had a total score of 12. A total score above 10 represented high risk for falls. During a record review of Resident 3 ' s Care Plan on falls, last revised on 10/27/2024, indicated the resident was high risk for falls. The Care Plan intervention indicated to be sure the resident ' s call light was within reach and encourage the resident to use it for assistance as needed. During an observation and concurrent interview on 11/14/2024 at 10:34 a.m. with the Assistant Director of Nursing (ADON), the ADON observed Resident 3 ' s call light hanging on the television (TV) rack located at the right head part of the resident ' s bed. The ADON stated Resident 3 ' s call light was not within the resident ' s reach. The ADON stated the residents used the call light to call nursing staff for assistance. The ADON stated Resident 3 ' s needs had the potential to not be met. The ADON stated Resident 3 had the potential to stand up unassisted, fall, and sustain an injury if the resident was unable to reach and use the call light to request nursing staff for assistance. The ADON stated the facility failed to ensure Resident 3 ' s call light was within the resident ' s reach. During an interview on 11/14/2024 at 12:14 p.m. with the Director of Nursing (DON), the DON stated a call light was a resident ' s way of communication to the staff. The DON stated Resident 3 ' s call light should be within the resident ' s reach. The DON stated Resident 3 ' s call light not within the resident ' s reach had the potential to cause delay in the Resident 3 ' s care. The DON stated the facility failed to ensure the call light was within Resident 3 ' s reach. During a record review of the facility ' s policy and procedure (PnP) titled, Residents Call System, last reviewed on 1/2024, indicated residents were provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 7/10/2024 with diagnoses including acute cerebrovascular insufficiency (a sudden and temporary lack of blood flow to the brain), essential hypertension (an abnormally high blood pressure that was not a result of a medical condition), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a record review of Resident 2 ' s Care Plan on falls, last revised on 7/11/2024, indicated the resident was high risk for falls. The Care Plan intervention indicated to be sure the resident ' s call light was within reach and encourage the resident to use it for assistance as needed. During a record review of Resident 2 ' s MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills was severely impaired. During an observation and concurrent interview on 11/14/2024 at 10:34 a.m. with the Assistant Director of Nursing (ADON), the ADON observed Resident 2 ' s call light hanging on the resident ' s right bedside rails with the call light button in between the mattress and the bedside rails. The ADON stated Resident 2 ' s call light was not visible to the resident. The ADON stated Resident 2 ' s needs had the potential to not be met if the call light was not visible and within the resident ' s reach. The ADIN stated the facility failed to ensure the Resident 2 ' s call light was within reach and was visible to the resident. During an interview on 11/14/2024 at 12:14 p.m. with the Director of Nursing (DON), the DON stated a call light was a resident ' s way of communication to the staff. The DON stated Resident 2 ' s call light should be visibly within the resident ' s reach. The DON stated Resident 2 ' s call light not within the resident ' s reach had the potential to cause delay in the Resident 2 ' s care. The DON stated the facility failed to ensure the call light was within Resident 2 ' s reach. During a record review of the facility ' s policy and procedure (PnP) titled, Residents Call System, last reviewed on 1/2024, indicated residents were provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries for one of the three sampled residents (Resident 1) by failing to: 1. Provide Resident 1 with fall mats (a soft, cushioned pad placed on the floor, designed to help absorb the impact of a fall and minimize injuries) on both sides of the resident ' s bed. 2. Ensure Resident 1 ' s risk for falls was communicated to the facility staff. The list of fall risk residents on the huddle report (a short meeting held to allow everyone on the team to know specific important information about patients) documents was inconsistent. This deficient practice had the potential to cause falls with injury or harm to Resident 1 and other residents. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 9/14/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), age-related osteoporosis (a disease that causes bones to become weak and more likely to break), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/16/2024, the MDS indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills was moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. During a record review of Resident 1 ' s Fall Risk Assessment, dated 10/19/2024, the Fall Risk Assessment indicated the resident had a total score of 16. A total score above 10 represented high risk for falls. During an observation and concurrent interview on 11/14/2024 at 11:02 a.m., Resident 1 was observed sitting on a wheelchair inside Resident 1 ' s room. Resident 1 ' s room surrounding was observed with Certified Nursing Assistant 2 (CNA 2). CNA 2 stated Resident 1 used either side of the resident ' s bed to get off the bed. CNA 2 stated Resident 1 ' s overbed table was observed on top of the resident ' s fall mat located at the left side of the Resident 1 ' s bed. CNA 2 stated Resident 1 should have a fall mat on both sides of the bed. CNA 2 stated Resident 1 could get off the right side of the bed, the side without a fall mat, and had the potential to fall and sustain an injury. During an observation and concurrent interview on 11/14/2024 at 11:08 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 ' s overbed table was observed on top of the resident ' s fall mat located at the left side of Resident 1 ' s bed. LVN 1 stated Resident 1 was able to get off the bed from either the left or the right side. LVN 1 stated Resident 1 ' s overbed table had the potential to cause injury or harm if the resident got off the left side of the bed. LVN 1 stated Resident 1 had the potential to fall and sustain an injury such as fracture (broken bone). LVN 1 stated the facility failed to provide Resident 1 with fall mat on both sides of the resident ' s bed. During a follow up interview on 11/14/2024 at 11:15 a.m. and a concurrent record review of nurse station 1 ' s Huddle Report, dated 10/2024 and 11/2024, reviewed with LVN 1, the Huddle Report indicated there were multiple days with Resident 1 not identified as high risk for falls. LVN 1 stated huddles were conducted at the start of every shift and the huddle report was completed. LVN 1 stated inconsistent information in the huddle book had the potential to cause confusion that may lead to an accident such as resident falls. During an interview on 11/14/2024 at 12:14 p.m., with the Director of Nursing (DON), the DON stated a huddle was a process to better communicate between the facility staff. The DON stated a huddle report should be done every shift. The DON stated the incomplete huddle reports meant the huddle was not done or the report was taken out for facility staff meeting purposes and was not returned in the huddle report binder. The DON stated Resident 1 had a risk for falls. The DON stated Resident 1 ' s fall mats should be on both sides of the resident ' s bed. The DON stated Resident 1 had the potential to fall and sustain an injury. The DON stated the facility failed to provide a fall mat on both sides of Resident 1 ' s bed for safety. During a review of the facility ' s policy and procedure (PnP) titled, Managing Falls and Fall Risk, last reviewed on 1/2024, the PnP indicated based on previous evaluation and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The PnP indicated if underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.

Nov 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide the requested medical records for one of three sampled residents (Resident 1) when a request for medical records was received on 10/24/2024. This deficient practice resulted to Resident 1's right to obtain a copy of the medical records to be violated. Findings: During a review of Resident 1's Face sheet (front page of the chart that contains a summary of basic information about the resident), the Face sheet indicated the facility admitted the resident on 2/29/2024, with diagnoses that included heart failure (long-term condition that occurs when the heart can't pump enough blood to meet the body's needs). During a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/6/2024, indicated the resident had severe cognitive (relating to thinking or reasoning) impairment (loss of function). During an interview and record review on 11/4/2024 at 10:34 a.m., the Medical Records Director (MDR) stated the request for copies of Resident 1's medical records was received on 10/24/2024 was not fulfilled by the facility. The MDR confirmed the delay. The MDR stated this failure to provide timely access to medical records potentially violates facility policy and may negatively impact Resident 1, and could lead to compliance issues. During an interview on 11/4/2024 at 11/4/2024 at 11:38 a.m., the Director of Nursing (DON) stated the facility failed to issue the requested documents in a timely manner. During a review of the facility's policy and procedure titled, Release of Information, last revised date of 11/2009, indicated the resident may have access to his or her records within 72 hours (excluding weekends or holiday) of the resident's written or oral request (sponsor).

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life for one of three sampled residents (Resident 1) when the transportation attendant stated to Resident 1 You shut up! This deficient practice had the potential to result in emotional distress and loss of dignity for Resident 1. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/26/2024 with diagnoses of end stage renal disease (irreversible kidney failure), dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), generalized muscle weakness, and abnormalities of gait and mobility (the pattern of movement a person uses when walking or running, and how well they can move). During a record review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/30/2024, the MDS indicated Resident 1 to be fully alert, able to answer questions, and capable of completing decision-making tasks. During a phone interview on 10/17/2024 at 2:17 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 10/2/2024 approximately between 4:30 p.m. to 5 p.m., Resident 1 was returning from dialysis in a gurney (a wheeled stretcher used for transporting patients) accompanied by two transportation attendants. LVN 1 stated she heard the transportation attendant yell You shut up! to Resident 1. During an interview with Registered Nurse 1 (RN 1) on 10/17/2024 at 2:57 p.m., RN 1 stated yelling shut up to resident is not appropriate or acceptable as the residents are elderly and may be sensitive especially if they are ill. RN 1 stated that staff need to be careful of what words are used when speaking to the residents. During an interview with Resident 1 on 10/17/2024 at 3:45 p.m., Resident 1 stated he recalled being told to Shut up by the transportation attendants. When asked about the encounter, Resident 1 stated feeling afraid to be abused. During an interview with Registered Nurse 2 (RN 2) on 10/17/2024 at 4:04 p.m., RN 2 stated when she interviewed Resident 1 on 10/2/2024 after the incident with the transpotation attendants, Resident 1 stated to RN 2 the transportation attendants were rude to him (Resident 1). RN 2 stated, It is not appropriate to say shut up to a resident because they are sick and whatever disease they have, they can already be moody, and we need to provide emotional support to help the residents. We need to be supportive to the residents all the time as they are already sick, and they need more support to fight and keep up with disease they have as sometimes it is a chronological disease (a long-term health condition) as they live with the disease to the best of their ability. A record review of the facility provided policy and procedure titled Resident Rights with last revised date of 2/2021 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation.

Aug 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop and implement a care plan a person-centered care plan with measurable objectives and timeframes to one out of three sampled residents (Resident 1) by failing to develop a care plan that addressed Resident 4's non compliance with the diet ordered by the physician. Resident 1 was ordering and buying food outside of the facility. This deficient practice had the potential to negatively impact Resident 4's over all health. Findings: During a record review of Resident 1 ' s admission Record, it indicated the facility admitted Resident 1 on 5/20/2024, with diagnoses that included unspecified (unconfirmed) sepsis (a serious condition in which the body responds improperly to an infection), generalized muscle weakness and right ankle and foot Charcot ' s joint (a rare complication that happens when diabetes [uncontrolled elevated blood sugar] damages nerves in your lower legs and feet). During a record review of Resident 1 ' s History and Physical (H&P), dated 5/20/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/27/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required moderate assistance from staff for all activities of daily living (ADL-oral hygiene, toileting, personal hygiene and transferring). During a record review of Resident 1 ' s Order Summary Report dated 5/20/2024, it indicated a physician ' s order for carbohydrate controlled (means that meals contain carbohydrate-rich foods in fairly equal amounts), no added salt regular texture diet. During a record review of Resident 1 ' s Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) Progress Note dated 8/13/2024, it indicated Resident 1 preferred to order food from ouside of the facility. During an interview on 8/19/2024 at 8:51 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 goes out of the facility to buy food. During an interview on 8/19/2024 at 9:37 a.m., the Dietary Supervisor (DS), the DS stated she (DS) was not aware that Resident 1 orders food from outside of the facility. During an interview on 8/19/2024 at 10:35 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 was noncompliant with the physician prescribed diet and buys out side food. The ADON stated there is no care plan created addressing Resident 4 ' s preference for outside food. The ADON stated staff should be aware of foods brought in to ensure the diet ordered by the physicain is followed. During a record review of facility ' s policy and procedure titled, Foods Brought/Bought by Residents/family/Visitors, dated 2/2014 indicated, Staff must be aware of, and approve, food(s) brought to a resident by family/visitors or bought by a resident from the outside. The Dietitian or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan. During a record review of facility ' s PnP titled, Comprehensive Assessment and the Care Delivery Process dated 12/2016, the PnP indicated, Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions. During a record review of facility ' s PnP titled, Resident on Leave or Pass, dated 4/2022, indicated, The food services department shall be notified when a resident will be away from the facility during scheduled mealtimes. Nursing services will notify the food services department when a resident will be away from the facility during mealtimes. Notification will be in writing unless time constraints require verbal notification. Such information will include, but is not necessarily limited to: a. which meal(s) the resident will miss. b. how long the resident will be absent; and c. which meal the resident will be served upon returning to the facility.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician ' s order for out on pass (leave the facility for a period of time and then come back to continue their treatment. Out on pass is requested by the patients or residents and signed by the treating team. It is granted to the patient after clinical assessment) before Resident 1 was allowed to go out of the facility unsupervised. This deficient practice had the potential to place Resident 1 at risk for injuries resulting from accidents. Findings: During a record review of Resident 1 ' s admission Record, it indicated the facility admitted Resident 1 on 5/20/2024, with diagnoses that included unspecified (unconfirmed) sepsis (a serious condition in which the body responds improperly to an infection), generalized muscle weakness and right ankle and foot Charcot ' s joint (a rare complication that happens when diabetes [uncontrolled elevated blood sugar] damages nerves in your lower legs and feet). During a record review of Resident 1 ' s History and Physical (H&P) dated 5/20/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/27/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required moderate assistance from staff for all activities of daily living (ADL-oral hygiene, toileting, personal hygiene and transferring). The MDS indicated Resident 1 was occasionally incontinent (unable to control) of bowel and bladder functions. During a record review of Resident 1 ' s Order Summary Report dated 5/20/2024, it indicated an order for non-weight bearing (for a certain period of time following injury or surgery you are not allowed to put any weight through the operated or injured limb to allow it to heal) on right lower extremity. During a record review of Resident 1 ' s Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) Care Conference Notes dated 5/31/2024, it indicated Resident 1 required moderate assists from staff for most ADL ' s. During a record review of Resident 1 ' s Interdisciplinary Team Progress Note dated 8/13/2024, it indicated an IDT meeting was conducted with Long Term Care Ombudsman (OMB- a person that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences). The IDT Progress Note indicated per OMB, Resident 1 had the right to leave the facility whether he had a physician order or not as long as he signs out, on the Out on Pass Binder with expected time of return. During a record review of Resident 1 ' s Temporary Leave of Absence log dated 8/2024, it indicated Resident 1 left the facility unsupervised eight times with no documented expected time of return on the following dates: 8/5/2024, 8/15/2024, 8/16/2024 and 8/17/2024. During an interview on 8/19/2024 at 8:51 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had always wanted to leave the facility unsupervised. LVN 1 stated Resident 1 uses wheelchair when leaving the facility. During a concurrent interview and record review on 8/19/2024 at 10:35 a.m., with the Assistant Director of Nursing (ADON), Resident 1 ' s Physician Orders was reviewed. The ADON stated there were no physician order for Resident 1 to go out on pass unsupervised. During a concurrent interview and record review on 8/19/2024 at 11.44 a.m., with the ADON, Resident 1 ' s Progress Notes dated 8/2024 and Temporary Leave of Absence log dated 8/2024 was reviewed. The ADON stated there was no documented expected time of Resident 1's return on the following dates: 8/5/2024, 8/15/2024, 8/16/2024 and 8/17/2024. The ADON stated on 8/12/2024 there was no documented time Resident 1 came back to the facility. The ADON stated nurses should document in Progress Note, the time Resident 1 left the facility and the time Resident 1 returned to the facility to ensure resident safety. The ADON stated Resident 1 was placed at risk for accident when the resident was allowed to leave the facility unsupervised without a physician's order. During a concurrent interview and record review of facility ' s policy and procedure (PnP) titled, Residents on Leave or Pass dated 4/2022 indicated, The resident may go out on pass with the physician ' s order. Nursing services will inform the physician of the resident's desire to go out on pass or leave. Resident will be notified of the order. Resident will sign out before leaving the facility and sign back in upon arrival to the facility. The ADON stated their policy is to obtain a physician ' s order first before allowing Resident 1 to leave the facility unsupervised.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) by failing to ensure Transporter 2 wore facemask while picking up Resident 3 for an appointment on 8/19/2024, when the facility had one staff who tested positive Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) on 8/17/2024. This deficient practice had the potential for spread COVID-19 among residents and staff. Findings: During a record review of Resident 3 ' s admission Record, it indicated the facility admitted Resident 3 on 3/29/2024 with diagnoses that included other toxic encephalopathy (indicate brain dysfunction caused by toxic exposure), diabetes mellitus (uncontrolled elevated blood sugar) and unspecified (unconfirmed) 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). During a record review of Resident 3 ' s History and Physical (H&P) dated 3/30/2024, the H&P indicated Resident 3 can make needs known but could not make medical decisions. During a record review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 4/5/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a record review of Resident 3 ' s Physician Order dated 8/13/2024, it indicated an order for a dental appointment at 1 p.m., with scheduled pick up at 11:45 a.m. During a concurrent observation and interview on 8/19/2024 at 12:09 p.m., with Licensed Vocational Nurse 2 (LVN 2), in front of Nurses Station. Observed Transporter 2 not wearing a facemask while transferring Resident 3 from the wheelchair to the gurney (a wheeled stretcher used for transporting hospital patients). LVN 2 stated Transporter 2 should have worn a facemask while inside the facility. Observed LVN 2 talked to Transporter 2 and provided Transporter 2 with a facemask. During an interview on 8/19/2024 at 12:10 p.m., Transporter 2, Transporter 2 stated they came in from the back entrance of the facility and was not informed to wear a facemask inside the facility. During an interview on 8/19/2024 at 12:11 p.m., with the Infection Preventionist (IP), the IP stated they have one staff who tested positive for COVID -19 on 8/17/2024. The IP stated the facility's policy for masking is for staff and trasnport personnel to wear a facemask when inside the facility to prevent spread of COVID-19. During a record review of facility ' s policy and procedure (PnP) titled, Personal Protective Equipment-Face Mask/ N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) dated 7/2024 indicated The facility permits universal use of facemask and N95 respirators to minimize exposure to droplet and airborne contaminants including severe acute respiratory syndrome coronavirus 2 (SARsCoV2- a strain of coronavirus that causes COVID-19, the respiratory illness responsible for the COVID-19 pandemic [global outbreak]). Healthcare personnel must wear N95 respirator or surgical face mask when entering the facility. Transport personnel must wear face covering and other required PPE when indicated.

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

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 and services for two of four sampled residents (Resident 2 and Resident 3) by failing to: 1. Ensure Resident 2 and Resident 3's oxygen tubings were dated when it was changed. 2. Ensure Resident 2's oxygen tubing was free from kinks. These deficient practices had the potential for the residents to receive less oxygen needed in the body and develop respiratory diseases or infections. Findings: a. A review of Resident 2's admission Record indicated the facility admitted the resident on 4/4/2024 with diagnoses that included interstitial pulmonary disease (a large group of diseases that cause scarring of the lungs), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/11/2024, indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills was severely impaired. A review of the Physician Orders, dated 4/4/2024, indicated an order to administer oxygen at two to five liters per minute via nasal cannula (is a device that delivers extra oxygen through a tube and into your nose continuously) to maintain oxygen saturation (measures how much oxygen is carried by the hemoglobin [a protein in red blood cells that carries oxygen] in your blood) above 90 percent (%-unit of measurement) as needed for shortness of breath. On 5/30/2024 at 10:22 a.m., during a concurrent observation and interview with Registered nurse 1 (RN 1), Resident 2's oxygen cannula was observed on the resident's chest under the blanket. RN 1 stated that Resident 2's nasal cannula should be on the resident's nose. Resident 2's oxygen tubing connecting the oxygen concentrator (a medical device that separates nitrogen from the air so a person can breathe up to 95% pure oxygen) to the humidifier (a device that release water vapor or steam) was observed to be kinked. RN 1 stated that a kinked oxygen tubing had the potential for Resident 2 to receive less than required oxygen. Resident 2's oxygen tubing and oxygen cannula were not labeled with the date the supplies were replaced. Resident 2 did not have an oxygen supplies bag at bedside. RN 1 stated that Resident 2's oxygen tubing and cannula should be dated and there should be a dated oxygen supplies bag at bedside. RN 1 stated Resident 2's undated oxygen supplies had the potential to cause infections. RN 1 stated the facility failed to ensure that oxygen supplies were changed and dated. On 5/30/2024 at 1:28 p.m., during a concurrent interview and record review, the facility's policy and procedure titled, Oxygen Administration and Storage, dated 1/2024, was reviewed with the Director of Nursing (DON). The DON stated the facility policy indicated all oxygen or respiratory supplies will be replaced every 7 days and as needed. The Steps in the Procedure section of the policy indicated to check the tubing connected to the oxygen cylinder to assure it is free of kinks. The DON stated the facility failed to label the oxygen supplies and tubing with the date they were replaced. The DON stated the facility failed to ensure Resident 2's oxygen tubing was free from kinks. b. A review of Resident 3's admission Record indicated the facility admitted the resident on 5/23/2024 with diagnoses that included pulmonary embolism (a blood clot that develops in a blood vessel in the body then travels to a lung artery blocking the blood flow) with acute cor pulmonale (a condition that causes the right side of the heart to fail), respiratory failure (a condition in which the blood does not have enough oxygen or too much carbon dioxide) unspecified with hypoxia (low levels of oxygen in your body tissues), and pulmonary hypertension (occurs when the blood pressure in the lungs is higher than normal). A review of Resident 3's MDS, dated [DATE], indicated the resident's cognitive skills was intact. A review of the Physician Orders, dated 5/27/2024, indicated an order to administer oxygen at one to two liters per minute via nasal cannula continuously to maintain oxygen saturation greater than 82 percent related to respiratory failure unspecified with hypoxia. On 5/30/2024 at 10:30 a.m., during a concurrent observation and interview with RN 1, Resident 3's oxygen tubing was observed undated. RN 1 stated that if the oxygen supply bag was dated, it indicated the tubing was also changed on the same date. RN 1 was not able to state the facility's policy on care of resident's with oxygen. On 5/30/2024 at 1:28 p.m., during a concurrent interview and record review, the facility's policy and procedure titled, Oxygen Administration and Storage, dated 1/2024, was reviewed with the Director of Nursing (DON). The DON stated the facility policy indicated all oxygen or respiratory supplies will be replaced every 7 days and as needed. The DON stated the facility failed to label the oxygen supplies and tubing with the date they were replaced.

Mar 2024 15 deficiencies

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 a person-centered comprehensive care plan to address the resident's medical and physical needs for one of two sampled residents reviewed under non-pressure skin conditions (Resident 6) when the facility failed to develop a plan of care for Resident 6's scabs (dry, brown crust formed over a cut or broken skin to stop bleeding and protect the tissue underneath) on the head. This deficient practice had the potential for the resident's scabs to be left untreated and placed the resident at risk for infection. Cross-reference F684 Findings: A review of Resident 6's admission Record indicated the facility originally admitted Resident 6 on 3/20/2021 and readmitted the resident on 2/26/2022 with diagnoses including, but not limited to, anemia (condition in which blood does not have enough healthy red blood cells to carry oxygen all through the body) and peripheral vascular disease (the reduced circulation of blood to a body part to other than the brain and heart). A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/6/2023, indicated Resident 6 had moderately impaired cognition (difficulty understanding and making decisions), required moderate assistance with eating, oral hygiene, sit to lying, required maximal assistance with upper body dressing, personal hygiene, rolling left to right, lying to sitting on the side of the bed, sit to stand, chair or bed-to-chair transfers, walking ten feet, and was dependent on staff for toileting hygiene, showering or bathing himself, lower body dressing, putting on or taking off footwear, toilet transfers, and tub or shower transfer. The MDS further indicated Resident 6 did not have other ulcers, wounds, and skin problems. A review of Resident 6's History and Physical (H&P), dated 2/20/2024, indicated Resident 6 can make his needs known but cannot make medical decisions. The H&P further indicated Resident 6 did not have skin lesions (altered or different area of skin) or rashes. During a concurrent observation and interview with Resident 6, on 3/5/2024, at 4:35 p.m., inside Resident 6's room, Resident 6 was observed lying down in bed with a dark brown and rough texture appearing tissue on the left and right side of Resident 6's scalp with spots of uneven skin tone next to the tissue. Resident 6 stated he has a history of cancer (disease caused by an uncontrolled division of abnormal cells in a part of the body), has had surgery performed on his head and scalp, and he sometimes picks his scars. Resident 6 confirmed he had scabbing on his scalp and further stated he does not get treatments for his scalp from the facility. During a concurrent interview and record review with Treatment Nurse (TX) 2, on 3/8/2024, at 1:24 p.m., Resident 6's medical record was reviewed. Resident 6's Order Summary Report was reviewed, and TX 2 confirmed Resident 6 received treatments for his groin and there were no orders for treatment on Resident 6's scalp. TX 2 stated today was the first time she saw the scabs on Resident 6's scalp. TX 2 reviewed Resident 6's medical record and stated she is unable to find an assessment for Resident 6's scalp and stated the resident's scabbing should have been assessed to prevent further complications and so the facility can take care of the scabbing. TX 2 stated a certified nursing assistant (CNA), licensed vocational nurse (LVN), or registered nurse (RN) can report the resident's scabbing to the TX. A review of Resident 6's Care Plans did not indicate a care plan to address the resident's scabbing and TX 2 stated it is important to develop a plan of care to ensure Resident 6 will not develop any complications and heal the resident's scab. A review of Resident 6's Weekly Summary, dated between 1/29/2024 to 3/4/2024, did not indicate new skin issues or the resident's scabbing. TX 2 further stated CNAs perform skin checks while performing care to residents and will report findings to the TX and to other licensed staff, if the TX is not available. During an interview with Family Member (FM) 1, on 3/8/2024, at 1:50 p.m., FM 1 stated he visits Resident 6 every day and Resident 6 has had the scabs on his scalp for a couple of weeks. FM 1 stated Resident 6 tends to scratch his scars where he had surgery, and it breaks his skin. During an interview with CNA 2, on 3/8/2024, at 4:38 p.m., CNA 2 stated she was assigned to Resident 6 on 3/7/2024 and today. CNA 2 stated she noticed Resident 6's scabbing on both sides of his head. CNA 2 further stated she believed the charge nurse were aware of Resident 6's scabbing. During an interview with LVN 4, on 3/8/2024, at 4:45 p.m., LVN 4 stated she was assigned to Resident 6 on 3/7/2024 and today. LVN 4 stated she did not notice the scabbing on Resident 6's head on 3/7/2024. LVN 4 stated she was not aware Resident 6 had scabbing on his head. LVN 4 stated if the scabbing was new, an SBAR (Situation-Background-Assessment-Recommendation - a communication tool that helps share information about the condition of a resident that needs to be addressed) would be performed and she would inform the physician and family. LVN 4 further stated she was unsure if Resident 6 received treatments for his scabbing. During an interview with the Director of Nursing (DON), on 3/8/2024, at 5:13 p.m., the DON stated when performing a skin assessment, it is performed from head-to-toe and residents are checked for skin openings, redness, rashes, and any abnormalities on the skin. The DON stated skin checks can be done by licensed nurses and CNAs can observe residents' skin while performing care, such as showers, and inform the RN, LVN, or TX of their findings. The DON stated if there is a finding, an SBAR is conducted, the physician and family are notified, and a plan of care is developed. The DON stated she has observed the scabbing on Resident 6's scalp and an SBAR should have been conducted and the physician should have been contacted. The DON stated it is important to make sure the resident's scabbing is treated to prevent infection or decline. The DON stated if a scab is left untreated, it can possibly lead to infection. The DON further stated it is important to create a plan of care to provide proper interventions, heal the scab, and prevent infections. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 1/2024, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The P&P further indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 40) investigated during review of unnecessary medications. Cross-reference F760 Findings: A review of Resident 40's admission Record indicated the facility originally admitted Resident 40 on 5/17/2021 and readmitted the resident on 9/30/2023 with diagnoses including, but not limited to, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/13/2023, indicated Resident 40 had moderately impaired cognition (difficulty understanding and making decisions), required maximal assistance or was dependent on staff for activities of daily living, such as eating, dressing, and personal hygiene. The MDS further indicated Resident 40 received insulin injections. A review of Resident 40's History and Physical (H&P), dated 10/9/2023, indicated Resident 40 does not have the capacity to understand and make decisions and has a diagnosis of type two diabetes mellitus. A review of Resident 40's Order Summary Report, dated 2/5/2024, indicated an order for Humalog Injection Solution (also known as insulin lispro, a medication used to treat type two diabetes mellitus) 100 units per milliliter (ml - a unit of measure) inject as per sliding scale: - 60 to 149 = 0 units; - Less than 60, hypoglycemic (low blood sugar) protocol and inform physician; - 150 to 199 = two units; - 200 to 249 = four units; - 250 to 299 = six units; - 300 to 349 = eight units; - 350 to 399 = 10 units; - Greater than 400, 12 units and inform physician. The order summary report further indicated to administer subcutaneously before meals and at bedtime for type two diabetes mellitus. During a concurrent interview and record review with the Director of Nursing (DON), on 3/8/2024, at 5:13 p.m., Resident 40's Location of Administration Report, dated 3/1/2024 to 3/31/2024 was reviewed and the DON confirmed the injection site for Humalog Injection Solution were not rotated on the following dates, times, route, and locations: - 3/1/2024 9:30 p.m. subcutaneously abdomen right upper quadrant (RUQ). - 3/2/2024 11:54 a.m. subcutaneously abdomen RUQ. - 3/4/2024 6:30 a.m. subcutaneously abdomen left upper quadrant (LUQ). - 3/4/2024 11:53 a.m. subcutaneously abdomen LUQ. - 3/7/2024 6:10 a.m. subcutaneously abdomen left lower quadrant (LLQ). - 3/7/2024 11:18 a.m. subcutaneously abdomen LLQ. The DON stated it is important to rotate insulin injection sites so that there is no accumulation of insulin at one site and to prevent lipodystrophy (complete or partial loss of and/or abnormal distribution of fat tissue). The DON further stated not rotating insulin injection sites might affect the absorption of medication. A review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 1/2024, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). A review of the Humalog Manufacturers' Guidelines provided by the facility, revised 7/2023, indicated to change (rotate) your injection sites within the area you choose for each dose to reduce the risk of getting lipodystrophy and localized cutaneous amyloidosis (skin with lumps) at the injection sites.

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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Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for one of two sampled residents reviewed under non-pressure skin conditions (Resident 6) when the facility failed to assess and treat Resident 6's scabs (dry, brown crust formed over a cut or broken skin to stop bleeding and protect the tissue underneath) on the head. This deficient practice had the potential for the resident's scabs to be left untreated and place the resident at risk for infection. Cross-reference F656 Findings: A review of Resident 6's admission Record indicated the facility originally admitted Resident 6 on 3/20/2021 and readmitted the resident on 2/26/2022 with diagnoses including, but not limited to, anemia (condition in which blood does not have enough healthy red blood cells to carry oxygen all through the body) and peripheral vascular disease (the reduced circulation of blood to a body part to other than the brain and heart). A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/6/2023, indicated Resident 6 had moderately impaired cognition (difficulty understanding and making decisions), required moderate assistance with eating, oral hygiene, sit to lying, required maximal assistance with upper body dressing, personal hygiene, rolling left to right, lying to sitting on the side of the bed, sit to stand, chair or bed-to-chair transfers, walking ten feet, and was dependent on staff for toileting hygiene, showering or bathing himself, lower body dressing, putting on or taking off footwear, toilet transfers, and tub or shower transfer. The MDS further indicated Resident 6 did not have other ulcers, wounds, and skin problems. A review of Resident 6's History and Physical (H&P), dated 2/20/2024, indicated Resident 6 can make his needs known but cannot make medical decisions. The H&P further indicated Resident 6 did not have skin lesions (altered or different area of skin) or rashes. During a concurrent observation and interview with Resident 6, on 3/5/2024, at 4:35 p.m., inside Resident 6's room, Resident 6 was observed lying down in bed with a dark brown tissue on the left and right side of Resident 6's scalp with spots of uneven skin tone next to the tissue. Resident 6 stated he has a history of cancer (disease caused by an uncontrolled division of abnormal cells in a part of the body), has had surgery performed on his head and scalp, and he sometimes picks his scars. Resident 6 confirmed he had scabbing on his scalp and further stated he does not get treatments for his scalp from the facility. During a concurrent interview and record review with Treatment Nurse (TX) 2, on 3/8/2024, at 1:24 p.m., Resident 6's medical record was reviewed. Resident 6's Order Summary Report was reviewed, and TX 2 confirmed Resident 6 received treatments for his groin and there were no orders for treatment on Resident 6's scalp. TX 2 stated today was the first time she saw the scabs on Resident 6's scalp. TX 2 reviewed Resident 6's medical record and stated she is unable to find an assessment for Resident 6's scalp and stated the resident's scabbing should have been assessed to prevent further complications and so the facility can take care of the scabbing. TX 2 stated a certified nursing assistant (CNA), licensed vocational nurse (LVN), or registered nurse (RN) can report the resident's scabbing to the TX. A review of Resident 6's Weekly Summary, dated between 1/29/2024 to 3/4/2024, did not indicate new skin issues or the resident's scabbing. TX 2 further stated CNAs perform skin checks while performing care to residents and will report findings to the TX and to other licensed staff, if the TX is not available. During an interview with Family Member (FM) 1, on 3/8/2024, at 1:50 p.m., FM 1 stated he visits Resident 6 every day and Resident 6 has had the scabs on his scalp for a couple of weeks. FM 1 stated Resident 6 tends to scratch his scars where he had surgery, and it breaks his skin. During an interview with CNA 2, on 3/8/2024, at 4:38 p.m., CNA 2 stated she was assigned to Resident 6 on 3/7/2024 and today. CNA 2 stated she noticed Resident 6's scabbing on both sides of his head. CNA 2 further stated she believed the charge nurse were aware of Resident 6's scabbing. During an interview with LVN 4, on 3/8/2024, at 4:45 p.m., LVN 4 stated she was assigned to Resident 6 on 3/7/2024 and today. LVN 4 stated she did not notice the scabbing on Resident 6's head on 3/7/2024. LVN 4 stated she was not aware Resident 6 had scabbing on his head. LVN 4 stated if the scabbing was new, an SBAR (Situation-Background-Assessment-Recommendation - a communication tool that helps share information about the condition of a resident that needs to be addressed) would be performed and she would inform the physician and family. LVN 4 further stated she was unsure if Resident 6 received treatments for his scabbing. During an interview with the Director of Nursing (DON), on 3/8/2024, at 5:13 p.m., the DON stated when performing a skin assessment, it is performed from head-to-toe and residents are checked for skin openings, redness, rashes, and any abnormalities on the skin. The DON stated skin checks can be done by licensed nurses and CNAs can observe residents' skin while performing care, such as showers, and inform the RN, LVN, or TX of their findings. The DON stated if there is a finding, an SBAR is conducted, the physician and family are notified, and a plan of care is developed. The DON stated she has observed the scabbing on Resident 6's scalp and an SBAR should have been conducted and the physician should have been contacted. The DON stated it is important to make sure the resident's scabbing is treated to prevent infection or decline. The DON stated if a scab is left untreated, it can possibly lead to infection. The DON further stated it is important to create a plan of care to provide proper interventions, heal the scab, and prevent infections. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, last reviewed 1/2024, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition. The P&P indicated a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. The P&P further indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure urinary catheter bags (container that connects to a urinary catheter and collects urine) are not touching the floor for one out of one sampled resident (Resident 83) investigated during review of urinary catheters (a tube that is inserted into the bladder, allowing urine to drain) care area. This deficient practice had the increased potential for residents to obtain a ueinary tract infection (UTI, common infections that happen when bacteria infect the urinary tract). Findings: A review of Resident 83's admission Record indicated the facility admitted Resident 83 on 1/23/2024 with diagnoses including, but not limited to, obstructive and reflux uropathy (when urine cannot drain through the urinary tract). A review of Resident 83's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/5/2024, indicated Resident 83 was rarely or never understood, required maximal assistance or was dependent on staff for activities of daily living, such as eating, dressing, and hygiene, and had an indwelling catheter. A review of Resident 83's History and Physical (H&P), dated 1/20/2024, indicated Resident 83 does not have the capacity to understand and make decisions and had a diagnosis including urinary retention with urinary catheter. A review of Resident 83's Order Summary Report, dated 2/27/2024, indicated to insert or change the indwelling catheter, 16 French (a scale used to measure the size of the catheter), 10 milliliters (ml - a unit of measure) to drainage bag for diagnosis of obstructive uropathy. The order summary report further indicated to change if there is blockage, leakage, removal, or dislodged. During an observation on 3/5/2024, at 10:42 a.m., inside Resident 83's room, Resident 83 was observed lying down in bed with her bed in low position, approximately two to three feet off the floor. On the left side of Resident 83's bed, opposite of the entrance of the room, a urinary catheter bag hung on the side of the bed's frame and was touching the floor. During a concurrent interview and record review, with the Director of Nursing (DON), on 3/8/2024, at 5:13 p.m. the DON stated urinary catheter bags should not be touching the floor to prevent infections. A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed 1/2024, indicated to be sure the catheter tubing and drainage bag are kept off the floor.

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on interview, and record review, the facility failed to ensure two (2) out of 2 Treatment Nurses (TX - licensed nurses responsible for providing primary skin care to residents, with an emphasis on treatment and therapy of skin disorders) (Treatment Nurse 1/TX 1, and Treatment Nurse 2/TX 2) have the specific competency and skills set necessary to care for residents with pressure injuries or wounds investigated under the sufficient and competent nurse staffing task by failing to: 1. Identify and address the change in condition when Resident 76's PI measurement increased in size and had a change in characteristics. 2. Ensure accurate documentation of Resident 76's PI measurement, characteristics, and classification. These deficient practices placed the residents at risk for development and worsening of pressure injuries. Cross Reference to F686 Findings: A review of Resident 76's admission Record indicated the facility admitted the resident on 9/20/2023 and readmitted the resident on 2/29/2024 with diagnoses including heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), presence of cardiac pacemaker (a small, battery-powered device placed under the skin thru surgery that prevents the heart from beating too slowly), and pressure ulcer (an injury that breaks down the skin and underlying tissue) of the sacral region (portion of the spine between the lower back and tailbone). A review of Resident 76's History and Physical (H&P) dated 3/1/2024, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 76 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 12/28/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) but able to understand others and make his needs known. The MDS indicated Resident 76 required substantial/maximal assistance with eating and totally dependent on staff with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 76's Weekly Skin Ulcer Report indicated the following: 1. 11/14/2023: facility acquired sacrococcyx stage 2 PI measuring 3.0 centimeters length (cm - a unit of measurement) x 7.0 cm width x 0.3 cm depth 50% yellowish pink slough (a non-viable tissue which formed when dead cells or bacteria accumulate in the wound) and 50% red granulation tissue (describes the appearance of the red, bumpy tissue in the wound bed as the wound heals). The report indicated the wound was slightly responding to treatment and was seen by the wound care physician. 2. 11/24/2023: facility acquired sacrococcyx stage 2 PI measuring 4.0 cm x 4.0 cm x 0.2 cm 70% yellowish slough and 30% red granulation tissue. The report indicated the wound was slightly responding to treatment and was seen by the wound care physician. 3. 1/19/2024: facility acquired sacrococcyx stage 2 PI measuring 3.5 cm x 1.5 cm x 0.5 cm 5% yellowish pink slough and 95% red granulation tissue. The report indicated the resident was seen by the wound care physician and performed debridement. 4. 1/26/2024: facility acquired sacrococcyx stage 2 PI measuring 3.5 cm x 1.2 cm x 0.5 cm 10% yellowish pink slough and 90% red granulation tissue. The report indicated the resident was seen by the wound care physician and performed debridement. 5. 2/2/2024: facility acquired sacrococcyx stage 2 PI measuring 3.5 cm x 1.2 cm x 0.5 cm 10% yellowish pink slough and 90% red granulation tissue. The report indicated the wound was slightly responding to treatment. 6. 2/8/2024: facility acquired sacrococcyx stage 3 PI measuring 3.5 cm x 2 cm x 1.3 cm 30% purple colored necrosis (dead or devitalized non-viable tissue which impedes wound healing) 30% yellowish pink slough 40% red granulation tissue. 7. 2/16/2024: 3.7 cm x 2.7 cm x 1.7 cm 60% purple colored necrosis 30% yellowish pink slough 10% red granulation tissue. 8. 2/22/2024 sacrococcyx stage 3 PI measuring 4.0 cm x 2.0 cm x 2.0 cm 70% necrosis 30% yellowish slough. A review of Resident 76's SBAR Communication Form indicated the following on the following dates: 1. 11/10/2023 indicated the resident developed moisture associated skin damage (MASD) on the sacrococcyx area and left buttock. The SBAR indicate the physician was notified with an order to clean with NS, pat dry, apply zinc oxide (a cream which helps managing skin conditions and leg ulcerations as it provides a protective barrier, reduces inflammation, and creates a moist wound healing environment where the skins integrity has been lost) and leave open to air for 14 days. 2. 1/3/2024 indicated the resident had reopening of healed stage two (2) PI of the sacrococcyx. The SBAR indicate the WCC 1 physician was notified and stated to continue with current plan of care until consultation. 3. 2/7/2024 indicated the resident had worsening of sacrococcyx stage 2 PI to stage 3 with the following descriptions, 3.5 centimeters (cm - a unit of measurement) x 1.2 cm x 0.5 cm 10 % slough 90% granulation tissue. The WCC 1 physician was notified and stated to continue with current order to cleanse with NS, pat dry, apply santyl ointment, cover with calcium alginate and dry dressing. A review of Resident 76's Wound Care Evaluation and Treatments by Wound Care Company 1 (WCC 1) physician indicated the following: 1. 11/22/2023: sacral ulcer stage 3 4.0 cm x 4.0 cm x 0.2 cm 70% yellowish slough and 30% red granulation tissue. The report indicated the wound condition as unchanged and a plan to clean wound with NS, apply santyl ointment to ulcer and cover with calcium alginate daily, zinc oxide to surrounding area. 2. 1/18/2024: sacral ulcer stage 2 3.5 cm x 1.5 cm x 0.5 cm 10% necrosis 40% yellowish slough and 50% red granulation tissue. The report indicated post debridement measurement as 3.6 cm x 1.6 cm x 0.8 cm stage 3. 3. 1/25/2024: sacral ulcer stage 2 3.2 cm x 1.2 cm x 0.5 cm 50% yellowish slough and 50% red granulation tissue. The report indicated post debridement measurement as 3.3 cm x 1.3 cm x 0.6 cm stage 3. 4. 2/1/2023: sacral ulcer stage 3 3.2 cm x 1.2 cm x 0.5 cm 30% necrosis 30% yellowish slough and 40% red granulation tissue. The report indicated post debridement measurement as 3.3 cm x 1.3 cm x 0.6 cm stage 3. 5. 2/8/2023: sacral ulcer stage 3 3.5 cm x 2 cm x 1.5 cm 60% necrosis 10% yellowish slough and 30% red granulation tissue. The report indicated post debridement measurement as 3.3 cm x 1.3 cm x 0.6 cm stage 3. 6. 2/15/2023: sacral ulcer stage 3 3.7 cm x 2.7 cm x 1.7 cm 60% necrosis 10% yellowish slough and 30% red granulation tissue. The report indicated post debridement measurement as 3.8 cm x 1.8 cm x 2.0 cm stage 3. 7. 2/22/2024: sacral ulcer stage 3 4.0 cm x 2.7 cm x 2.0 cm 70% necrosis 30% yellowish slough. The report indicated post debridement measurement as 4.1 cm x 2.8 cm x 2.3 cm stage 3. During a concurrent interview and record review on 3/8/2024 at 11:09, reviewed TX 1's and TX 2's Licensed Nurse Core Clinical Competency Checklist dated 4/16/2023 with the Director of Staff Development (DSD). The DSD verified the checklist did not specify competency skills specific for skin and wound care or treatment. The DSD verified the competency checklist only indicated competency checked for measuring pressure ulcer/non-pressure ulcer size. During a concurrent interview and record review on 3/8/2024 at 9:30 a.m., reviewed Resident 76's weekly Skin Ulcer Report, SBAR Communication Form, and Wound Care and Treatment Notes by WCC 1 in the HER with TX 1. TX 1 verified there was no documented evidence that SBAR Communication Forms were initiated on 11/14/2023 when the sacrococcyx PI deteriorated from MASD to a stage 2, on 11/22/2023 when the WCC 1 physician documented the sacrococcyx stage 2 PI as stage 3, and on 2/1 2023 when the WCC 1 physician documented the reopened sacrococcyx stage 2 PI as stage 3. TX 1 stated he should have initiated the SBAR so the resident/resident representative, physician, staff, and other members of the team would be aware of Resident 76's current PI condition or status and provide the resident the necessary treatment and services. TX 1 stated that a slough was not a healthy tissue, and he should have documented Resident 76's sacrococcyx PI as stage 3 upon observation of slough on 11/14/2024. TX 1 stated wounds or PIs should be classified accurately to ensure the resident receive the proper treatment as it may lead to worsening of the wound and/or infection. TX 1 verified that the measurements and descriptions he indicated on the weekly Skin Ulcer Reports on 11/14/2023, 11/24/2023, 1/19/2024, 1/26/2024, 2/2/2024, 2/8/2024, and /26/2024 were different from WCC 1 physician's notes and were documented inaccurately. TX 1 stated he should have documented more accurately so staff would be aware of Resident 76's PI status to prevent confusion. During an interview on 3/8/2024 at 12:30 p.m., the Director of Nursing (DON) stated Licensed Nurse competencies are checked upon hire and annually either by the Registered Nurse (RN), Director of Staff Development (DSD), or DON. The DON stated they will check the performance of a task and sign the paper after observation. The DON stated the facility did not have competency check specific to skin and wound care or treatment. The SBAR on 11/14/2023, 11/22/2023, and 2/1/2024 should have been done when Resident 76's sacrococcyx PI increased in size and changed in classification so the proper treatment would be initiated to prevent further deterioration of the PI. The DON stated the SBAR is important so the resident/resident representative, physician, and staff would be aware of Resident 76's current PI status. The DON stated initiation of proper treatment for PI is important to prevent provision of care and services the resident needs. The DON stated it was important to identify and address any change in Resident 76's PI for the resident to receive the necessary care and treatment needed to promote healing. The DON further stated TX 1 should have documented Resident 76's sacrococcyx PI accurately in the EHR for accuracy of records to prevent confusion between staff and/or members of the team. A review of the facility's undated job description for Licensed Vocational Nurse (LVN) indicated the duties and responsibilities include but not limited to the following: 1. Implements resident plan of care and evaluates resident response. 2. Works in accordance with the current federal, state, and local guidelines and regulations, company policies and procedures and nursing standards. 3. Performs interventions and treatments in a timely manner. Explanations of intervention or treatment are provided to resident/family as appropriate. 4. Performs documentation responsibilities in accordance with company requirements. Completes accurate, thorough, and timely admission records, routine resident observations/transfer notes, death/discharge summaries and changes in resident's physical/psychological condition in accordance with facility policies and procedures. 5. Must be knowledgeable of nursing/medical practices and procedures, and/or terminology, laws, regulations, and the guidelines that pertain to long term. A review of the facility's policy and procedure titled, Competency of Nursing Staff, last reviewed 1/14/2024, indicated the following: 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. Licensed nurses employed by the facility will demonstrate specific competencies and skill sets necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. 3. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as skin and wound care, and identification of changes in condition. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, last reviewed 1/16/2024 indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The policy indicated the following: -Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider including information prompted by the Interact SBAR Communication Form. -Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. -The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the facility's policy and procedure titled, Charting and Documentation, last reviewed 1/16/2024 indicated the following: 1. All services provided to the resident, progress toward the care plan goals, or an changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. 2. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective, complete, and accurate. 4. Documentation of procedures and treatments will include care-specific details including the assessment data and/or any unusual findings obtained during the procedure/treatment, and notification of family, physician, or other staff, if indicated. A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last reviewed 1/16/2024 indicated the following: 1. The nurse shall describe and document/report a full assessment of pressure sore including location, stage, length, width, and depth, presence of exudate or necrotic tissue. 2. The physician will assist staff to identify the type and characteristics of an ulcer.

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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Based on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Resident 193 in one of two inspected medication carts (Station 2 Cart 4.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and that Resident 193 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an observation and concurrent interview of Station 2 Cart 4, on 3/7/24 at 2:05 PM, with the Licensed Vocational Nurse (LVN 4), the following discrepancies were found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): Resident 193's Controlled Drug Record for hydrocodone/apap (a medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) indicated there were 12 doses left, however, the medication card contained 11 doses. During a concurrent interview, LVN 4 stated she gave the missing dose of hydrocodone/apap 5/325 to Resident 193 at 9:00 AM but failed to document the dose on the Controlled Drug Record at that time. LVN 4 stated she failed to sign the Controlled Drug Record at the time of administration because she was distracted by other tasks. LVN 4 stated she understands that the policy is to sign the accountability log immediately after the administration in order to maintain continuous accountability of controlled substances. LVN 4 stated failing to keep this record accurate could result in Resident 193 receiving too much or too little medication which could cause medical complications possibly resulting in hospitalization. A review of the facility's policy Controlled Substances, revised April 2019, indicated .Controlled substances are reconciled upon receipt, administration, disposition and at the end of each shift . upon administration: The nurse administering the medication is responsible for recording . signature of nurse administering medication .

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 follow up on the consultant pharmacist's request for an iron panel (a laboratory test showing a resident's blood iron levels) lab draw after resident refusal or notify the physician of resident refusal of the lab draw in one of five sampled residents (Resident 38.) The deficient practices of failing to notify the physician of a resident refusal for lab draw and failing to follow up on the consultant pharmacist's request to obtain lab values increased the risk that Resident 38 could have experience toxicity from too much iron resulting in health complications and a decreased quality of life. Findings: A review of Resident 38's admission Record, dated 3/8/24, indicated he was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including: anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells sometimes caused by an iron deficiency.) A review of Resident 38's physician note (a record of a physician's comprehensive medical examination), dated 2/18/24 indicated Resident 38 does not have the capacity to understand and make decisions. A review of Resident 38's Order Summary Report (a monthly recap report of all active physician's orders), dated 3/8/24, indicate on 2/17/24, Resident 38's attending physician prescribed ferrous sulfate (an iron supplement) 325 milligrams (mg - a unit of measure for mass) by mouth daily for a supplement. A review of Resident 38's available care plans, last revised 12/13/23, indicated he had a known problem of striking out and screaming during care and being non-compliant with care due to dementia (a condition characterized by a progressive or persistent loss of intellectual functioning, especially with impairment of memory and personality change.) A review of the consultant pharmacist's recommendation, dated 1/17/24, indicated the consultant pharmacist recommended to Resident 38's attending physician to obtain an iron panel lab draw to assess the safety and effectiveness of long-term iron therapy. Further review of this recommendation indicated Resident 38's physician agreed and accepted the recommendation on 1/20/24. A review of the facility's lab requisition (physician order for a lab report), dated 1/24/24, indicated the facility attempted to draw blood from Resident 38 to obtain the iron panel on 1/24/24, but the resident refused to have his blood drawn. A review of Resident 38's clinical record indicated there were no other documented attempts to draw Resident 38's blood to obtain the iron panel after 1/24/24 or any documented notification to the physician that the resident had refused to allow the blood draw. A review of the facility's policy Consultant Pharmacist Reports, dated June 2021, indicated Recommendations are acted upon and documented by the facility staff and/or the prescriber . A review of the facility's policy Resident Rights Guidelines for All Nursing Procedures, revised October 2010, indicated Ask permission to implement the procedure. If the resident refuses, notify your supervisor . During an interview on 3/8/24 at 12:17 PM with the Director of Nursing (DON), the DON stated the facility entered an order to obtain a lab draw from Resident 38 for the iron panel as recommended by the consultant pharmacist on 1/24/24, however, Resident 38 refused the lab draw at that time. The DON stated the facility failed to attempt to obtain the lab draw from Resident 38 later or notify the physician regarding the refusal. The DON stated Resident 38 could be at risk of iron toxicity because the lab order was never obtained and no other attempt to obtain it was made after 1/24/24. The DON stated Resident 38 has a history of refusing care due to his dementia and the facility should have notified the physician that he was refusing to allow the facility to collect his blood for labs and requested further instruction at that time. The DON stated failure to obtain the iron panel lab values per the pharmacist's recommendation and the physician's order could have resulted in health complications possibly leading to hospitalization or a diminished quality of life.

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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Based on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 40) investigated under unnecessary medications. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross-reference F658 Findings: A review of Resident 40's admission Record indicated the facility originally admitted Resident 40 on 5/17/2021 and readmitted the resident on 9/30/2023 with diagnoses including, but not limited to, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/13/2023, indicated Resident 40 had moderately impaired cognition (difficulty understanding and making decisions), required maximal assistance or was dependent on staff for activities of daily living, such as eating, dressing, and personal hygiene. The MDS further indicated Resident 40 received insulin injections. A review of Resident 40's History and Physical (H&P), dated 10/9/2023, indicated Resident 40 does not have the capacity to understand and make decisions and has a diagnosis of type two diabetes mellitus. A review of Resident 40's Order Summary Report, dated 2/5/2024, indicated an order for Humalog Injection Solution (also known as insulin lispro, a medication used to treat type two diabetes mellitus) 100 units per milliliter (ml - a unit of measure) inject as per sliding scale: - 60 to 149 = 0 units; - Less than 60, hypoglycemic (low blood sugar) protocol and inform physician; - 150 to 199 = two units; - 200 to 249 = four units; - 250 to 299 = six units; - 300 to 349 = eight units; - 350 to 399 = 10 units; - Greater than 400, 12 units and inform physician. The order summary report further indicated to administer subcutaneously before meals and at bedtime for type two diabetes mellitus. During a concurrent interview and record review with the Director of Nursing (DON), on 3/8/2024, at 5:13 p.m., Resident 40's Location of Administration Report, dated 3/1/2024 to 3/31/2024 was reviewed and the DON confirmed the injection site for Humalog Injection Solution were not rotated on the following dates, times, route, and locations: - 3/1/2024 9:30 p.m. subcutaneously abdomen right upper quadrant (RUQ). - 3/2/2024 11:54 a.m. subcutaneously abdomen RUQ. - 3/4/2024 6:30 a.m. subcutaneously abdomen left upper quadrant (LUQ). - 3/4/2024 11:53 a.m. subcutaneously abdomen LUQ. - 3/7/2024 6:10 a.m. subcutaneously abdomen left lower quadrant (LLQ). - 3/7/2024 11:18 a.m. subcutaneously abdomen LLQ. The DON stated it is important to rotate insulin injection sites so that there is no accumulation of insulin at one site and to prevent lipodystrophy (complete or partial loss of and/or abnormal distribution of fat tissue). The DON further stated not rotating insulin injection sites might affect the absorption of medication. A review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed 1/2024, indicated injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). A review of the facility's P&P titled, Adverse Consequences and Medication Errors, last reviewed 1/2024, indicated a medication error is defined as the preparation of administration of drugs or biological (substance that is made from a living organism or its products and is used in the prevention, diagnosis or treatment of diseases) which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. A review of the Humalog Manufacturers' Guidelines provided by the facility, revised 7/2023, indicated to change (rotate) your injection sites within the area you choose for each dose to reduce the risk of getting lipodystrophy and localized cutaneous amyloidosis at the injection sites.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) in a consistent manner for one of one sampled resident (Resident 76) investigated during review of hospice services by failing to provide documented evidence that an interdisciplinary team (IDT - a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meeting was held with hospice representatives to discuss Resident 76's hospice plan of care. This deficient practice had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services. Findings: A review of Resident 76's admission Record indicated the facility admitted the resident on 9/20/2023 and readmitted the resident on 2/29/2024 with diagnoses including heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), presence of cardiac pacemaker (a small, battery-powered device placed under the skin thru surgery that prevents the heart from beating too slowly), and pressure ulcer (an injury that breaks down the skin and underlying tissue) of the sacral region (portion of the spine between the lower back and tailbone). A review of Resident 76's History and Physical (H&P) dated 3/1/2024, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 76 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 12/28/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) but able to understand others and make his needs known. The MDS indicated Resident 76 required substantial/maximal assistance with eating and totally dependent on staff with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 76's facility care plan on hospice care, initiated on 3/11/2024, last revised 3/5/2024, indicated will respect and support resident and family wishes regarding health care directives and the resident will be free from signs and symptoms of pain the care plan included an intervention to integrate care with hospice care team. A review of Resident 76's Order Summary Report, indicated a physician's order dated 2/29/2024 to admit resident to Hospice Provider 1 (HP 1). A review of Resident 76's Physician Certification for Hospice Benefit, effective date 2/29/2024 to 5/28/2024, indicated the resident was certified for hospice benefit and with terminal diagnosis of heart failure. During a review of Resident 76's electronic health record (EHR) there was no documented evidence the facility conducted an IDT meeting with Hospice Provider 1 (HP 1) representative and resident/resident representative. During a concurrent interview and record review on 3/8/2024 at 1:53 p.m., reviewed resident 76's EHR with the Director of Nursing (DON). The DON stated that she is the designated facility representative to coordinate care with hospice providers. The DON stated she spoke with HP 1 Registered Nurse (RN) via telephone regarding Resident 76's readmission from the general acute care hospital (GACH) for hospice care. The DON verified there was no documented evidence that an IDT was conducted with HP 1 and resident and or the resident representative when Resident 76 was readmitted to the facility. The DON stated IDT meetings are held upon admission, quarterly and as needed. The DON stated the facility did not have specific policy addressing frequency of IDT meetings. The DON stated the IDT meeting should have been held upon admission with HP 1 representative to integrate Resident 76's care plan with hospice care to prevent delay in the provision of necessary care and services. A review of the facility's policy and procedure titled, Hospice Program, last reviewed 1/2024, indicated the following: It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs including communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. The facility has designated the DON to coordinate care provided to the resident by collaborating with hospice representative and coordinating facility staff participation in the hospice care planning process for residents receiving these services.

CONCERN (E)

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

Deficiency F0678 (Tag F0678)

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 implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (AHA, a non-profit organization that aims to reduce disability and death from cardiovascular diseases and stroke) CPR certification for three of five sampled employees (Registered Nurse 1 [RN 1], Treatment Nurse 1 [TX 1], and Certified Nursing Assistant [CNA 1]) investigated during review of sufficient and competent nurse staffing task. These deficient practices had the potential of delayed provisions of emergency care for current residents who wishes to have full treatment in a life-threatening situation. Findings: During a concurrent interview and record review on [DATE] at 10:52 a.m. with the Director of Staff Development (DSD), reviewed the facility's employee files. The DSD stated CNA 1, TX 1, and RN 1's basic life support/CPR trainings were completed online and were not from the American Red Cross (ARC) or American Heart Association (AHA). During a concurrent interview and record review on [DATE] at 2:47 p.m. with CNA 1, reviewed CNA 1's CPR certificate. CNA 1 stated she completed her CPR training online. During a concurrent interview and record review on [DATE] at 2:50 p.m. with TX 1, reviewed TX 1's CPR certificate. TX 1 stated he took his CPR training online. During an interview on [DATE] at 3:14 p.m., the Director of Nursing (DON) stated licensed and non-licensed staff should have been provided an in-person CPR training. The DON stated the DSD is responsible for checking the CNAs and licensed staff received their CPR training. The DON stated staff who took online CPR class may not be able provide the necessary resuscitative efforts which could lead to potential loss of life. A review of the facility's policy and procedure titled, Emergency Procedure - Cardiopulmonary Resuscitation, reviewed and approved on 1/2024, indicated personnel will obtain or maintain basic life support or CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. The CPR team include at least one nurse, licensed practical nurse/licensed vocational nurse, and CNAs, all of whom have received training and certification in CPR/BLS.

CONCERN (E)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure injury (PI - breakdown of skin integrity due to pressure) for two out of two sampled residents (Residents 22 and 76) investigated under pressure ulcer care area, by: 1. Failing to ensure Resident 22's low air loss mattress (LALM - mattress designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set according to the manufacturer's guideline. 2. Failing to ensure there was documented evidence that a Situational-Background-Assessment-Recommendation (SBAR - (SBAR, communication form between members of the health care team caring for a resident about his/her condition) was done on 11/14/2023 and 11/22/2024 when there was a change in size and/or characteristics in Resident 76's skin breakdown and PI. 3. Failing to identify and address the change in condition when Resident 76's PI measurement increased in size and characteristics. 4. Failing to accurately document Resident 76's PI measurement, characteristics, and classification. These deficient practices placed Residents 22 and 76 at risk for development and/or worsening of pressure ulcers and had a potential in the delay of provision of necessary care and services to the residents. Findings: a. A review of Resident 22's admission Record indicated the facility admitted the resident on 9/5/2022 and readmitted the resident on 2/13/2024 with diagnoses including syncope (also known as fainting - a temporary loss of consciousness with a quick recovery) and collapse, right hand contracture (tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), and muscle wasting and atrophy (a decrease in size and thinning of muscle tissue). A review of Resident 22's History and Physical (H&P), dated 2/13/2024, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 22's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/17/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 22 was wheelchair bound, unable to ambulate, to stand from sitting, and to get on and off a toilet or commode. The MDs indicated Resident 22 was dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 22's Order Summary Report indicated the following physician's orders dated 2/13/2024: - LALM in place for skin/wound management: monitor every shift for appropriate settings, functioning and resident comfort every shift. - Healed left trochanter stage 4 PI: monitor skin for reopening and skin breakdown every day shift. A review of Resident 22's electronic health record (EHR) indicated Resident 22's current weight dated 2/27/2024 was 118 pounds (lbs.-measurement of weight). During a concurrent observation, interview, and record review on 3/5/2024 at 2:34 p.m., observed Resident 22 lying in bed asleep with the LALM device labeled with a silver-colored sticker with a red arrow pointing between 180-250 pounds. TX 1 verified the LALM was set between 180-25 lbs. TX 1 stated the facility follows the manufacturer's guidelines for the LALM setting to be based on the resident's weight. Resident 22's EHR was reviewed with TX 1 and TX 1 verified that the resident weighed 118 lbs. on 2/27/2024. TX 1 stated Resident 22 LALM should have been set between 110-120 lbs. TX 1 stated not following the manufacturer's guidelines placed Resident 22 at risk for development of PI or skin breakdown. During a concurrent interview and record review on 3/7/2024 at 3:40 p.m., reviewed Resident 22's current weight in the HER with Treatment Nurse 2 (TX 2). TX 2 verified Resident 22's weight is 118 lbs. TX 2 stated licensed nurses are responsible in ensuring LALM settings are based on resident's weight [er manufacturer's guideline. TX 2 stated Resident 22's LALM setting should have been set at 120 lbs. TX 2 stated not following the manufacturer's guideline placed the resident at risk for skin breakdown and or development of PI. TX 2 stated the firm setting placed Resident 22 at risk for rolling out of the bed and falling. During a concurrent observation and interview on 3/8/2024 at 2:30 p.m., with the DON, the DON stated LALM should be set according to the resident's weight as indicated in the manufacturer's guideline for PI management or prevention. The DON stated not following the recommended setting placed the resident at risk for development of PI and/or skin breakdown. A review of LALM's 1 manufacturer's guidelines, undated, indicated users can adjust the pressure level of the air mattress, using the analog pressure dial, to a desired firmness based on personal comfort or weight setting. A review of the facility's policy and procedure titled, Specialty Mattress - Pressure Relieving Devices, last reviewed 1/16/2024, indicated a purpose to provide guidelines for the appropriate pressure relieving devices or low air loss mattress for residents at risk for skin breakdown. The policy indicated the following: - Follow the mattress manufacturer's user instructions. - Set the comfort pressure to the comfort level as stated or desired by the resident or set the mattress according to the resident's weight when a resident is not able to provide the comfort preference. Verify the proper setting. b. A review of Resident 76's admission Record indicated the facility admitted the resident on 9/20/2023 and readmitted the resident on 2/29/2024 with diagnoses including heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), presence of cardiac pacemaker (a small, battery-powered device placed under the skin thru surgery that prevents the heart from beating too slowly), and pressure ulcer (an injury that breaks down the skin and underlying tissue) of the sacral region (portion of the spine between the lower back and tailbone). A review of Resident 76's History and Physical (H&P) dated 3/1/2024, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 76 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 12/28/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) but able to understand others and make his needs known. The MDS indicated Resident 76 required substantial/maximal assistance with eating and totally dependent on staff with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 76's Weekly Skin Ulcer Report indicated the following: 1. 11/14/2023: facility acquired sacrococcyx (bone formed by fusion of the sacrum [large triangle-shaped bone in the lower spine that forms part of the pelvis] and coccyx [small bone at the end of the spine])) stage 2 PI measuring 3.0 centimeters length (cm - a unit of measurement) x 7.0 cm width x 0.3 cm depth 50% yellowish pink slough (a non-viable tissue which formed when dead cells or bacteria accumulate in the wound) and 50% red granulation tissue (describes the appearance of the red, bumpy tissue in the wound bed as the wound heals). The report indicated the wound was slightly responding to treatment and was seen by the wound care physician. 2. 11/24/2023: facility acquired sacrococcyx stage 2 PI measuring 4.0 cm x 4.0 cm x 0.2 cm 70% yellowish slough and 30% red granulation tissue. The report indicated the wound was slightly responding to treatment and was seen by the wound care physician. 3. 12/25/2023: facility acquired sacrococcyx stage 2 PI wound is healed with 100% epithelial tissue (a thin layer of tissues covering the surfaces of the body exposed to assist in wound healing. 4. 1/19/2024: facility acquired sacrococcyx stage 2 PI measuring 3.5 cm x 1.5 cm x 0.5 cm 5% yellowish pink slough and 95% red granulation tissue. The report indicated the resident was seen by the wound care physician and performed debridement. 5. 1/26/2024: facility acquired sacrococcyx stage 2 PI measuring 3.5 cm x 1.2 cm x 0.5 cm 10% yellowish pink slough and 90% red granulation tissue. The report indicated the resident was seen by the wound care physician and performed debridement. 6. 2/2/2024: facility acquired sacrococcyx stage 2 PI measuring 3.5 cm x 1.2 cm x 0.5 cm 10% yellowish pink slough and 90% red granulation tissue. The report indicated the wound was slightly responding to treatment. 7. 2/8/2024: facility acquired sacrococcyx stage 3 PI measuring 3.5 cm x 2 cm x 1.3 cm 30% purple colored necrosis (dead or devitalized non-viable tissue which impedes wound healing) 30% yellowish pink slough 40% red granulation tissue. 8. 2/16/2024: 3.7 cm x 2.7 cm x 1.7 cm 60% purple colored necrosis 30% yellowish pink slough 10% red granulation tissue. 9. 2/22/2024 sacrococcyx stage 3 PI measuring 4.0 cm x 2.0 cm x 2.0 cm 70% necrosis 30% yellowish slough. A review of Resident 76's SBAR Communication Form indicated the following: 1. 11/10/2023 indicated the resident developed moisture associated skin damage (MASD) on the sacrococcyx area and left buttock. The SBAR indicated the physician was notified with an order to clean with NS, pat dry, apply zinc oxide (a cream which helps managing skin conditions and leg ulcerations as it provides a protective barrier, reduces inflammation, and creates a moist wound healing environment where the skins integrity has been lost) and leave open to air for 14 days. 2. 1/3/2024 indicated the resident had reopening of healed stage two (2) PI of the sacrococcyx. The SBAR indicate the WCC 1 physician was notified and stated to continue with current plan of care until consultation. 3. 2/7/2024 indicated the resident had worsening of sacrococcyx stage 2 PI to stage 3 with the following descriptions, 3.5 centimeters (cm - a unit of measurement) x 1.2 cm x 0.5 cm 10 % slough 90% granulation tissue. The WCC 1 physician was notified and stated to continue with current order to cleanse with NS, pat dry, apply santyl ointment, cover with calcium alginate and dry dressing. A review of Resident 76's Wound Care Evaluation and Treatments by Wound Care Company 1 (WCC 1) physician indicated the following: 1. 11/22/2023: sacral ulcer stage 3 4.0 cm x 4.0 cm x 0.2 cm 70% yellowish slough and 30% red granulation tissue. The report indicated the wound condition as unchanged and a plan to clean wound with NS, apply santyl ointment to ulcer and cover with calcium alginate daily, zinc oxide to surrounding area. 2. 1/18/2024: sacral ulcer stage 2 3.5 cm x 1.5 cm x 0.5 cm 10% necrosis 40% yellowish slough and 50% red granulation tissue. The report indicated post debridement measurement as 3.6 cm x 1.6 cm x 0.8 cm stage 3. 3. 1/25/2024: sacral ulcer stage 2 3.2 cm x 1.2 cm x 0.5 cm 50% yellowish slough and 50% red granulation tissue. The report indicated post debridement measurement as 3.3 cm x 1.3 cm x 0.6 cm stage 3. 4. 2/1/2023: sacral ulcer stage 3 3.2 cm x 1.2 cm x 0.5 cm 30% necrosis 30% yellowish slough and 40% red granulation tissue. The report indicated post debridement measurement as 3.3 cm x 1.3 cm x 0.6 cm stage 3. 5. 2/8/2023: sacral ulcer stage 3 3.5 cm x 2 cm x 1.5 cm 60% necrosis 10% yellowish slough and 30% red granulation tissue. The report indicated post debridement measurement as 3.3 cm x 1.3 cm x 0.6 cm stage 3. 6. 2/15/2023: sacral ulcer stage 3 3.7 cm x 2.7 cm x 1.7 cm 60% necrosis 10% yellowish slough and 30% red granulation tissue. The report indicated post debridement measurement as 3.8 cm x 1.8 cm x 2.0 cm stage 3. 7. 2/22/2024: sacral ulcer stage 3 4.0 cm x 2.7 cm x 2.0 cm 70% necrosis 30% yellowish slough. The report indicated post debridement measurement as 4.1 cm x 2.8 cm x 2.3 cm stage 3. During a concurrent interview and record review on 3/8/2024 at 9:30 a.m., reviewed Resident 76's weekly Skin Ulcer Report, SBAR Communication Form, and Wound Care and Treatment Notes by WCC 1 in the EHR with TX 1. TX 1 verified there was no documented evidence that SBAR Communication Forms were initiated on 11/14/2023 when the sacrococcyx PI deteriorated from MASD to a stage 2, on 11/22/2023 when the WCC 1 physician documented the sacrococcyx stage 2 PI as stage 3, and on 2/1 2023 when the WCC 1 physician documented the reopened sacrococcyx stage 2 PI as stage 3. TX 1 stated he should have initiated the SBAR so the resident/resident representative, physician, staff, and other members of the team would be aware of Resident 76's current PI condition or status and address the provision of care and services the resident needs. TX 1 stated that a slough was not a healthy tissue, and he should have changed Resident 76's sacrococcyx PI from stage 2 to stage 3 upon observation of slough on 11/14/2024. TX 1 stated wounds or PIs should be classified accurately to ensure the resident receive the proper treatment as it may lead to worsening of the wound or possibly acquire infection. TX 1 verified that the measurements and descriptions he indicated on the weekly Skin Ulcer Reports on 11/14/2023, 11/24/2023, 1/19/2024, 1/26/2024, 2/2/2024, 2/8/2024, and 2/16/2024 were different from WCC 1 physician's notes and were documented inaccurately. TX 1 stated he should have documented more accurately so staff would be aware of Resident 76's PI status to prevent confusion. During an interview on 3/8/2024 at 12:30 p.m., the Director of Nursing (DON) stated the SBAR on 11/14/2023, 11/22/2023, and 2/1/2024 should have been done when Resident 76's sacrococcyx PI increased in size and changed in classification so the proper treatment would be initiated to prevent further deterioration of the PI. The DON stated the SBAR is important so the resident/resident representative, physician, and staff would be aware of Resident 76's current PI status. The DON stated initiation of proper treatment for PI is important to prevent provision of care and services the resident needs. The DON stated it was important to identify and address any change in Resident 76's PI for the resident to receive the necessary care and treatment needed to promote healing. The DON further stated TX 1 should have documented Resident 76's sacrococcyx PI accurately in the EHR for accuracy of records and prevent confusion between staff and/or members of the team. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, last reviewed 1/16/2024 indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The policy indicated the following: - Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider including information prompted by the Interact SBAR Communication Form. - Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. - The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. A review of the facility's policy and procedure titled, Charting and Documentation, last reviewed 1/16/2024 indicated the following: 1. All services provided to the resident, progress toward the care plan goals, or an changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. 2. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective, complete, and accurate. 4. Documentation of procedures and treatments will include care-specific details including the assessment data and/or any unusual findings obtained during the procedure/treatment, and notification of family, physician, or other staff, if indicated. A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last reviewed 1/16/2024 indicated the following: 1. The nurse shall describe and document/report a full assessment of pressure sore including location, stage, length, width, and depth, presence of exudate or necrotic tissue. 2. The physician will assist staff to identify the type and characteristics of an ulcer.

CONCERN (E)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

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Based on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency (the ability to do something successfully) skills as followed: a. Two (2) of 2 staff were not able to verbalize dishwashing machine temperatures, dishwashing procedures and were not able to follow manufacturer's guidelines for testing dishmachine chlorine solution (used as bleach and disinfectant) concentration with the use of the test strips. b. Two (2) of 2 staff were not following the test strip manufacturer's guidelines when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. These failures had a potential to result to cross-contamination (a transfer of bacteria from one object to another), ineffective dishmachine, and unsanitized food preparation areas that could lead to food borne illness (an illness caused by contaminated food and beverages) in 93 of 98 medically compromised residents who received food and ice from the kitchen. Findings: a. During a concurrent observation of the dishwashing process and interview with Diet Aide 2 (DA 2) on 3/6/2024 at 9:30 a.m., DA 2 stated she washed dishes everyday and she checked the dishmachine temperature at 5:20 a.m., but did not record it on the log as she got busy. DA 2 demonstrated washing dishes in the low temperature dishmachine and stated the temperature was at 120-degree Fahrenheit (°F, a scale of temperature) but unable to verbalize when to look at the temperature gauge for wash and rinse cycle. DA 2 checked the sanitizer, dipped the test strip inside the dishmachine and compared it to the color chart. DA 2 stated the concentration of the chlorine was 100 parts per million (ppm, describes the concentration of a solution) and it was okay. During a demonstration of the low dishmachine temperature checks and interview with Dietary Supervisor (DS) on 3/6/2024 at 9:50 a.m., DS run the low temperature dishmachine and demonstrated when to read the temperature for the wash cycle and rinse cycle. DS stated the temperature for the wash cycle was 120°F and the rinse temperature was at 140°F. DS checked the chlorine concentration and dipped the test strip in the dishmachine. DS compared the test strip to the color chart and stated the ppm was at 100. DS stated it was important for staff to understand the acceptable temperature ranges of the dishmachine and sanitizer concentration because the dishes could have bacteria and still could be soil. During a concurrent review of the chlorine manufacturer's guidelines and interview with DS on 3/6/2024 at 10:20 a.m., manufacturer's guidelines were as follows: Expiration date: 12/1/2023 Dip and remove quickly. Blot immediately with paper towel. Compare to color chart at once. DS stated he and DA 2 did not blot the test strips with a paper towel and did not follow the manufacturer's guidelines. DS stated not following manufacturer's guidelines would not produce accurate testing of chlorine concentration. During a concurrent observation of the dishwashing process and interview with Dietary Aide 3 (DA 3) and DS on 3/7/2024 at 1:24 p.m., DA 3 wiped the dishes with a dry cloth. DA 3 stated she got trained about dishwashing process, and she used dry cloth to dry the dishes, but she was not sure if it was okay to use the cloth to dry the dishes. DS stated he provided the staff an in-service about dishwashing procedures on 9/2023 and yesterday however, he forgot to mention to employees that they cannot use a cloth for drying the dishes. DS stated it was not okay to wipe the dishes with cloth due to cross-contamination. A review of the facility's Job Description titled Diet Aide signed by DA 2 on 11/21/2018, indicated (14) Washes/sanitizes service ware, utensils, pots/pans according to established procedures and returns items to their proper storage areas. Ensure that clean items ae available for the next meal service, A review of the facility's Competency Checklist titled Skills Performance Checklist signed by DA 2 and DS on 3/14/2023, indicated DA 2 was competent for sanitation of equipment and utensils and chemical and cleaning agent's use, purpose, and storage. A review of the facility's Competency checklist titled Skills Performance Checklist signed by DA 3 and DS on 4/6/2023 indicated DA 3 met the competency for Sanitation of equipment and utensils. A review of the facility's Policies and Procedure (P&P) titled Dishwashing dated 1/2024, indicated Policy Statement: All dishes will be properly sanitized through the dishwasher. The dishwasher will be kept clean and in good working order. Procedure: (5) Dishes are allowed to air-dry in racks before stacking and storing. A temperature log (and chlorine log on low temperature machines) will be kept and maintained by the dishwasher to assure the dishmachine is working correctly. This log will be completed each meal prior to any dishwashing. The dishwasher will run the dishmachine until the temperature is within manufacturer's recommendation. Low temperature machine-if you do not achieve the proper temperature per manufacturer's recommendation you can use the machine at a range of 120 to 140°F. The chlorine should read 50-100 ppm- the proper chlorine is crucial in sanitizing dishes. Otherwise resort to the manual method of utensil washing. A review of the facility's P&P titled Temperature/Sanitizer Record dated 1/2024, indicated Purpose: To recognize trends that may indicate equipment/utility failure. Ensure sanitation of dishes and utensils. Frequency for completion: Initiate monthly and record data after each meal and before washing dishes. b. During a concurrent red bucket sanitizer concentration testing demonstration and interview with [NAME] 2 on 3/7/2024 at 1:30 p.m., [NAME] 2 stated she does the quat sanitizer testing every morning. [NAME] 2 stated, red bucket was for sanitizer and green bucket was for soap. [NAME] 2 washed the red bucket, filled it with pre-mix sanitizer, pulled a test strip from the container, dipped the test strip in the bucket for three (3) seconds then compared it with the color chart. [NAME] 2 stated the color read 200 ppm and it was a good sanitizer concentration. During a concurrent red bucket sanitizer concentration testing demonstration and interview with DS on 3/7/2024 at 1:34 p.m., DS filled the red bucket with a pre-mix sanitizer, read the test strips instruction, pulled a test strip from the dispenser, dipped the test strip in the dishmachine for ten (10) seconds by counting 1001, 1002, 1003, . 1010 then compared to the color chart. DS stated the sanitizer concentration was at 200 ppm and it was a good concentration. During a concurrent interview with DS and review of the Quat Sanitizer test kit manufacturer's guidelines on 3/7/2024 at 1:36 a.m., Quat sanitizer test kit indicated the following manufacturer's instructions: Dip paper in Quat solution. Not foam surface, for 10 seconds. Do not shake. Compare color at once. Testing solution should be between 65°F to 75°F. Testing solution should have a neutral pH. Follow manufacturer's dilution instructions carefully. DS stated the process was new to him and no one ever asked him to take the temperature of the testing solution. DS stated it was important to check the concentration of the sanitizer to ensure its effectivity to kill bacteria and if manufacturer's guidelines were not being followed then there could be bacteria on the surfaces even after wiping it with the Quat sanitizer. DS checked the testing solution, and it was at 58°F. A review of the facility's competency checklist titled Skills Performance Checklist, signed by [NAME] 2 on 4/4/2023, indicated [NAME] 2 met the competencies for chemical and cleaning agents for use and purpose, and sanitary procedures. A review of the facility's job description titled Dietary Services Director, signed by DS on 12/24/2021, indicated POSTION SUMMARY: Responsible for planning, organizing, developing, and directing he overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations; our established policies and procedures; and as may be directed by the Administrator, to ensure quality food service and nutritional care is provided at all times. Duties and Responsibilities (23) Assumes responsibilities for selecting, training, directing, and motivating competent department personnel. Leads team and provides proactive support, removing obstacles and providing solutions as needed. Evaluate employee's performance. Knowledge, Skills, Abilities and Qualifications (11) Ability to understand and follow applicable regulations, policies, and procedures fully and consistently. A review of the facility's competency checklist titled Skills Performance Checklist signed by DS and Registered Dietitian on 6/16/2023 indicated DS met the competency for Food Code, Sanitation and dishmachine use.

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 the menu and did not meet nutritional needs of 41 of 98 residents on Soft Mechanical diet (diet that contains chopped foods that are half an inch or less) and ten (10) of 98 residents on puree diet (diet that contains soft pudding like consistency of food) by: a. Not following standardized recipes for puree green beans, puree pasta and puree bread. b. Not chopping the Italian green beans for Soft Mechanical Diet. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food intake resulting to weight loss. Findings: a. During an observation of puree beans, puree pasta and puree bread preparation of [NAME] 2 for lunch service on 3/5/2024 at 11:35 a.m., [NAME] 2 poured thickener directly from the container to the puree green beans, puree pasta and puree bread without the use of any measuring tools. During an observation of [NAME] 2 cooking puree bread on 3/5/2024 at 11:53 a.m., [NAME] 2 poured milk to the puree bread without the use of any measuring tools. During an interview with [NAME] 2 and Dietary Supervisor (DS) on 3/5/2024 at 1:05 p.m., [NAME] 2 stated she prepared the puree pasta, puree green beans and puree bread for lunch's use. [NAME] 2 stated she poured milk to the puree bread because it was sticky but does not know how much milk she poured. [NAME] 2 stated she did not measure the milk. [NAME] 2 stated she estimated the amount of thickener she added on the puree pasta, puree green beans and puree bread. [NAME] 2 stated she read the recipe and followed it to ensure that food taste good. DS stated recipes were available for every food item in the kitchen, and it was important to follow the recipe of the food, so it had the right number of calories, sodium, and consistency of the food to prevent residents from chocking. During an interview with the DS on 3/6/2024 at 9:50 a.m., DS stated he in-serviced the staff about the use of thickener on 2/2024. DS stated, maybe the staff did not understand the in-service. A review of facilities recipe titled Zesty Lasagna not dated, indicated ingredients: ground turkey, onions, oregano, thyme, cayenne, garlic powder, basil, tomato sauce, tomato paste, large, pasteurized egg, cottage cheese, mozzarella cheese, parmesan cheese, lasagna noodles and boiling water. Pureeds: Puree. Cut off any hard edges before pureeing. Follow the puree recipes in the Food Safety/Misc. section of Book #1. A review of facilities' recipe titled Recipe: Pureed Casserole not dated, indicated ingredients (serves 12), casserole per recipe 12 serving, warm fluid such as milk, gravy, or low sodium broth 12-24 oz, stabilizer: instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice o farina, or commercial instant food thickener 6 to 24 Tbsp. Directions: (4) Puree should reach a consistency slightly softer than whipped topping. May add more liquid if need to reach this consistency. Taste and adjust seasoning (without salt), as needed. A review of facilities' recipe titled Recipe: Italian [NAME] beans not dated, indicated Ingredients: frozen Italian green beans, Italian seasoning, margarine, garlic powder. PUREEDS: Puree following the pureed recipes in the Food Safety/Misc. section of Book 1. A review of facilities recipe titled Pureed Vegetables not dated, indicated Ingredients serves 12: vegetable per recipe, warm fluid such as milk, or low sodium broth 2-6 oz, Stabilizer: instant potatoes or commercial instant food thickener 5-12 Tbsp. Directions: Puree should reach the consistency of applesauce. Taste and adjust seasoning (without salt), as needed. A review of facilities' recipe titled Recipe: Pureed Breads, Cakes, Cookies, Pancakes, French toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and other Bread Products, not dated, indicated 1 ½ to 3 cups milk and 3/8 to ¾ cup stabilizer or commercial instant food thickener for 12 servings of puree bread. Directions: 1. Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for puree diets. 2. Puree on low speed adding milk gradually. See above recommended amount of milk, starting with the small amount and adding in more as needed to achieve the desired consistency. 3. Puree should reach a consistency of applesauce. 4. Add stabilizer to increase the density of the pureed food if needed. Breaded items may not need stabilizer. If using commercial food thickener, check the can for directions on usage, otherwise see above for recommended amounts of stabilizer. A review of facilities' Policies and Procedures (P&P) titled Standardized Recipes dated 1/2024 indicated Standardized recipes shall be developed and used in the preparation of foods. (1) Only tested, standardized recipes will be used to prepare foods. A review of the facilities' P&P titled Menus dated 1/2024, indicated Menus are written and approved by Registered Dietitian to: Meet the nutritional needs of the residents. Achieve the dietary standards stated in the Diet manual. Menu must: meet the nutritional needs of the residents in accordance with the recommended dietary allowances of the food and Nutrition Board of the National Research Council, National Academy of Sciences. b. During a trayline (an area for observation for lunch service on 3/5/2024 at 12:08 p.m., Italian green beans that were not chopped was served to soft mechanical diets. During a concurrent test tray observation and interview with the DS on 3/5/2024 at 12:48 p.m., DS stated the Italian green beans would not pass a soft mechanical diet because it was cut to more than one (1) inch (in., unit of measurement) size. DS stated mechanical soft was chopped to a quarter inch, soft in consistency and diced and it was used to assist resident with chewing and swallowing difficulties. A review of facilities' Diet Manual titled Comparison of IDDSI Level #6-Soft and Bite Size to Healthcare Menus Direct dated 2023, indicated It is suggested you place any IDDSI Level #6-Soft and Bite Size orders onto the Mechanical Soft Diet. Below ae the differences between the diets, should your facility RD or Speech Therapist wish to make changes on a resident's diet. Note that any texture modified classification liquid thickness must be at the prescribed level. IDDSI Level 6 Soft/Bite size vegetable, cooked, soft chopped ½ inches. Healthcare LLC. Mechanical Soft Vegetable may have soft, Mashable, whole cooked vegetables. A review of facilities' Diet Manual titled Comparison of IDDSI Level 5- Minced and Moist to Healthcare Menus Direct, LLC's Dysphagia Mechanical Diet dated 2023, indicated IDDSI Level 5- Minced and moist vegetables cooked, mashable, 1/8 inch. Dysphagia mechanical, vegetables cooked ½ inch (may need to reduce size). Restricted vegetables are pureed.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. This deficient practice had a potential to cause unplanned weight loss, a consequence of poor food intake to 52 of 98 facility residents who are on regular (no diet restrictions) and puree diet (food with smooth pudding like consistency) consistencies, getting food from the kitchen. Findings: A review of Resident 85's admission Record indicated the facility admitted Resident 85 on 12/19/2023 with diagnoses including, but not limited to, type two diabetes mellitus (disease that results in too much sugar in the blood). A review of Resident 85's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/9/2024, indicated Resident 85 was cognitively intact (able to understand and make decisions and was independent with eating. A review of Resident 85's History and Physical (H&P), dated 12/20/2023, indicated Resident 85 had the mental capacity to make decisions. A review of Resident 85's Order Summary Report, dated 12/27/2023, indicated Resident 85 was ordered a controlled carbohydrate (foods containing sugars, starch, cellulose) diet (CCHO - a diet involving eating the same number of carbohydrates everyday to manage blood sugar levels), no added salt, with regular texture, regular liquid consistency, and a double portion of protein and vegetables. During an interview with Resident 85, on 3/5/2024, at 11:08 a.m., Resident 85 stated the food he receives from the facility is bland and does not have enough salt. A review of the facility's spring menu spreadsheets dated 3/5/2023, indicated regular diet and regular consistencies included the following food items on the tray: Zesty Lasagna 1 serving =3x3 1/3 inches (in., unit of measurement) Italian [NAME] beans ½ cup (c, a household unit of measurement) Parsley garnish yes Garlic Bread ½ slice Peanut butter cookies 1 each Milk ½ c. A review of the facility's spring menu spreadsheet dated 3/5/2023 indicated puree diet included the following food items on the tray: Puree zesty lasagna 1 c Puree Italian green beans 2.5 ounces (oz, unit of measurement) Parsley flakes Puree Garlic bread ½ slice or 1.35 oz Puree Peanut butter cookies 2.5 oz. During a test tray conducted with the Dietary Supervisor (DS) on 3/5/2024 at 12:49 p.m., for regular and puree diet, regular zesty lasagna and puree lasagna tasted bland in flavor. DS stated puree lasagna was bland in flavor and the consistency of the puree lasagna, puree bread, and puree green beans were thin. DS stated the consistency of puree foods should be thicker and stiffer so it could form. DS stated serving bland foods could result for residents not eating the food and weight loss. During an interview with [NAME] 2 and DS on 3/5/2024 at 1:05 p.m., [NAME] 2 stated she did not measure the milk in the puree bread, the chicken base, butter, and salt for the Italian green beans. [NAME] 2 state she did not measure the thickener in the puree food and estimated the amount of thickener for the food to thick. [NAME] 2 stated it was important to follow standardized recipes so that the food taste good. DS stated it was important to follow the recipes to ensure everything was in the right number of calories, sodium and for food to taste good. During an interview with DS on 3/5/2024 at 1:30 p.m., DS stated residents like tasty food for their satisfaction and happiness. DS stated residents could complain and would not eat affecting their food intake and their health resulting to weight loss if foods were not tasty. During an interview with the Director of Nursing (DON), on 3/8/2024, at 5:13 p.m., the DON stated it is important to serve residents palatable (referring to the taste and/or flavor of the food) food to prevent weight loss and so that residents consume the therapeutic diet prescribed for the resident. A review of the facility's recipe titled Recipe: Zesty Lasagna dated 2024, indicated may give to low salt, low fat, and low cholesterol. A review of the facility's recipe titled Recipe: Italian [NAME] Beans dated 2024, indicted May give to 2 grams sodium, low salt, low fat, low cholesterol. A review of the facility's diet manual titled Sodium Restricted diet dated 2020, indicated Regular No Added Salt. This diet is a regular diet with the exception that no salt maybe added to food after preparation per recipe. No salt packet or saltshaker is allowed with the resident's meal. Food may be lightly salted during cooking. A record review of the facility's policies and procedures (P&P) titled Menu Changes dated 1/2024, indicated Menus may be changed to meet the preferences of the facility's population. A review of facilities' P&P titled Standardized Recipes dated 1/2024 indicated Standardized recipes shall be developed and used in the preparation of foods. (1) Only tested, standardized recipes will be used to prepare foods. A review of the facilities' P&P titled Menus dated 1/2024, indicated Menus are written and approved by Registered Dietitian to: Meet the nutritional needs of the residents. Achieve the dietary standards stated in the Diet manual. Menu must: meet the nutritional needs of the residents in accordance with the recommended dietary allowances of the food and Nutrition Board of the National Research Council, National Academy of Sciences.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Broken sugar container in the dry storage area. b. Dust build-up on the canned foods and oatmeal debris on storage shelves and dirty floors in the dry storage area. c. Two (2) regular penne pasta and wheat penne pasta was not labeled and dated. d. Clean chopping boards and breads were not protected from dirt splash from an open trash container. e. Forty five of 81 resident's trays had tape residues and 9 trays were cracked and chipped. f. Soiled gloves on the chopping board while the cook was preparing chopped salad. g. Domes and dishes were not air-dried before storing. h. [NAME] was wearing gold bracelet and wristwatch. i. Expired chlorine test strips. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in 93 of 98 medically compromised residents who received food and ice from the kitchen. Findings: a. During an initial kitchen tour observation with the Dietary Supervisor (DS)on 3/5/2024 at 9:16 a.m., a sugar container had cracked. During an interview with DS on 3/7/2024 at 1:39 p.m., DS stated he replaced the cracked sugar container. DS stated it was important to have a non-broken container because it could attract pest and other physical contaminants that could go inside the sugar container like dust and dirt. DS stated residents could get sick from cross-contamination (transfer of bacteria from one thing to another or one place to another). A review of the facility's Policies and Procedures (P&P) titled Ingredient Bins, dated 1/2024, indicated Statement Policy: To prepare food contamination, ingredient bins must be kept clean and covered. A review of the facility's P&P titled Storage of Food and Supplies, dated 1/2024, indicated POLICY: Food and supplies will be stored properly and in a safe manner. (6) Dry bulk food (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in a seamless metal or plastic containers with tight covers, or in bind which are easily sanitized. A review of the facility's P&P titled Sanitation, dated 1/2024, indicated All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. A review of Food Code 2017 indicated 3-306.12 (A) Condiments shall be protected from contamination by being kept in dispensers that are designed to provide protection, protected food displays provided with the proper utensils, original containers designed for dispensing, or individual packages or portions. b. During concurrent initial kitchen tour observation of the dry storage area and interview with the DS on 3/5/2024 at 9:16 a.m., shelves had dry oatmeal and dirt debris, canned foods had dust and the dry storage floors had lentil and other food debris. DS stated they clean the dry storage once a week every Thursday. DS stated it was important to maintain the cleanliness of the food storage so it would not attract pest in the food. DS stated residents could get sick due to cross-contamination. A review of the facility's P&P titled Storeroom, dated 1/2024, indicated The general cleanliness and care if the storeroom and supplies are important to ensure safe wholesome food. Procedure: (1) The floor, walls, ceiling, lights, shelves and equipment in the storeroom must be kept clean by setting up, maintaining a regular cleaning schedule. (2) Routine inspections of the storeroom must be made to ensure cleanliness and high standard of sanitation. A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning. c. During concurrent initial kitchen tour observation of the dry storage area and interview with DS on 3/5/2024 at 9:25 a.m., a labeled penne pasta on the plastic indicated 2/16/2024 with no name. A wheat penne pasta has no label and date. DS stated the penne pasta was labeled with the receive date but not the name of the food item and best buy date. DS stated the staff used a marker on the plastic that could be easily erased, and that the wheat penne pasta does not have a label, so it needed to be thrown away. DS stated it was important for the product to have a label to know the expiration dates. DS stated resident could get sick if they consumed expired foods. A review of the facility's P&P titled Storage of Food and Supplies, dated 1/2024, indicated (8) Food stores should be arranged in food groups to facilitate storing, locating, and taking inventories. Similar items as cereals, fruits should be grouped and alphabetized within group. Labels should be visible, and the arrangement should permit rotation of supplies so that the oldest items will be used first. All food will be dated-month, day, year. All food products will be used per the times specified in the Dry Food Storage Guidelines. The storage times in the guidelines are intended to be on the safe side. A review of Food Code 2017 indicated 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. d. During concurrent observation of preparation area and interview with DS on 3/5/2024 at 9:45 a.m., an uncovered container full of trash was near the clean chopping board and an open plastic of bread. DS stated there would be a possible cross contamination from the trash to the food and clean chopping board and they will have to change this practice in the kitchen. A review of the facility's P&P titled Food Preparation and Service, dated 1/2024, indicated Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area (4) Appropriate measures are used to prevent cross- contamination. A review of the facility's P&P titled Food Handling Practices, dated 1/2024, indicated Cover trash containers when not in continuous use. A review of Food Code 2017 indicated 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. e. During concurrent observation of the resident's tray and interview with DS on 3/5/2024 at 9:48 a.m., 45 out of 81 resident's trays had tape debris and sticky residue. Nine (9) resident's trays had chips and cracks. DS stated they tape a lot on the resident's tray, and it was not okay to have tape residue on the residents' tray as it could go to the food and contaminate the food. DS stated they have been throwing cracked trays but might have missed some trays. DS stated it was not okay to use cracked or chipped trays as it could attract more dirt causing contamination to food. A review of the facility's P&P titled Sanitation, dated 1/2024, indicated (10) Plastic ware, China and glassware that become unsightly, unsanitary, or hazardous because of chips, cracks or loss of glaze shall be discarded. (19-c) Cracked or chipped dishes and glasses are disposed. A review of Food Code 2017 indicated 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be clean to sight and touch. (B) NonFood-Contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. A review of Food Code 2017 indicated 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. f. During a concurrent observation of [NAME] 3's chef's salad preparation and interview with [NAME] 3 on 3/5/2024 at 11:07 a.m., [NAME] 3 was preparing the chef salad beside soil blue and white gloves. [NAME] 3 stated it was not his gloves and it was not okay to prepare food near soil gloves because the gloves were dirty. During an interview with the DS on 3/5/2024 at 11:12 a.m., DS stated [NAME] 3 should have thrown the gloves right away because of cross-contamination. DS stated [NAME] 3 was training with [NAME] 2 however [NAME] 2 might missed to coach him. A review of the facility's P&P titled Food Preparation and Service, dated 1/2024, indicated Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area (4) Appropriate measures are used to prevent cross- contamination. A review of Food Code 2017 indicated 3-305.14 Food Preparation. During preparation, unpackaged food shall be protected from environmental sources of contamination. g. During an observation of the dishwashing process on 3/5/2024 at 11:24 a.m., Diet Aide 1 (DA 1) stacked the dishes and domes wet in the storage area by the trayline. During concurrent observation of the dishwashing process and interview with Diet Aide 4 (DA 4) on 3/6/2024 at 8:40 a.m., Diet Aide 4 (DA 4) stacked the wet dishes in the cart. DA 4 stated all the dishes needed to be dry before storing them. During an interview with the DS on 3/6/2024 at 8:47 a.m., DS stated the process of dishwashing was to rinse off dishes, scrub if need, wash, rinse and remove them from the dishmachine. DS stated staff air dried the dishes before storing them and it was important to do this process as wet dishes can attract bacteria. During a concurrent observation of the domes by the trayline storage area and interview with DS on 3/6/2024 at 8:57 a.m., domes were stacked wet. DS stated the AP rinse dry the dishes and he could just increase the AP rinse to dry the dishes. During concurrent observation of Dietary Aide 3 (DA 3) dishwashing process and interview with DA 4 and DS on 3/7/2024 at 1:24 p.m., DA 4 wiped the dishes, trays, and domes with a cloth. DS stated he provided staff with air drying training yesterday but forgot to mention to that staff could not use a cloth. DA 3 stated she got training regarding dishwashing process and used a cloth to dry dishes, but she was not sure if it was okay for her to use a cloth or not. A review of the facility's P&P titled Dish Washing dated 1/2024, indicated All dishes will be properly sanitized through the dishwasher. Procedure: (5) Dishes are allowed to air-dry in racks before stacking and storing. A review of Food Code 2017 indicated 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining. (B) May not be cloth dried. h. During concurrent observation of [NAME] 1's food preparation with DS and interview with DS on 3/6/2024 at 9:20 a.m., [NAME] 1 was wearing a gold bracelet and a wristwatch. DS stated staff were only allowed to wear wedding bands and they are not to wear other jewelries due to cross-contamination during food preparation. During an interview with [NAME] 1 on 3/6/2024 at 10:20 a.m., [NAME] 1 stated he does not know the uniform policy, but he was not allowed to wear earrings, watches, rings. [NAME] 1 stated he did not know if he is allowed to wear bracelet however, wearing rings and other jewelries during food preparation could contaminate food. [NAME] 1 stated he could not remove the gold bracelet as it was permanent. A review of the facility's P&P titled Food Preparation and Service, dated 1/2024, indicated Food Service/Distribution 8) Food and nutrition services staff keep fingernails trimmed and clean. Jewelry is worn minimally and hand jewelry (i.e., wedding ring) is covered with gloves. A review of the facility's P&P titled Food Handling Practices, dated 1/2024, indicated Practice good personal hygiene: Limit jewelry to wedding bands. A review of Food Code 2017 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. i. During concurrent observation of the chlorine test strip manufacturer's guidelines and interview with DS on 3/6/2024 at 10:12 a.m., chlorine manufacturer's guidelines indicated chlorine test strips had an expiration date of 12/1/2023. DS stated the test strip was expired and would not read accurate reading of the chlorine concentration. DS stated if the chlorine was not in the accurate concentration, it would not sanitize the dishes and residents could get sick. A review of the facility's Policies and Procedure (P&P) titled Dishwashing dated 1/2024, indicated The chlorine should read 50-100 ppm- the proper chlorine is crucial in sanitizing dishes. A review of Food Code 2017 indicated 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. Verifying the adequacy of chlorine-based solutions can be accomplished on an on-going basis by confirming that the concentration, temperature, and pH of the sanitizing solutions comply with paragraphs 4-501.114 (A) using acceptable test methods and equipment. The manufacturer should provide methods (e.g. test strips, kits, etc.) to verify that the equipment consistently generates solution on-site at the necessary concentration to achieve sanitation.

Aug 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a resident ' s dignity for one of three sampled residents (Resident 2) by failing to ensure that resident ' s urinary collection bag was covered with privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 2. Findings: A review of Resident 2 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 11/14/2014 and readmitted the resident on 8/28/2023 with diagnoses that included cirrhosis (scarred or damage) of liver (large organ in the abdomen that performs many important bodily functions, including blood filtering), dysphagia (difficulty in swallowing), diabetes mellitus (uncontrolled elevated blood sugar) and Alzheimer ' s disease (a brain disease that controls memory, language and thinking skills). A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/20/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required extensive assistance from staff for bed mobility, dressing, eating, and toilet use. Resident 2 was always incontinent (unable to control) of bowel and bladder functions. During a concurrent observation and interview on 8/30/2023 at 9:01 a.m., with the Director of Staff Development (DSD) right by Resident 2 ' s door, observed urine collection bag with no privacy cover. The DSD stated a privacy bag was missing and urine bag was left uncovered. During an interview on 8/30/2023 at 10:44 a.m. Certified Nursing Assistant 1 (CNA 1) stated she noticed that morning that Resident 2 had a urine bag with no privacy cover. CNA 1 stated she was distracted by another resident and was not able to notify the nurse that the resident needed the privacy cover. During an interview on 8/30/2023 at 11:19 a.m., Licensed Vocational Nurse 3 (LVN 3) stated Resident 2 was readmitted on [DATE]. LVN 3 stated the admitting nurse should have applied the dignity bag to cover the resident ' s urine bag. During an interview on 8/30/2023 at 12:49 p.m., the Director of Nursing (DON) stated nurses should apply the privacy bag for residents ' dignity. A review of facility ' s policy and procedure titled Catheter Care, Urinary dated 12/2018 and reviewed on 3/2023 indicated Provide a privacy bag when the resident is out of the room or as indicated.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to maintain the resident's right to privacy and confidentiality by failing to ensure the resident's right to receive mails unopened for one of three sampled resident (Resident 1). This deficient practice violated Resident 1's right to receive mails unopened. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 2/15/2023, with diagnoses including acute kidney failure (a condition in which suddenly one or both of your kidneys no longer work on their own), obstructive and reflux uropathy (a condition in which your urine can not flow out because of a blockage), hemiplegia and hemiparesis affecting the right side of the body (a condition in which one side of the body is weak and not able to move). A review of Resident 1's History and Physical dated 7/14/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/25/2023, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. During an interview on 8/30/2023 at 10:07 a.m., Resident 1 stated the facility brought an opened certified mail envelope addressed to resident and tried to cover it up by taping up the envelope. Resident 1 showed the envelope with the tape. During an interview on 8/30/2023 at 11:37 a.m., the Business Office Manager (BOM) stated she opened the resident's mail by mistake thinking it was an envelope she was expecting. During an interview on 8/30/2023 at 1:05 p.m., the Administrator (ADM) stated the resident notified her that a piece of certified mail belonging to the resident was opened by the facility, and the resident was very upset. The ADM stated residents have the right to privacy and receive unopened mail. A review of the facility's policy and procedure titled, Mail and Electronic Communication, dated 5/2017 and reviewed on 3/2023 indicated Residents are allowed to communicate privately with individuals of their choice and may send and receive personal mail, email, and other electronic forms of communication confidentially. Mail will be delivered to the resident unopened. Staff Members of this facility will not open mail of the resident unless the resident request them to do so. (Such request will be documented in the resident's plan of 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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 2) by failing to ensure that resident's indwelling catheter tubing (a tube that allows urine to drain from the bladder into a bag) was not touching the floor. These deficient practice placed the resident at risk for infection. Findings: A review of Resident 2's admission Record (Face Sheet) indicated the facility admitted the resident on 11/14/2014 and readmitted on [DATE] with diagnoses that included cirrhosis (scarred or damage) of liver (large organ in the abdomen that performs many important bodily functions, including blood filtering), dysphagia (difficulty in swallowing), diabetes mellitus (uncontrolled elevated blood sugar), Alzheimer's disease (a brain disease that controls memory, language and thinking skills) and urinary tract infection (UTI- when bacteria travels up to the bladder causing an infection). A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/20/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required extensive assistance from staff for bed mobility, dressing, eating, and toilet use. Resident 2 was always incontinent (unable to control) of bowel and bladder functions. During a concurrent observation and interview on 8/30/2023 at 9:01 a.m., with the Director of Staff Development (DSD) right by Resident 2's door, observed residents indwelling catheter tubing touching the floor. The DSD stated tubing should not touch the floor for infection control. During an interview on 8/30/2023 at 12:31 p.m., the Infection Preventionist (IP) stated indwelling catheter tubing should not touch the floor. The IP stated Resident 2 had urinary tract infection and having her urinary bag touching the floor can further increase her risk of infection. During an interview on 8/30/2023 at 12:49 p.m., the Director of Nursing (DON) stated indwelling catheter tubing should not be touching the floor for infection control. A review of facility's policy and procedure titled Urinary Catheter Care dated 12/2018 and reviewed on 3/2023, indicated Be sure the catheter tubing and drainage bag are kept off the floor .

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication error for two out of three sampled residents (Residents 4 and 5) observed during medication administration by failing to: 1. Administer allopurinol (a medication used to treat gout [a common form of inflammatory arthritis that is very painful] attacks) oral (by mouth) tablet with a full glass of water to Resident 5. 2. Ensure LVN 2 did not use the same spoon to mix and stir another crushed medication via gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach) to Resident 4. These deficient practices had a potential to place Resident 5 to develop kidney stones and Resident 4's medication to have physical and chemical incompatibilities leading to an altered therapeutic response. Findings: 1. A review of Resident 5's admission Record indicated the facility admitted the resident on 3/27/2023, with diagnoses including chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems), hepatic encephalopathy (a decline in brain function that occurs because of severe liver disease), and gout. A review of Resident 5's History and Physical (H&P), dated 3/27/2023, indicated the resident was alert and oriented to person, place, and time. The H&P indicated the resident had chronic kidney disease stage 3 (a condition where the kidneys have mild to moderate damage and are less able to filter waste and fluid out of the body) currently at baseline and to avoid nephrotoxins (poisonous to the kidney). A review of Resident 5's Order Summary Report, dated 3/27/2023, indicated an order of allopurinol oral tablet. Give 400 milligrams (mg, a unit of weight) by mouth one time a day for gout with a full glass of water. During a medication administration observation on 3/30/2023, at 9:59 a.m., observed Licensed Vocational Nurse 3 (LVN 3) administer allopurinol oral tablet to Resident 5 without instructing the resident to drink one glass of water with the medication. During an interview on 3/30/2023, at 10:30 a.m., Resident 5 stated he got 3 gulps of water on medication administration. Resident 5 stated that he was not instructed by LVN 3 to drink one glass of water with the allopurinol. During an interview on 3/30/2023, at 10:32 a.m., LVN 3 stated that she should have given and instructed Resident 5 to take one glass of water to take with allopurinol to flush the medication. During an interview on 3/30/2023, at 10:33 a.m., the Assistant Director of Nursing (ADON) stated the staff should have given additional fluid to Resident 5 to prevent gastrointestinal (GI, relating to both stomach and intestine) upset and kidney issues. 2. A review of Resident 4's admission Record indicated that the facility admitted the resident on 1/17/2020, with diagnoses including gastrostomy (a surgical opening through the skin of the abdomen to the stomach), type 1 diabetes mellitus (a condition in which your immune system destroys insulin (hormone that lowers the level of glucose [sugar] in the blood) making cells and gastro-esophageal reflux disease (happens when a muscle at the end of the esophagus does not close properly). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/18/2023, indicated the resident rarely to never had the ability to make self-understood and understand others. A review of Resident 4's Order Summary Report, dated 6/25/2022, indicated an order: may crush crushable medicines and administer via gastrostomy tube. During a concurrent medication administration observation for Resident 4 and interview on 3/30/2023, at 9:16 a.m., observed Licensed Vocational Nurse 2 (LVN 2) used the same spoon to mix and stir the crushed acetaminophen (a drug that reduces pain and fever) tablet to stir and mix aspirin (a mild drug that reduces pain and fever). Called the attention of LVN 2. LVN 2 stated she should have used individual spoons for each medication to mix the medicine with water to prevent possible reaction. During an interview on 3/30/2023, at 10:33 a.m., the ADON stated that the staff should use one spoon per medication to stir medications. The ADON further stated the previous spoon could still have medication on it and could mix it with another medication that can cause reaction. A review of the facility's recent policy and procedure titled, Medication Administration- General Guidelines, dated 10/2017, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are crushed (between two souffle cups/or in a plastic pouch) to prevent contact between medication and crushing device. If contact occurs, the crushing device is to be properly cleaned prior to further use. Medications are administered in accordance with written orders of the attending physician.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure prompt efforts to resolve the grievance of one of three sampled residents (Resident 1). The facility did not file Resident 1 ' s grievance about missing food items in facility Resident Grievance/Complaint Log and did not make efforts to resolve the resident ' s grievance. This deficient practice violated the residents ' right to have his grievance addressed. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 9/13/2022 with a readmission dated 10/02/2022 and diagnoses including cervical spinal stenosis (a space inside the neck region of backbone is too small and cause the neck pain). A review of Resident 1 ' s History and Physical exam dated 10/3/2022, indicated the resident had the capacity to understand and make decisions. During an interview, on 12/16/2022 at 4:40 p.m., Resident 1 stated he reported to the business office staff all his food was gone (unopened fruit cups, snacks, cookies, water bottles, etc.) after returning from a 5-day hospitalization. Staff promised reimbursement but had not. During an interview, on 12/19/2022 at 4:44 p.m., the admission Coordinator (AC) stated she reported to the Director of Social Services (DSS) when she received Resident 1 ' s concerns about the missing food items as per protocol. DSS stated the report to the DSS was verbal. During a concurrent interview and record review on 12/19/2022 at 5: 05 p.m., the DSS reviewed the Resident Grievance/Complaint Log but did not find any grievance/complaint from Resident 1. The DSS stated when staff receive a grievance or concerns from residents, they should put it in writing and provide to the Social Services staff would file it on the grievance log and would investigate and find resolution. A review of the facility ' s policy and procedures revised April 2017 titled, Grievances/Complaints, Recording and Investigating indicated, All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s) The administrator has assigned the responsibility of investigating grievances and complaints to the Grievance Officer. Upon receiving a grievance and complaint report, the Grievance Officer will begin an investigation into the allegations The Grievance Officer will record and maintain all grievances and complaints on the Resident Grievance Complaint Log The resi

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0885 (Tag F0885)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to implement its COVID-19 (an acute respiratory illness capable of producing severe symptoms, and in some cases death), Prevention and Control policy by not ensuring residents' representatives were informed of COVID-19 cases in the facility for one of six sampled residents (Resident 6). This deficient practice has the potential to violate residents' rights and/or representatives' rights to be informed of the facility's COVID-19 status. Findings: During an interview with the Infection Preventionist (IP) on 12/8/2022, at 11:30 a.m., the IP stated that on 12/1/2022, five residents tested positive for COVID-19 and on 12/2/2022, the local Public Health Department notified them, in writing, the facility had a COID-19 outbreak. During an interview with the IP, on 12/8/2022, at 1:07 pm, the IP stated all resident and residents' responsible parties are made aware of the facility's COVID-19 status. The IP stated she did not know how the responsible parties were made aware and the Administrator was responsible for informing residents and responsible parties of the COVID-19 status of the facility. During an interview with the Administrator, on 12/8/2022, at 2:23 p.m., the Administrator stated emails were sent to the responsible parties of the COVID-19 status of the facility. The ADM stated weekly emails were sent and when the facility has new cases. Residents who were self-responsible were given letters directly. During a telephone interview with Resident 6's Responsible Party (RP) on 12/8/2022, at 2:34 p.m., RP stated that she found out this morning (12/8/2022) that there was an outbreak in the facility. RP stated someone left a message on her voicemail this morning and did not receive an email. RP states she did not receive an email or a phone call on 12/1/2022 or 12/2/2022 regarding the COVID-19 status of the facility. A review of the facility provided policy and procedure titled COVID-19, Prevention and Control , revised 10/14/2022, indicated under Communication/Reporting: a. The facility has a plan for communications with residents and their families regarding the status and impact of Covid-19 in the facility, including the prevalence of confirmed cases of Covid-19 in staff and residents, Covid-19 related deaths as directed by CMS guidance, b. The facility designated staff will provide regular updates to staff about the status and impact of Covid-19 in staff and residents as directed by CMS guidance and about PPE (Personal Protective Equipment); c. A designated staff member: Social Service Staff or Designee has been assigned responsibility for daily or weekly communications with residents, and their families by 5:00 p.m.

Apr 2021 21 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide documented evidence that the physician obtained informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) for the administration of lorazepam (medication use to manage anxiety disorders [extreme fear or worry]), quetiapine (medication used to manage psychosis [abnormal condition of the mind described as involving a loss of contact with reality]) and venlafaxine (medication used to manage depression [persistent feeling of sadness and loss of interest]) for two out of nine residents investigated addressing unnecessary medications (Resident 38 and Resident 66). This deficient practice had the potential for the resident and resident representative not to be well-informed of the medications and the potential risks and side effects (expected, well-known reaction that occurs with a predictable frequency and may or may not rise to the level of being an adverse consequence). This also had the potential to place the resident and resident representative to miss the opportunities to decide whether to proceed or to refuse the treatments. Findings: a. A review of Resident 38's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorder (common serious medical illness that negatively affects a person's feelings, thinking, and acting), and anxiety disorder (extreme fear or worry). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 02/28/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed extensive assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 38's Order Summary Report dated 02/24/2021, indicated Quetiapine (medication used to manage abnormal condition of the mind described as involving a loss of contact with reality) tablet 25 milligrams (mg - unit of measurement), by mouth at bedtime for psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) manifested by outburst of anger. Informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) obtained by Medical Doctor (MD). A review of Resident 38's Order Summary Report dated 03/09/2021, indicated Lorazepam concentrate 2 milligrams/milliliters (mg/ml - a unit of measurement), give 0.5 mg sublingually (under the tongue) every 2 hours as needed for anxiety manifested by agitation. The physician order also indicated Lorazepam concentrate 2 mg/ml, give 1 mg sublingually every 2 hours as needed for anxiety manifested by hyperventilation (abnormally fast breathing). A review of Resident 38's Medication Administration Records (MAR) indicated the resident received quetiapine from 02/25/2021 to 04/20/2021. The MAR also indicated the resident received lorazepam on 03/02/2021, 03/05/2021 and 03/08/2021. During a concurrent interview and record review, on 04/22/2021 at 9:02 a.m., Minimum Data Set Assistant (MDS 2) stated there was no documented evidence of informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) available for the use of quetiapine and lorazepam medications in Resident 38's clinical record. MDS 2 stated, informed consent should have been obtained for use of quetiapine and lorazepam medications by the physician. MDS 2 also stated, the informed consent for Resident 38 should have obtained from responsible party since the resident was not able to make healthcare decisions, and the licensed nurse who received the order from physician should have verified the consent. MDS 2 stated, the informed consent for psychotropic medications (drug that affects the brain function and causes changes in mood, awareness, thoughts, feelings, or behavior) was necessary because of the serious side effects and was one the resident's rights. During an interview, on 04/22/2021 at 3:55 p.m., the Director of Nursing (DON) stated, the informed consent for use quetiapine and lorazepam for Resident 38 should have been obtained by the physician from the responsible party. The DON also stated, the licensed nurse should have verified the consent before administering medication. The DON further stated, the informed consent from resident or resident representative is important to make sure that they agree with the use the medications and is one of the resident's rights. A review of the facility's policy and procedures titled, Informed Consent for Psychotropic Medications and Physical Restraints, revised in 08/2014, indicated, the physician is responsible for obtaining consent for the use of psychotherapeutic drugs. It is the responsibility of the attending physician to determine what information to provide to the resident or decision maker to consider material to a decision to accept or refuse a proposed treatment or procedure. The facility is responsible to assure that consent was obtained. The facility staff is responsible to verify that the physician has obtained the consent. b. A review of Resident 66's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 66's Minimum Data Set (MDS - an assessment and care screening tool) dated 03/26/2021, indicated the resident's cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision making are moderately impaired. The MDS also indicated the resident required extensive assistance from staff for dressing, toilet use, personal hygiene, and bathing. A review of Resident 66's Physician's Order dated 03/26/2021 indicated an order for venlafaxine 75 milligrams (mg- unit of measurement) tablet by mouth one time a day for depression. During a concurrent interview and record review, on 04/20/2021 at 10:33 a.m., the Director of Nursing (DON) verified that there was no informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) for the use of venlafaxine. The DON stated that consents are obtained for psychotherapeutic medications (medications capable of affecting the mind, emotions, and behavior) to make sure residents or their representatives are aware of the side effects and the indication for the use of the medications. The DON further stated that a complete informed consent would have the medication name, dosage, indication for use, duration, has to be obtained by the physician from the resident or the responsible party. The DON also stated the nurses are responsible to make sure they are complete. A review of the facility's policy and procedures titled, Informed Consent for Psychotropic Medications and Physical Restraints, dated 08/2014, indicated, Physician is responsible for obtaining consent for the use of psychotherapeutic drugs and it is the responsibility of the attending physician to determine what information to provide to the resident or decision maker to consider material to a decision to accept or refused a proposed treatment or procedure. The facility is responsible to assure that consent was obtained, and facility staff is responsible to verify that the physician has obtained consent.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to ensure Resident 73's call lights was placed within reach, for one out of three sample residents. This failure had the potential to result in a delay or in an inability for the residents to obtain necessary care and services. Findings: A review of the Facesheet, indicated Resident 73 was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included stroke with hemiplegia (damage to the brain causing weakness to one side of the body). A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 3/28/2021, indicated Resident 73 was usually able to understand others. The MDS indicated Resident 73 required extensive assistance in bed mobility, dressing, eating, and was totally dependent on staff in toilet use, personal hygiene, and bathing. A review of the Initial History and Physical, dated 3/24/2021, indicated Resident 73 had the capacity to understand and make decisions. A review of Resident 73's Care Plan, dated 9/4/2020, indicated staff's interventions were to make sure the resident's call light was within reach and to encourage the resident to use it for assistance as needed. The Care Plan indicated the resident needed prompt response to all requests for assistance. During a concurrent observation and interview, on 4/19/2021, at 9:52 a.m., the Certified Nursing Assistant 2 (CNA 2) stated Resident 73 was able to push the call light and should have been within reach at all the time. Resident 73 was observed lying in his bed with his call light on the floor. CNA 2 was observed picking up the call light and handing it to Resident 73's left hand. A review of the facility's policy, dated 10/2010, titled Call Light indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's Advanced Directive (written document that indicated a person's wishes regarding medical treatment if that person is no longer able to communicate) was in the resident's medical record, for one of three sampled residents (Resident 73). This deficient practice had the potential to cause conflict with Resident 73's wishes regarding health care. Findings: A review of the Face Sheet indicated Resident 73 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included stroke with hemiplegia (brain blockage causing weakness to one side of the body). A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 3/28/2021, indicated Resident 73 was able to understand others usually. The MDS indicated Resident 73 required extensive assistance in bed mobility, dressing, eating, and he is totally dependent on staff in toilet use, personal hygiene, and bathing. A review of the Initial History and Physical (H & P), dated 3/24/2021, indicated Resident 73 had the capacity to understand and make decisions. A review of the Physician Orders for Life-Sustaining Treatment (POLST - a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency), dated 3/09/2021, indicated advanced directives were not discussed with Resident 73. During a concurrent interview and record review, on 4/22/2021, at 7:54 a.m., the Director of Nursing (DON) stated the POLST form did not replace the Advance Directives form and should have been completed within 24 hours. The DON stated that the licensed nurses should discuss the advance directives with the family during admission and during the interdisciplinary team meeting (IDT- interdisciplinary team a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient). The DON stated there was no documentation in the clinical records that written information was provided to Resident 73 or his/her responsible party regarding the right to formulate an advance directive. A review of the facility's policy, dated 12/2018, titled Advance Healthcare Directives indicated at the time of admission, admission Staff or designee will inquire about the existence of an Advance Healthcare Directive. A copy of the Advance Healthcare Directive is maintained as part of the resident's medical record.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Assistant 1 (RNA 1) provided complete privacy while doing range of motion (ROM - activity aimed to improve movement of a specific joint) exercises for one (Resident 30) out of one sampled resident investigated for privacy. This deficient practice violated the resident's right to privacy. Findings: A review of Resident 30's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included cerebral aneurysm (a bulging or ballooning in a blood vessel in the brain) and hemiplegia (paralysis of one side of the body). A review of Resident 30's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/12/2021, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. The MDS also indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 04/21/2021 at 9:11 a.m., during an observation, Restorative Nursing Assistant 1 (RNA 1) performed range of motion (ROM - activity aimed to improve movement of a specific joint) exercises with Resident 30. RNA 1 pulled the privacy curtain closed but left the foot of the bed open. On 04/21/2021 at 9:30 a.m., during an interview, RNA 1 stated she should have closed the privacy curtain all the way to cover the foot of the bed when doing treatments for the resident. On 04/22/2021 at 9:26 a.m., during an interview, the Director of Nursing (DON) stated she expected the nurses to close the residents' privacy curtains all the way when providing care or treatments. A review of the facility's policy and procedures titled, Quality of Life - Dignity, revised in 08/2009, indicated staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of two sampled residents (Resident 232) reviewed under care planning. This deficient practice had the potential for the resident not to receive appropriate care and treatment specific to his needs. Findings: A review of Resident 232's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included seizures (sudden surge of electrical activity in the brain when a person experiences involuntary muscle movements, sensory disturbances and altered consciousness), metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body) and gastroesophageal reflux disease ( a digestive disease in which stomach acid irritates the food pipe lining). A review of Resident 232's History and Physical (H & P - an important reference document that provides concise information about a patient's history and exam findings at the time of admission. It outlines a plan for addressing the issues which prompted the hospitalization), indicated the resident had known history that included alcohol abuse and chronic encephalopathy presenting with new seizures, and patient had significant physical disability as such required skilled nursing needs. The H & P indicated the resident had the capacity to understand and make decisions. On 04/20/2021 at 8:11 a.m., during an interview and record review, the Director of Nursing (DON) verified that Resident 232`s baseline care plan (initial written guide that organizes information about the resident's care) was only developed and implemented on 04/19/2021 which was 72 hours since the resident`s admission. According to the DON, baseline care plans are developed within 24 hours of admission because without a care plan, staff will not be able to properly provide care and intervention for the resident. A review of the facility`s policy and procedures, titled Care Plans - Baseline, revised in 12/2016, indicated A baseline plan of care to meet the resident`s needs shall be developed for each resident within forty-eight (48) hours of admission. To assure that the resident`s immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight hours of admission.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive plan of care with measurable objectives and interventions for the use of the medication Buspirone (medication used to treat anxiety disorders) for one of four residents (Resident 55). These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: A review of the Facesheet indicated Resident 55 was readmitted to the facility on [DATE] with diagnosis that included, major depressive disorder (also referred to as clinical depression [mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily function], bipolar disorder (mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), and other psychoactive substance abuse (use of a substance for a purpose not consistent with legal or medical guidelines, as in the non-medical use of prescription medications). A review of the History and Physical dated 4/9/2021 indicated Resident 55 had fluctuating capacity to understand and make decisions. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/17/2021 indicated Resident 55 had intact cognition (thinking process). A review of Resident 55's physician's orders, dated 4/15/2021 indicated to provide Buspirone HCl tablet 7.5 milligrams (mg-unit of measure) by mouth two times a day for anxiety manifested by (m/b) repetitive health complaints. A review of Resident 55's medication administration record (MAR) dated between 4/1/2021 to 4/31/2021 indicated to monitor behavior of repetitive health concern and tally by hashmarks- Buspirone hcl every shift dated 4/15/2021. During a concurrent interview and record review of Resident 55's medical records with MDS 1 on 4/2021/21 at 12:23 pm, MDS 1 confirmed that there was no care plan for Buspirone for Resident 55. MDS 1 stated that there should be care planned to help provide guidance with the implementation of care. During a review of the facility's policy and procedure revised on 12/2016 and titled, Care Plans, Comprehensive Person-Centered, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also indicated the comprehensive, person-centered care plan will describe the service that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure nurses followed physician's orders to assist a resident who was at high risk for aspiration (breathing foreign objects into the airway) with feeding for one (Resident 30) out of four sampled residents investigated for accidents. This deficient practice had the potential to place the resident at risk of aspirating. 2. Ensure Resident 132, who required oxygen therapy, had an oxygen in use sign immediately outside the room, for one of six sampled residents investigated for respiratory care. This deficient practice had the potential to cause a fire hazard and safety issues. Findings: a. A review of Resident 30's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included cerebral aneurysm (a bulging or ballooning in a blood vessel in the brain) and hemiplegia (paralysis of one side of the body). A review of Resident 30's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 02/12/2021, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact. The MDS also indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 30's Physician's Orders, dated 02/24/2020, indicated to provide 1:1 assistance during meals. On 04/19/2021 at 9:45 a.m., during an observation and interview, Resident 30 was awake and alert in bed. Resident 30 answered questions, but her speech was slurred. Resident 30 stated she had a stroke (occurs when the blood supply to part of one's brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and had weakness on her right side. On 04/21/2021 at 7:38 a.m., during an observation, observed Resident 30 in bed eating breakfast by herself. On 04/21/2021 at 8:57 a.m., during an interview, Resident 30 stated no one ever helped her with eating. On 04/21/2021at 4:05 p.m., during a concurrent interview and record review, the Assistant Director of Nursing (ADON) stated Resident 30 had a diagnosis of cerebral aneurysm and had weakness on her right side. ADON stated the resident was on aspiration precautions (practices that help prevent food or fluids from getting into one's airway) and required 1:1 assistance with feeding. ADON stated the resident was able to use her left hand to feed herself but required a nurse to watch her so she did not aspirate. On 04/22/2021 at 9:26 a.m., during an interview, the Director of Nursing (DON) stated Resident 30 could aspirate if she was not supervised while eating. A review of the facility's policy and procedures titled, Assistance with Meals, revised in 07/2017, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. b. A review of the Face Sheet indicated Resident 132 was admitted to the facility, on 4/18/2021, with diagnoses that included chronic congestive heart failure (inability of the heart to keep up with the demands with failure of the heart to pump blood with normal efficiency). On 4/19/2021, at 9:57 a.m. during an initial tour of the facility, Resident 132 was observed sleeping in her bed with oxygen therapy. There was no sign for oxygen in use posted in the room. During a concurrent observation and interview, the Director of Staff Development (DSD) stated there should have been a sign indicating Oxygen in Use at the door or designated place on or over the resident's bed. A review of the facility's policy and procedures, revised 10/2010, titled Oxygen Administration, indicated place an Oxygen in Use sign on the outside of the room entrance door. Place an Oxygen in Use sign in a designated place on or over the resident's bed.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

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 assess the risks of entrapment (being caught in or as in a trap) for the use of bed rails for one out of three sampled residents (Resident 38) investigated under the care area of accidents. This deficient practice placed the resident at risk for potential accidents such as falls or being caught between the rails. Findings: A review of Resident 38's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorder (common serious medical illness that negatively affects a person's feelings, thinking, and acting), and anxiety disorder (extreme fear or worry). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 02/28/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed extensive assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 38's Order Summary Report dated 02/24/2021, indicated to use bilateral quarter (1/4 x 2) side rails up in bed as enabler to assist with bed mobility and repositioning. During an observation, on 04/19/2021 at 1:04 a.m., observed Resident 38 in his room laying on bed with bilateral upper quarter side rails up. During a concurrent interview and record review, on 04/22/2021 at 9:17 a.m., Minimum Data Set Assistant (MDS 2) stated, the facility uses the bed safety assessment instead of entrapment (being caught in or as in a trap) risk assessment for residents who had orders for use of side rails. MDS 2 confirmed there was no documented evidence of bed safety assessment or entrapment risk assessment in Resident 38's record. MDS 2 stated bed safety assessment for resident should have done by the admitting licensed nurse. MDS 2 also stated, it was important to conduct the assessment to ensure resident safety. During an interview, on 04/22/2021 at 3:46 p.m., the Director of Nursing (DON) stated Resident 38 should have been assessed for risk for entrapment by the licensed nurses before using the side rail. The DON also stated, entrapment risk assessment is necessary for the safety of the resident. A review of the facility's policy and procedures titled, Proper Use of Side Rails, revised in 12/2016, indicated the purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. An assessment will be made to determine the resident's symptoms, risk of entrapment, and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails.

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** c. A review of Resident 432's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included hypertension (high blood pressure) and bipolar disorder (a mental health condition that causes extreme mood swings). A review of History and Physical (H & P) dated 04/15/2021 indicated Resident 432 had the capacity to understand and make decisions. A review of Order Summary Report dated 04/14/2021, indicated to give aripiprazole 10 milligrams (mg - unit of measurement) tablet by mouth one time a day for bipolar disorder (a mental health condition that causes extreme mood swings) and lisinopril 5 mg 1 tablet by mouth once a day for hypertension (medication for the treatment of hypertension [high blood pressure]). On 04/22/2021 at 8:15 a.m., during an observation of Station 2 Medication Cart 2 (used to organize, store, and transport medications to resident room) and a concurrent interview with Licensed Vocational Nurse 5 (LVN 5), observed empty bubble packs (individually sealed compartments that hold medication) for aripiprazole and lisinopril for Resident 432; both medications were due to be administered at 9 a.m. LVN 5 stated the empty bubble packs were kept to hold the space until the medications were refilled. She said she will call the pharmacy. On 04/22/2021 at 9:52 a.m., during an interview, the Director of Nursing (DON) stated refills should be ordered when three to five supplies are remaining on the bubble packs. The DON stated once the order was placed, they call the pharmacy to get the medication on the same day. The DON stated it is the licensed nurse's responsibility in ordering the refill. The DON stated if it is not ordered on time, resident will miss the medication, and this can cause adverse reaction based on the type of medications. During an interview, on 04/22/2021 at 10:50 a.m., LVN 5 confirmed she did not give the two medications that were not available during the review of Station 2 Medication Cart 2 at 8:15 a.m. LVN 5 stated she called the pharmacy and was told by the pharmacy staff that the medications were delivered. LVN 5 stated she had to check the other station. During an interview and record review, on 04/22/2021 at 12:30 p.m., LVN 5 stated she found the two medications and they were mixed with another resident's medications. LVN 5 has not yet administered Resident 432's aripiprazole and lisinopril as scheduled to be administered at 9 a.m. A record review of Resident 432's electronic medical record also indicated no documented blood pressure since 2:16 a.m. During a phone interview, on 04/22/2021 at 1:07 p.m., Pharmacist 2 stated Resident 432's lisinopril was refilled on 04/20/2021 at 8:02 a.m. and the refill request was sent to them on 04/20/2021. Pharmacist 2 also stated aripiprazole was filled on 04/20/2021 and was delivered to the facility with lisinopril. A review of the Medication Administration Record (MAR) indicated Resident 432's blood pressure was not checked and documented; and aripiprazole and lisinopril were not administered as scheduled on 04/22/2021 at 9 a.m. During an interview, on 04/22/2021 at 1:32 p.m., LVN 5 stated checking Resident 432's blood pressure and administered aripiprazole and lisinopril that were due at 9 a.m. A review of the facility's policy and procedures titled, Administering Medications, revised in 12/2012, indicated medications must be administered within one hour of their prescribed time, unless otherwise specified before and after meal orders. Based on observation, interview, and record review, the facility failed to: 1. Ensure vitamin supplements were available as prescribed for two out of six residents observed during medication administration (Resident 29 and Resident 482). a. Thiamine (vitamin supplement) was not available for Resident 29 and Resident 482 during medication administration. b. Folic acid (vitamin supplement) was not available for Resident 482 during medication administration. 2. Ensure to administer lisinopril (medication for the treatment of hypertension [high blood pressure]) and aripiprazole (medication for the treatment of bipolar disorder [a disorder associated with episodes of mood swings ranging from depressive lows to manic highs]) in a timely manner as prescribed by the physician for Resident 432. Both medications were scheduled for 9 a.m. administration but were administered to the resident at 1 p.m. This deficient practice resulted in delayed medication administration for the residents. Findings: a. A review of Resident 29's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included congestive heart failure (weakening of the heart muscles and valves) and alcohol dependence. A review of Resident 29's Order Summary Report indicated a physician's order dated 02/15/2020 indicated to administer thiamine hydrochloride (vitamin supplement) tablet 100 milligrams (mg - unit of measurement) one tablet by mouth two times a day for vitamin B supplement. On 04/20/2021 at 8:30 a.m., during an observation of medication administration for Resident 29 and a concurrent interview and record review, Licensed Vocational Nurse 2 (LVN 2) stated there were no more thiamine in the medication cart. A review of Resident 29's Medication Administration Record (MAR) indicated the resident received thiamine the night before at 11:07 p.m. LVN 2 stated she usually gets medications from central supply (department responsible for receiving, storing, and distributing medical supplies including over-the-counter medications) and would check there. During an interview, on 04/20/2021 at 8:46 a.m., Central Supply staff (CS) stated four bottles of thiamine were ordered the day before. A review of Resident 29's Progress Notes indicated the following regarding thiamine: 1. Medication arrived and administered to patient on 04/20/2021 at 11:20 a.m. 2. Called office of medical doctor to notify of late administration on 04/20/2021 at 12:15 p.m. On 04/21/2021 at 3:36 p.m., during an interview, the Director of Nursing (DON) stated when a medication is unavailable, the licensed nurses need to check with the central supply staff first if there were supplies, and then notify them to reorder if necessary. The DON further stated the licensed nurses should notify the doctor that a medication is unavailable so they can order for any substitute or hold (don't administer) the medication. She stated all licensed nurses are responsible for medications due on their shift including medication cart supply. She also stated CS ensures over-the-counter medications and other supplies are in stock; if not available, then CS asks the pharmacy for the needed medications. A review of facility policy and procedures titled, Administering Medications revised in 12/2012, indicated medications must be administered in accordance with the orders and within 1 hour of prescribed time unless otherwise specified like before or after meal orders . b. A review of Resident 482's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and alcohol dependence. A review of Resident 482's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 04/12/2021 indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). A review of Resident 482's Physician's Orders dated 04/10/2021 indicated to administer vitamin B1 (thiamine mononitrate) tablet 100 milligrams (mg - unit of measurement) one tablet by mouth one time a day for supplement. The order also indicated to administer folic acid tablet 1 mg give 1 tablet by mouth one time a day for supplement. On 04/20/2021 at 10:03 a.m., during an observation of medication administration for Resident 482 and a concurrent interview, Director of Staff Development (DSD) stated there were no more thiamine in Station 2 Medication Cart 2. DSD asked Registered Nurse 2 (RN 2) to check with central supply (department responsible for receiving, storing, and distributing medical supplies including over-the-counter medications) and to notify the doctor. DSD stated thiamine is a house stock medication and was last given the day before when she put in an urgent (stat) order and let the resident know. She also stated Central Supply staff (CS) makes sure the house stock is complete. On 04/20/2021 at 10:55 a.m., during an interview, CS stated thiamine was delivered around 10 a.m. that day, and as soon as she received them, she restocked the medication carts. On 04/20/2021 at 11:42 a.m., a review of Resident 482's Progress Notes indicated the following: 1. Vitamin B1 was not delivered yet per CS from central supply on 04/20/2021at 10:09 a.m. Nurse Practitioner notified with new order to hold (do not administer) vitamin B 1 for 7 days or until medication was delivered. 2. Vitamin B 1 tablet had been placed on hold for today, 04/20/2021 at 10:40 a.m.; awaiting shipment of medication. A review of Resident 482's Progress Notes dated 04/20/2021 at 10:51 a.m. indicated folic acid tablet 1 mg medication was unavailable; awaiting pharmacy delivery; medical doctor notified. During an interview on 04/20/2021 at 4:38 p.m., DSD stated she received thiamine 10 minutes after finishing administration for Resident 482. DSD stated folic acid was not given earlier because she had to call pharmacy and the expected delivery is the next day. DSD stated she did not call the doctor regarding folic acid. On 04/21/2021 at 9:02 a.m., Licensed Vocational Nurse 3 (LVN 3) stated folic acid was filled on 4/20/2021 at 7:50 p.m. On 04/21/2021 at 3:36 p.m., during an interview, the Director of Nursing (DON) stated when a medication is unavailable, the licensed nurses need to check with the central supply staff first if there were supplies, and then notify them to reorder if necessary. The DON further stated the licensed nurses should notify the doctor that a medication is unavailable so they can order for any substitute or hold (don't administer) the medication. She stated all licensed nurses are responsible for medications due on their shift including medication cart supply. DON stated folic acid should have a hold order by the doctor, but there was no new order; the doctor was only notified. DON also stated the process for prescribed medications was to ensure adequate supply of medications that are not on cycle (not automatically delivered) by requesting 3-5 days before the supply runs out and should be done by the licensed nurse. A review of facility policy and procedures titled, Administering Medications revised in 12/2012, indicated medications must be administered in accordance with the orders and within 1 hour of prescribed time unless otherwise specified like before or after meal orders .

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 ensure the physician acted upon the Medication Regimen Review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage) recommendations in a timely manner for one of nine sampled residents (Resident 38) investigated addressing unnecessary medications. This deficient practice placed the resident at risk of receiving unnecessary medications. Findings: A review of Resident 38's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorder (common serious medical illness that negatively affects a person's feelings, thinking, and acting), and anxiety disorder (extreme fear or worry). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 02/28/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed extensive assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). The MDS indicated the resident was receiving hospice (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms) services. A review of Resident 38's Order Summary Report dated 03/09/2021, indicated a physician's order to administer lorazepam (a psychotropic [drug that affects the brain function and causes changes in mood, awareness, thoughts, feelings, or behavior] medication used to manage anxiety) concentrate 2 milligrams/milliliters (mg/ml - unit of measurement), give 0.5 mg sublingually (under the tongue) every 2 hours as needed (PRN) for anxiety manifested by agitation. The physician's orders also indicated to administer lorazepam concentrate 2 mg/ml, give 1 mg sublingually every 2 hours as needed for anxiety manifested by hyperventilation (abnormally fast breathing). A review of Resident 38's Consultant Pharmacist's Medication Regimen Review (MRR - thorough evaluation of the medications of the patient with the goal of promoting positive outcomes and minimizing adverse consequences related to medications), dated 03/09/2021, indicated the resident had an order for as needed (PRN) lorazepam. The MRR indicated according to Centers for Medicare and Medicaid Services (CMS) MEGA Rules, PRN psychotropic (drug that affects the brain function and causes changes in mood, awareness, thoughts, feelings, or behavior) orders are limited to 14 days, unless the prescriber believes it is appropriate to extend the order beyond 14 days and document this in the clinical record. It applies to hospice too. Please consider the above regulation and document or discontinue the above PRN medication. A review of Resident 38's Consultant Pharmacist's Medication Regimen Review, dated 04/15/2021, indicated the resident had an order for duplicate PRN lorazepam 0.5 mg every two hours and 1 mg every two hours. According to CMS MEGA Rules, PRN psychotropic orders are limited to 14 days, unless the prescriber believes it is appropriate to extend the order beyond 14 days and document this in the clinical record. Please consider the above regulation and document or discontinue the above PRN medication. During a concurrent interview and record review, on 04/21/2021 at 4:15 p.m., Minimum Data Set Assistant (MDS 2) confirmed there was no duration (length of time) for lorazepam PRN order. MDS 2 stated, the PRN order for lorazepam should have renewed after 14 days. MDS 2 also stated, side effects or effectivity of PRN psychotropic medication should be reevaluated by the physician after 14 days. During an interview, on 04/21/2021 at 5 p.m., the Director of Nursing (DON) stated, the pharmacist comes in middle of each month for MRR. The pharmacist usually e-mails the recommendations to DON upon completion of the MRR, which she then hands over to Assistant Director of Nursing (ADON). She further stated that the ADON then notifies the physician within five to seven days, who should respond through fax, phone calls or sign it upon visit to the facility. During an interview, on 04/21/2021 at 5:16 p.m., ADON stated, she informed the nurse from hospice care upon visit to the facility about the pharmacy recommendations, and the nurse stated, she would inform the physician. During a concurrent interview and record review, on 4/21/2021 at 5:19 p.m., the DON confirmed there was no progress notes available in the resident's record from physician for not following the pharmacy recommendations. The DON stated, the licensed nurse who was responsible for the resident should have followed up and informed the physician. The DON also stated, the physician should have written the rationale (underlying reason) in the resident's clinical record for continuing lorazepam or not following the pharmacy recommendation. The DON stated, it was important to ensure the resident had no adverse effects (any unexpected or dangerous reaction to a drug) of lorazepam and it was effective for the resident. The physician needed to re-evaluate the resident and renew lorazepam order every 14 days if necessary. A review of the facility's policy and procedures titled, Medication Regimen Review, revised in 4/2007, indicated the consultant pharmacist shall review the medication regimen of each resident at least monthly. The consultant pharmacist will perform a medication regimen review (MRR) for every resident in the facility. The consultant pharmacist will document his/her findings and recommendations on the monthly drug/ medication regimen review report. The consultant pharmacist will provide a written report to physicians for each resident with identified irregularity. A review of the facility's policy and procedures titled, Behavioral Assessment, Intervention, Monitoring and Use of Psychotropic Medications, revised in 12/2016, indicated residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses monitored a resident for bruising and bleeding while the resident received enoxaparin (anticoagulant - medication that helps prevent blood clots) for one (Resident 82) out of ten sampled residents investigated for unnecessary medications. This deficient practice had the potential to result in the resident experiencing adverse side effects (any unexpected or dangerous reaction to a drug) from the medication. Findings: A review of Resident 82's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and dementia (a general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 82's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 04/07/2021, indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS also indicated the resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 04/21/2021 at 3:27 p.m., during a concurrent interview and record review, the Assistant Director of Nursing (ADON) stated Resident 82 had a physician's order for enoxaparin (anticoagulant - medication that helps prevent blood clots) 40 milligrams (mg - unit of measurement) subcutaneously (injected into the tissue layer between the skin and the muscle) one time a day to prevent blood clotting. Upon review of Resident 82's Medication Administration Record (MAR - the report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional), dated 04/21/2021, ADON stated the resident received enoxaparin 17 times, from 4/3/2021 to 4/19/2021. When asked if the nurses monitored the resident for bruising or bleeding, ADON stated she did not see any documentation indicating licensed nurses were monitoring the resident for bruising or bleeding. ADON stated it was important to know if the resident had any bruising or bleeding so the physician would know if the medication needed to be discontinued. On 04/22/2021 at 9:19 a.m., during an interview, the Director of Nursing (DON) stated when a physician prescribed enoxaparin to residents, licensed nurses were supposed to monitor them for bleeding and discoloration. DON stated it was important to monitor for bleeding and discoloration because enoxaparin increased residents' risk of bleeding. DON stated the licensed nurses should have monitored the resident for bruising and bleeding. A review of the facility's policy and procedures titled, Anticoagulation - Clinical Protocol, revised in 10/2014, indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated (agent used to prevent the formation of blood clots) and will manage related problems.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one out of nine residents reviewed by failing to ensure the duration (length of time) of lorazepam (a psychotropic [drug that affects the brain function and causes changes in mood, awareness, thoughts, feelings, or behavior] medication used to manage anxiety [extreme fear or worry]) as needed (PRN) was indicated for 14 days for Residents 38. This deficient practice placed Resident 38 at risk for receiving an unnecessary psychotropic medication that can potentially result in experiencing harmful side effects. Findings: A review of Resident 38's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorder (common serious medical illness that negatively affects a person's feelings, thinking, and acting), and anxiety disorder (extreme fear or worry). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 02/28/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed extensive assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). The MDS indicated the resident was receiving hospice (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms) services. A review of Resident 38's Order Summary Report dated 03/09/2021, indicated a physician's order to administer lorazepam (a psychotropic [drug that affects the brain function and causes changes in mood, awareness, thoughts, feelings, or behavior] medication used to manage anxiety) concentrate 2 milligrams/milliliters (mg/ml - unit of measurement), give 0.5 mg sublingually (under the tongue) every 2 hours as needed (PRN) for anxiety manifested by agitation. The physician's orders also indicated to administer lorazepam concentrate 2 mg/ml, give 1 mg sublingually every 2 hours as needed for anxiety manifested by hyperventilation (abnormally fast breathing). A review of Resident 38's Consultant Pharmacist's Medication Regimen Review (MRR - thorough evaluation of the medications of the patient with the goal of promoting positive outcomes and minimizing adverse consequences related to medications), dated 03/09/2021, indicated the resident had an order for as needed (PRN) lorazepam. The MRR indicated according to Centers for Medicare and Medicaid Services (CMS) MEGA Rules, PRN psychotropic (drug that affects the brain function and causes changes in mood, awareness, thoughts, feelings, or behavior) orders are limited to 14 days, unless the prescriber believes it is appropriate to extend the order beyond 14 days and document this in the clinical record. It applies to hospice (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms) too. Please consider the above regulation and document or discontinue the above PRN medication. A review of Resident 38's Consultant Pharmacist's Medication Regimen Review, dated 4/15/2021, indicated the resident had an order for duplicate PRN Lorazepam 0.5 mg every two hours and 1 mg every two hours. According to CMS MEGA Rules PRN psychotropic orders are limited to 14 days, unless the prescriber believes it is appropriate to extend the order beyond 14 days and document this in the clinical record. Please consider the above regulation and document or discontinue the above PRN medication. During a concurrent interview and record review, on 4/21/2021 at 4:15 p.m., Minimum Data Set Assistant (MDS 2) confirmed there was no duration (length of time) for lorazepam PRN order. MDS 2 stated, the PRN order for lorazepam should have renewed after 14 days. MDS 2 also stated, side effects or effectivity of PRN psychotropic medication should be reevaluated by the physician after 14 days. During an interview, on 4/21/2021 at 5:16 p.m., ADON stated, she informed the nurse from hospice care upon visit to the facility about the pharmacy recommendations, and the nurse stated, she would inform the physician. During a concurrent interview and record review, on 4/21/2021 at 5:19 p.m., the DON confirmed there was no progress notes available in the resident's record from physician for not following the pharmacy recommendations. The DON stated, the licensed nurse who was responsible for the resident should have followed up and informed the physician. The DON also stated, the physician should have written the rationale (underlying reason) in the resident's clinical record for continuing lorazepam or not following the pharmacy recommendation. The DON stated, it was important to ensure the resident had no adverse effects (any unexpected or dangerous reaction to a drug) of lorazepam and it was effective for the resident. The physician needed to re-evaluate the resident and renew lorazepam order every 14 days if necessary. A review of the facility's policy and procedures titled, Medication Regimen Review, revised in 4/2007, indicated the consultant pharmacist shall review the medication regimen of each resident at least monthly. The consultant pharmacist will perform a medication regimen review (MRR) for every resident in the facility. The consultant pharmacist will document his/her findings and recommendations on the monthly drug/ medication regimen review report. The consultant pharmacist will provide a written report to physicians for each resident with identified irregularity. A review of the facility's policy and procedures titled, Behavioral Assessment, Intervention, Monitoring and Use of Psychotropic Medications, revised in 12/2016, indicated residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.

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 it was free of medication error rate of five percent (5 %) or greater, as evidenced by the identification of two medication administration errors out of 29 opportunities (observations during medication pass) for error, to yield a cumulative error rate of 6.89 % for two out of six residents observed during medication administration (Residents 29 and 482) as follows: 1. For Resident 29, thiamine was not administered timely. 2. For Resident 482, folic acid was not administered timely. These deficient practices resulted in not following the physician's orders, not notifying the physician about unavailability of medications, and delayed medication administration. Findings: a. A review of Resident 29's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses that included congestive heart failure (weakening of the heart muscles and valves) and alcohol dependence. A review of Resident 29's Order Summary Report indicated a physician's order dated 02/15/2020 indicated to administer thiamine hydrochloride (vitamin supplement) tablet 100 milligrams (mg - unit of measurement) one tablet by mouth two times a day for vitamin B supplement. On 04/20/2021 at 8:30 a.m., during an observation of medication administration for Resident 29, and a concurrent interview and record review, Licensed Vocational Nurse 2 (LVN 2) stated there were no more thiamine in the medication cart. LVN 2 also stated Resident 29's Medication Administration Record (MAR) indicated the resident received thiamine on 4/19/2021 at 11:07 p.m. LVN 2 stated she usually gets medications from central supply (department responsible for receiving, storing, and distributing medical supplies) and would check there. During an interview, on 04/20/2021 at 8:46 a.m., Central Supply staff (CS) stated four bottles of thiamine were ordered the day before. On 04/20/2021 at 11:18 a.m., LVN 2 stated though medication was unavailable, she should have called the doctor after seeing the resident. A review of Resident 29's Progress Notes indicated the following regarding thiamine: 1. Medication arrived and administered to patient on 04/20/2021 at 11:20 a.m. 2. Called office of medical doctor to notify of late administration on 04/20/2021 at 12:15 p.m. On 04/21/2021 at 3:36 p.m., during an interview, the Director of Nursing (DON) stated when a medication is unavailable, the licensed nurses need to check with the central supply staff first if there were supplies, and then notify them to reorder if necessary. The DON further stated the licensed nurses should notify the doctor that a medication is unavailable so they can order for any substitute or hold (don't administer) the medication. A review of facility policy and procedures titled, Administering Medications revised in 12/2012, indicated medications must be administered in accordance with the orders and within 1 hour of prescribed time unless otherwise specified like before or after meal orders . b. A review of Resident 482's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and alcohol dependence. A review of Resident 482's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 04/12/2021 indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). A review of Resident 482's Physician's Orders dated 04/10/2021 indicated to administer folic acid tablet 1 mg give 1 tablet by mouth one time a day for supplement. On 04/20/2021 at 10:03 a.m., during an observation of medication administration for Resident 482 and a concurrent interview, Director of Staff Development (DSD) stated there were no more thiamine in Station 2 Medication Cart 2. DSD asked Registered Nurse 2 (RN 2) to check with central supply (department responsible for receiving, storing, and distributing medical supplies including over-the-counter medications) and to notify the doctor. DSD stated thiamine is a house stock medication and was last given the day before when she put in an urgent (stat) order and let the resident know. She also stated Central Supply staff (CS) makes sure the house stock is complete. A review of Resident 482's Progress Notes dated 04/20/2021 at 10:51 a.m. indicated folic acid tablet 1 mg medication was unavailable; awaiting pharmacy delivery; medical doctor notified. During an interview on 04/20/2021 at 4:38 p.m., DSD stated folic acid was not given earlier because she had to call pharmacy and the expected delivery is the next day. DSD stated she did not call the doctor regarding folic acid. On 04/21/2021 at 9:02 a.m., Licensed Vocational Nurse 3 (LVN 3) stated folic acid was filled on 4/20/2021 at 7:50 p.m. On 04/21/2021 at 3:36 p.m., during an interview, the Director of Nursing (DON) stated when a medication is unavailable, the licensed nurses need to check with the central supply staff first if there were supplies, and then notify them to reorder if necessary. The DON further stated the licensed nurses should notify the doctor that a medication is unavailable so they can order for any substitute or hold (do not administer) the medication. She stated all licensed nurses are responsible for medications due on their shift including medication cart supply. DON stated folic acid should have a hold order by the doctor, but there was no new order; the doctor was only notified. DON also stated the process for prescribed medications was to ensure adequate supply of medications that are not on cycle (not automatically delivered) by requesting 3-5 days before the supply runs out and should be done by the licensed nurse. A review of facility policy and procedures titled, Administering Medications revised in 12/2012, indicated medications must be administered in accordance with the orders and within 1 hour of prescribed time unless otherwise specified like before or after meal orders . The medication error rate was calculated as two (2) medication errors divided by 29 opportunities (observations during medication pass), multiplied by 100, which resulted in the medication error rate of 6.89%, exceeding the five (5) percent threshold.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure administration of Lantus insulin (a medication used to control high blood sugar) was documented in accordance with accepted professional standards for Resident 38. This deficient practice had the potential to result to inadequate management of Resident 38's diabetes mellitus (DM - abnormally high levels of sugar in the blood). 2. Ensure Resident 73's Clothing and Possessions Record was completed, for one of three sampled residents. This deficient practice had the potential for misappropriation of properties with inaccurate documentation of staff. Findings: a. A review of Resident 38's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and diabetes mellitus (DM - abnormally high levels of sugar in the blood). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 02/28/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident received insulin (a medication used to control the high blood sugar) during the look back period (time frame for observation). A review of Resident 38's Physician and Telephone Order dated 02/24/2021 indicated to check resident's blood sugar in the morning and administer 10 units of Lantus Solostar (insulin Glargine - a medication used to control high blood sugar) injection 100 units per milliliters (units/ml - unit of measurement) subcutaneously (tissue layer between the skin and the muscle), if the resident's blood sugar is more than 200 milligrams per deciliter (mg/dl - unit of measurement). A review of Resident 38's Order Summary Report dated 030/9/2021, indicated to check resident's blood sugar in the morning and inject (administer) 10 units of Lantus Solostar solution Pen-Injector 100 units/ml subcutaneously, if the resident's blood sugar is more than 200 mg/dl. During a concurrent interview and record review, on 04/21/2021 at 4:41 p.m., Minimum Data Set Assistant (MDS 2) confirmed, from the review of Resident 38's Medication Administration Record (MAR), the resident received Lantus Solostar solution 10 units when the resident's blood sugars were less than 200 mg/dl in: 1. 02/2021 for three times 2. 03/2021 for 16 times 3. 04/2021 for seven times MDS 2 stated the licensed nurses should not have administered the insulin if Resident 38's blood sugars were less than 200 mg/dl because it can cause hypoglycemia (abnormally low blood sugar). During a concurrent interview and record review, on 04/22/2021 at 8:14 a.m., Registered Nurse 1 (RN 1) stated, placing a check mark in the MAR indicated the medication was administered. RN 1 stated, she used check marks for eight times in 03/2021 and six times in 4/2021 on Resident 38's MAR for Lantus insulin administration to indicate that she checked the resident's blood sugar. RN 1 stated she did not administer the insulin for the resident when the blood sugars were less than 200 mg/dl. RN 1 stated it was a documentation error. RN 1 stated, she should have documented in as hold (do not administer) in the MAR by using the code numbers assigned, instead of using check mark. RN 1 stated, insulin is a critical medication and accurate documentation is important for the safety of the resident. During a concurrent interview and record review, on 04/22/2021 at 8:27 a.m., Director of Staff Development (DSD) stated indicating a check mark in the MAR means the medication was administered. DSD stated, the MAR documentation on 02/28/2021 at 9 a.m. indicated that she administered the Lantus insulin, but she did not recall whether she administered it. DSD also stated the insulin should be held if the blood sugar is less than 200 mg/dl and it might be a documentation error. The DSD stated accurate documentation was important to know the resident's status. A review of Resident 38's MAR indicated RN 1 documented holding (not administering) Lantus Solostar solution 10 units on 04/10/2021, 04/16/2021, and 04/17/2021. During a follow up phone interview, on 04/22/2021 at 1:51 p.m., RN 1 stated she was inconsistent with the documentation of Lantus insulin administration on Resident 38's records. RN 1 stated sometimes she used check mark and sometimes she used the code numbers assigned to indicate holding of Lantus insulin. RN 1 also stated, she did not administer insulin on both times. During a concurrent interview and record review, on 04/22/2021 at 1:57 p.m., Licensed Vocational Nurse 2 (LVN 2) stated placing a check mark in Resident 38's MAR on Lantus insulin administration indicated the medication was administered. LVN 2 also stated, holding of Lantus insulin should be indicated by using the designated code numbers in the MAR. During a concurrent interview and record review, on 4/22/2021 at 2:02 p.m., Licensed Vocational Nurse 3 (LVN 3) stated placing a check mark in Resident 38's MAR on Lantus insulin administration indicated the medication was administered. LVN 2 also stated, holding of Lantus insulin should be indicated by using the designated code number in the MAR. During an interview, on 04/22/2021 at 4 p.m., the Director of Nursing (DON) stated RN 1 should have documented accurately using appropriate coding in Resident 38's MAR. The DON also stated, documentation error can lead to improper assessment of resident and miscommunication among the licensed nurses. A review of the facility's policy and procedures titled, Administering Medications, revised in 12/2012, indicated medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. If a drug is withheld, refused, given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. A review of the facility's policy and procedures titled, Competency of Nursing Staff, revised in 5/2019, indicated, all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. In addition, licensed nurses and nursing assistants employed by the facility will demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plan of care. Facility and resident -specific competency evaluations will include a pre and post-test for documentation issues. b. A review of the admission Record indicated Resident 73 was admitted to the facility on [DATE], with diagnoses that included a stroke (the sudden death of brain cells in a localized area due to inadequate blood flow) with hemiplegia (paralysis on one side of the body). A review of the Minimum Data Set (MDS- a comprehensive assessment and screening tool), dated 03/28/2021, indicated Resident 73 was able to understand others usually. Resident 73 required extensive assistance in bed mobility, dressing, eating, and he is totally dependent on staff in toilet use, personal hygiene, and bathing. A review of the Initial History and Physical, dated 03/24/2021, indicated Resident 73 had the capacity to understand and make decisions. A review of the Resident 73's Clothing and Possessions Record (inventory list), dated 03/23/2021, indicated the resident was admitted to the facility with a cellular phone. The record further indicated missing resident's signature and his acknowledgement. During a concurrent interview and record review, on 03/24/2021, at 11:20 a.m. the Director of Medical Record (DMR) stated Resident 73's inventory list should have been completed upon admission by obtaining the resident's signature and his acknowledgement. The DMR stated the inventory list was signed by one of Certified Nursing Attendants (CNA) and one Licensed Nurse, yet the resident's signature was missing. The DMR stated that the missing signature should have been followed up by the Director of Staff Development (DSD), CNAs, and licensed nurses. A review of the facility's policy and procedures, dated 9/2012, titled Personal Property indicated the resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a plan of care (written guide that organizes information about the resident's care) was established for one of one sampled resident (Resident 38) receiving hospice services (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs). This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 38. Findings: A review of Resident 38's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), major depressive disorder (common serious medical illness that negatively affects a person's feelings, thinking, and acting), and anxiety disorder (extreme fear or worry). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 02/28/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. The MDS also indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed extensive assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 38's Order Summary Report dated 02/24/2021, indicated a physician's order to admit resident to hospice service (a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs) under routine level of care with diagnosis of cerebrovascular accident (CVA- blood flow to the brain stops and brain cells start to die). A review of Resident 38's Written Recertification (report from the doctor justifying the need for hospice services) dated 04/01/2021, indicated the resident was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. It also indicated the certification period was from 04/07/2021 to 07/05/2021. During a concurrent interview and record review, on 04/22/2021 at 1:24 p.m., Minimum Data Set Coordinator (MDS 1) confirmed there was no documented evidence of plan of care order in Resident 38's hospice record for the period of 04/07/2021 to 07/05/2021 by the hospice service provider. MDS 1 also stated, the plan of care order should have been developed by hospice service provider and was important to provide the specific care needed for the resident. During an interview, on 04/22/2021 at 4:08 p.m., the Director of Nursing (DON) stated, the hospice service provider should have renewed the plan of care when they renewed the certification of terminal illness period, and they should have communicated with the facility staff. The DON stated the facility staff could have incorporated the hospice care plans with the facility plans of care. The DON also stated, it was important to ensure the delivery of proper care for the resident on hospice care, and to provide collaborative care. A review of the facility's policy and procedures titled, Hospice Program, revised in 07/2017, indicated hospice services are available to residents at the end of life. Upon admission and periodically during their stay, residents are informed of the availability of hospice services coordinated through the facility. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including determining the appropriate hospice plan of care. Our facility has designated the Social Service Director to coordinate care provided to the resident by our facility staff and the hospice staff. He or she is responsible in obtaining the most recent hospice plan of care specific to each resident.

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** Based on observation, interview, and record review, the facility failed to ensure: 1. A Certified Nursing Assistant (CNA) treated a resident with dignity and respect by telling the resident she was too busy to help her for one (Resident 11) out of six sampled residents investigated for dignity. 2. A Restorative Nursing Assistant (RNA) was not standing over a resident while feeding her for one (Resident 76) out of six sampled residents investigated for dignity. 3. A Certified Nursing Assistant (CNA) was not standing over a resident while feeding him for one (Resident 3) out of six sampled residents investigated for dignity. These deficient practices had the potential to affect the residents' sense of self-worth and self-esteem. Findings: a. A review of Resident 11's admission Record indicated the resident was originally admitted to the facility on [DATE] with diagnoses that included generalized osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down, often resulting in chronic pain), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with one's daily functioning), generalized muscle weakness, and anxiety disorder (specific psychiatric disorders that involve extreme fear or worry). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/21/2021, indicated the resident was cognitively intact and required limited assistance from staff for walking in the room and corridor, locomotion on and off the unit, eating, and personal hygiene. On 04/19/2021 at 11 a.m., during an interview, Resident 11 stated Certified Nursing Assistant 1 (CNA 1) was rude to her today. Resident 11 stated when she asked CNA 1 for assistance to wheel her outside to the patio, CNA 1 responded, No, I'm too busy right now. Resident 11 stated she had to find another staff member to assist her to the patio. On 04/21/2021 at 9:35 a.m., during an interview, CNA 1 stated she was working with Resident 11's roommate when Resident 11 asked her for assistance to be wheeled out to the patio. CNA 1 stated the two residents often got jealous of each other. CNA 1 stated she told Resident 11 she could not help her right now because she was with another resident, and if she wanted to be taken to the patio she could ask someone else. On 04/22/2021 at 9:23 a.m., during an interview, the Director of Nursing (DON) stated CNA 1 should have responded to give her a minute, and she would get back to the resident, or stopped to call another staff to assist the resident. A review of the facility's policy and procedures titled, Quality of Life - Dignity, revised in 08/2009, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Resident shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Resident shall be assisted in attending the activities of their choice, including activities outside the facility. b. A review of Resident 76's admission Record indicated the resident was originally admitted to the facility on [DATE] with a diagnosis that included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). A review of Resident 76's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 03/30/2021, indicated the resident was severely impaired in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS also indicated the resident was totally dependent on staff for assistance with bed mobility, transfers, locomotion on and off the unit, eating, toilet use, and personal hygiene. On 04/19/2021 at 12:36 p.m., during the dining observation, observed Resident 76 sitting in her wheelchair inside her room. Restorative Nursing Assistant 1 (RNA 1) was standing over Resident 76 while assisting the resident with feeding. On 04/19/2021 at 12:46 p.m., during an interview, RNA 1 stated when assisting residents with feeding, the facility's practice was for staff to sit next to the residents while feeding them. When asked what the rationale (reason) was for sitting beside residents while feeding them, RNA 1 could not answer the question. On 04/22/2021 at 9:29 a.m., during an interview, the Director of Nursing (DON) stated RNA 1 should have been sitting down while feeding Resident 76 so she could be at eye level with the resident while observing for signs of aspiration. A review of the facility's policy and procedures titled, Assistance with Meals, revised in 7/2017, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. For example, not standing over residents while assisting them with meals. c. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (caused by a complete lack of oxygen to the brain, resulting in the death of brain cells after approximately four minutes of oxygen deprivation) and gastroesophageal reflux disease (a digestive disease in which stomach acid irritates the food pipe lining). A review of Resident 3's Minimum Data Set (MDS - an assessment and screening tool) dated 04/9/2021 indicated Resident 3`s cognitive skills (conscious mental activities and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making was severely impaired. The MDS also indicated Resident 3 required extensive assistance with dressing, eating, personal hygiene, toilet use (using the bathroom), and bathing. On 04/19/2021 at 12:34 p.m., during a dining observation and concurrent interview, observed Resident 3 seated in a wheelchair while Certified Nurse Assistant 2 (CNA 2) faced and stood in front of the resident while assisting Resident 3 with feeding. Observed Resident 3 tilting his head back every time a spoonful of food is brought towards his mouth. CNA 2 was then interviewed after she finished assisting the resident. CNA 2 stated that it`s not dignified for the resident when the person or staff feeding the resident is standing and not on resident`s eye level. A review of the facility`s undated policy and procedures, titled Resident Rights, indicated Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident`s right to be treated with respect, kindness, and dignity. A review of the facility's policy and procedures titled, Assistance with Meals, revised in 7/2017, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. For example, not standing over residents while assisting them with meals.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of the admission Record indicated Resident 482 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism (blood clot in the lungs), muscle weakness, and anxiety disorder (state of excessive worry or fear). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 04/12/2021, indicated Resident 482 had intact cognition (mental action or process of acquiring knowledge and understanding). A review of the Order Listing Report, dated 04/22/2021, indicated the following for active and discontinued physician orders for Resident 482: 1. Norco (hydrocodone-acetaminophen-pain medication) 10-325 milligrams (mg - unit of measurement) ) give 1 tablet by mouth every 6 hours as needed for moderate pain not to exceed (NTE) 3 grams (g - unit of measurement) in 24 hours. Active order created on 04/13/2021. 2. Norco 10-325 mg give 1 tablet by mouth every 6 hours as needed for pain. Order created on 04/10/2021 and discontinued on 4/13/2021. 3. Norco 5-325 mg give 1 tablet by mouth every 6 hours as needed for moderate to severe pain NTE 3 grams of acetaminophen for 24 hours. Order created on 04/05/2021 and discontinued on 04/10/2021. A review of Resident 482's Medication Administration Record (MAR), dated 04/06/2021 until -4/10/2021, indicated a total of seven doses of Norco 5-325mg were marked as administered. A review of Resident 482's MAR, dated 04/10/2021 until 04/21/2021, indicated a total of 14 doses of Norco 10-325mg were marked as administered. During a concurrent interview and record review, on 04/22/2021 at 1:24 pm, Licensed Vocational Nurse (LVN 2) stated sometimes when a medication was discontinued the point click care (PCC - documentation software) still showed up on the MAR on top of the active order. LVN 2 stated that she got confused seeing the discontinued order and active order together. LVN 2 stated she administered Norco 5-325mg instead of Norco 10-325 mg. LVN 2 stated the risk of giving the wrong dosage to the resident was that the medication could be ineffective because it's a lower dose. During a concurrent interview and record review, on 04/22/2021 at 1:35 pm, the Director of Staff Development (DSD) stated the failure was not having Norco 5-325 mg removed from the cart when it was discontinued so that it could not be accessed in the medication cart. DSD stated the orders should have been double checked before administering the medication. The DSD stated the nurses should remove discontinued medications to prevent medication errors from happening again. During a concurrent interview and record review, on 4/22/2021 at 10:10 am, the Director of Nursing (DON) stated the order for Norco 5-325mg was discontinued on 4/10/21. DON stated 20 doses were signed off and documented on the antibiotic or controlled substance records for Norco 5-325 for Resident 482. DON stated the nurses should check the order before administering medication to check if the order was still active. DON further stated the Registered Nurse (RN) supervisor was supposed to check, along with the pharmacist. The DON stated that the failure was that the nurses were administering a discontinued medication. A review of the facility's policy titled, Administering Medications, revised 12/2012, indicated as required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. the date and time the medication was administered; the dosage; the route of administration; the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.' Based on interview and record review, the facility failed to ensure residents were free from potential significant medication errors for three out of three sampled residents (Residents 38, 482, and 73) reviewed by failing to: 1. Ensure licensed nursing staff did not administer insulin (a medication used to control the high blood sugar) outside of physician ordered parameters for Resident 38. This deficient practice placed Resident 38 at risk of inadequate blood sugar management, which can cause hypoglycemia (abnormally low blood sugar). 2. Ensure to administer the correct dose of Norco (hydrocodone-acetaminophen - a drug with potential for abuse, used to manage moderate to severe pain) to Resident 482. The licensed nursing staff administered nine doses of Norco 5-325 milligrams (mg - unit of measurement) instead of nine doses of Norco 10-325 mg. This deficient practice had the potential for Resident 482's pain control getting undertreated and as a result the medical doctor could potentially order a higher dose of pain medication. 3. Administer five doses of an antibiotic (medication used to treat an infection) after tooth extraction (Resident 73). This deficient practice had the potential for Resident 73 to develop infection. Findings: a. A review of Resident 38's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and diabetes mellitus (DM - abnormally high levels of the sugar in the blood). A review of Resident 38's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 2/28/2021, indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed extensive assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). The MDS indicated the resident received insulin (a medication used to control the high blood sugar) during the look-back period (time frame for observation). A review of Resident 38's Physician and Telephone Order dated 2/24/2021, indicated, Lantus Solostar (insulin Glargine - a medication used to control high blood sugar) injection 100 units/milliliters (units/ml - unit of measurement). Please check sugar in morning and administer 10 units if more than 200 blood sugar. A review of Resident 38's Order Summary Report dated 03/09/2021, indicated, Lantus Solostar solution Pen-Injector 100 unit/ml (insulin Glargine) inject 10 unit subcutaneously (tissue layer between the skin and the muscle) in the morning for DM, check blood sugar first and give if blood sugar is more than 200. A review of Resident 38's Medication Administration Record (MAR) from 3/01/2021-3/31/2021, indicated the following blood sugars recorded at 6:30 a.m. on the following dates: 1. 3/13/2021 = 155 2. 3/14/2021 = 162 3. 3/25/2021 = 133 Resident 38's MAR also indicated the resident received Lantus Solostar solution 10 units at 6:30 AM on 3/13/2021, 3/14/2021, and 3/25/2021. During an interview, on 04/22/2021 at 2:05 p.m., Licensed Vocational Nurse 1 (LVN1) stated, she administered Lantus insulin 10 units at 6:30 a.m. on 3/13/2021, 3/14/2021, and 3/25/2021. LVN 1 stated, she should have held (not administer) the Lantus insulin because Resident 38's blood sugars were less than 200. LVN 1 also stated, it was important to hold Lantus insulin prevent hypoglycemia (abnormally low blood sugar). During an interview, on 04/22/2021 at 4 p.m., the Director of Nursing (DON) stated, LVN 1 should have followed the physician's holding parameter and held Lantus insulin for Resident 38 on 3/13/2021, 3/14/2021, and 3/25/2021. The DON also stated, it was important to hold the Lantus insulin according to physician's order because insulin can cause hypoglycemia. A review of the facility's policy and procedures titled, Administering Medications, revised in 12/2012, indicated, medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The individual administering the medication must check the label THREE times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. c. A review of the admission Record indicated Resident 73 was admitted to the facility on [DATE], with diagnoses that included a stroke with hemiplegia (brain blockage causing weakness to one side of the body). A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 03/28/2021, indicated Resident 73 was able to usually understand others. The MDS indicated Resident 73 required extensive assistance in bed mobility, dressing, eating; and was totally dependent on staff in toilet use, personal hygiene, and bathing. A review of the Initial History and Physical, dated 03/24/2021, indicated Resident 73 had the capacity to understand and make decisions. A review of the Medication Administration Record (MAR) indicated for facility staff to start administering doxycycline (antibiotic - used to prevent the growth and spread of bacteria-causing infection) 100 milligrams (mg - unit of measurement) to Resident 73 one tablet by mouth twice a day for ten days post (after) tooth extraction, dated 04/05/2021. A review of Antibiotic or Controlled Drug Record indicated Resident 73 was given 15 doses, instead of 20 doses. During a concurrent interview and record review, on 04/21/2021 at 2:15 p.m., the Director of Nursing (DON) stated the antibiotics should have been completed for ten days was not completed. The DON stated that five doses were missing. A review of the facility's policy and procedures, dated 07/2016, titled Medication and Treatment Orders, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing.

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** b. A review of Resident 433's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), atrial fibrillation (an irregular and often rapid heart rate), and dementia (a loss of thinking ability, memory, and other mental abilities). A review of Resident 433's Progress Notes indicated the resident died on [DATE] at 10:13 a.m. On 04/11/2021 at 8:14 a.m., during an observation of Station 2 Medication Cart 2 with Licensed Vocational Nurse 5 (LVN 5), observed nine prescription medications for Resident 433 inside the medication cart. The medications were as follows: 1. Oxybutynin (medication to control frequency of urination) 2. Amlodipine (medication to treat high blood pressure) 3. Olmesartan (medication to treat high blood pressure) 4. Meloxicam (medication to treat pain and inflammation of the joint) 5. Folic Acid (medication to treat anemia [condition characterized by lowered ability of blood to carry oxygen]) 6. Fenofibrate (medication to treat high level of fat) 7. Donepezil (medication to treat brain disorder) 8. Rosuvastatin (medication to lower high level of fats) 9. Escitalopram (medication to treat a mood disorder) On 04/22/2021 at 9 a.m., during an interview, LVN 5 stated Resident 433's medications were supposed to be removed since the resident died. On 04/22/2021 at 9:52 a.m., during an interview, the Director of Nursing (DON) stated after a resident dies, all medications should be removed immediately. A review of the facility's policy and procedures titled Disposal of Medications and Medication-Related Supplies, with effective date 04/2014, indicated discontinued medications including medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed. All these medications are placed in the proper waste container per facility policy. Based on observation, interview, and record review, the facility failed to: 1. Remove and dispose Resident 482's discontinued medication, Norco (hydrocodone-acetaminophen - a drug with potential for abuse, used to manage moderate to severe pain) 5-325 milligrams (mg - unit of measurement) from Station 2 Medication Cart 2. 2. Remove and dispose the medications of Resident 433 from Station 2 Medication Cart 2, after the resident expired in the facility. 3. Ensure the Assure control solution (used to test the accuracy of a blood glucose meter) for blood glucose monitoring machine was not expired. 4. Ensure Resident 69's Novolog flex pen insulin (a medication used to control high blood sugar) and Resident 40's Humulin insulin, which were unopened, were stored in the refrigerator until removed for administration. Findings: a. A review of the admission Record indicated Resident 482 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism (blood clot in the lungs), muscle weakness, and anxiety disorder (state of excessive worry or fear). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 04/12/2021, indicated Resident 482 had intact cognition (mental action or process of acquiring knowledge and understanding). A review of the Order Listing Report, dated 04/22/2021, indicated a discontinued physician order for Resident 482: Norco (hydrocodone-acetaminophen-pain medication) 5-325 milligrams (mg- unit of measurement) give 1 tablet by mouth every 6 hours as needed for moderate to severe pain not to exceed (NTE) 3 grams (g - unit of measurement) of acetaminophen for 24 hours. Order created on 04/05/2021 and discontinued on 04/10/2021. During an observation of Station 2 Medication Cart 2, in the presence of Licensed Vocational Nurse 6 (LVN 6) and Director of Staff Development (DSD), and a concurrent review of Resident 482's Antibiotic/Controlled Drug Record (accountability record of medications considered to have strong potential for abuse), on 04/20/2021 at 3:58 p.m., observed two bubble packs (individually sealed compartments that hold medication) of Norco 5-325 mg as follows: 1. Norco 5-325 mg, with fill date (date when the pharmacy packed the medication) of 04/14/2021 and original quantity of 28 tablets. The bubble pack currently contained 16 tablets. 2. Norco 5-325mg, with fill date of 04/19/2021 and original quantity of 30 tablets. The bubble pack currently contained 30 tablets. During a concurrent interview and record review, on 04/21/2021 at 4:16 p.m., the Director of Nursing (DON) stated there was a discrepancy and that the narcotic medication (Norco 5-325mg) was accepted twice after it was discontinued. The DON stated it should not have been accepted and placed in medication cart 2. DON further stated the discontinued medication should have been brought to DON's office for narcotic disposal and storage for disposition with pharmacist. During a review of the facility's policy and procedures, titled Disposal of Medication and Medication-related Supplies, dated 12/2014, indicated it is the policy for discontinued medications and medications left in the facility after a resident's discharge, which do no quality for return to pharmacy for credit, are destroyed. During a review of the facility's policy and procedures titled, Pharmacy Services, dated revised 04/2007, the policy indicated the facility shall contract with a licensed pharmacist to help . all aspects of pharmacy services including ordering, delivery and acceptance, storage, distribution . disposal, documentation, and reconciliation of all medications and biologicals in the facility. c. During an inspection of Medication Cart 1 and a concurrent interview with Licensed Vocational Nurse 4 (LVN 4), on 04/20/2021 at 4:15 p.m., observed Assure control solutions (used to test the accuracy of a blood glucose meter) for blood glucose monitoring machine with a handwritten date of 10/26/2020. LVN 4 confirmed, 10/26/2020 was the opening date of the control solutions. LVN 4 stated, the control solutions should have been discarded after 90 days of opening, which was on 1/26/2021. LVN 4 also stated, the use of expired control solutions on blood glucose monitoring machine control test will result in inaccurate reading. LVN 4 stated, the night shift charge nurse was responsible on blood glucose monitoring machine control test. During an interview, on 04/22/2021 at 4:24 p.m., Director of Nursing (DON) stated, Assure control solution for blood glucose monitoring machine should be discarded after 90 days of opening. The DON also stated, the use of expired control solutions on blood glucose monitoring machine will result in inaccurate calibration (an act of ensuring that a method or instrument used in measurement will produce accurate results). The DON stated, the licensed nurses from night shift were responsible on discarding the control solution upon expiration. A review of the facility's policy and procedures titled, Assure Control Solution, revised in 10/2011, indicated, for use with Assure Pro, Assure Platinum as a quality control check to verify accuracy of blood glucose test results. Use control solution within 90 days of first opening. A review of Resident 69's admission Record (face sheet) indicated the resident was admitted to the facility on o3/13/2021, with diagnoses that included metabolic encephalopathy (a syndrome of temporary or permanent disturbance of brain functions that occurs related to other diseases) and diabetes mellitus (DM - disease causes abnormally high levels of the sugar in the blood). A review of Resident 69's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 03/19/2021, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS also indicated the resident had moderately impaired cognitive skills (mental action or process of acquiring knowledge and understanding) for decision-making. The MDS indicated the resident needed limited to extensive assistance with activities of daily living (ADLs - term used in healthcare to refer to daily self-care activities). A review of Resident 69's Order Summary Report dated 03/13/2021, indicated Novolog (a medication used to control high blood sugar) Penfill solution cartridge 100 unit/milliliters (unit/ml - unit of measurement) inject as per sliding scale (progressive increase in the insulin dose based on pre-defined blood glucose ranges) subcutaneously (tissue layer between the skin and the muscle) before meals and at bedtime for diabetes. A review of Resident 69's Medication Administration Record (MAR) indicated the resident received Novolog insulin from 3/13/2021 to 4/20/2021. During an inspection of Medication Cart 1 in Station 1 and concurrent interview with Licensed Vocational Nurse 4 (LVN 4) on o4/20/2021 at 4:01 p.m., observed Resident 69's unopened Novolog flex pen insulin stored at room temperature in the cart. The resident's insulin pen did not have a label with the date on which the facility had begun storing at room temperature. LVN 4 stated she did not know the time the Novolog flex pen insulin was taken out from the refrigerator. LVN 4 also stated, unopened Novolog flex pen insulin should have stored in the refrigerator until ready for use. LVN 4 stated that once the insulin is taken out of the refrigerator and opened for use, it should be labelled with the date and the insulin pen can be used up to 28 days. During an interview on 04/22/21 at 4:20 PM, the Director of Nursing (DON) stated, unopened Novolog flex pen insulin should have stored in the refrigerator until ready for use according to manufacturer guidelines. A review of the facility's policy and procedures titled, Storage of Medications, revised in 04/2019, indicated, medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secures location. Unopened insulin vials, parenteral (intra-venous [in to vein]) medications and other medications requiring refrigeration should only be removed from the refrigerator if the temperature variance failed to meet the manufacturer's guidelines for storage. Medications must be stored separately from food and must be labeled accordingly. d. A review of Resident 40's admission Record (face sheet) indicated the resident was admitted to the facility originally on 02/24/2016 and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus (a condition that affects how the body processes blood sugar) and hypertension (high blood pressure). A review of Resident 40's Minimum Data Set (MDS-a standardized assessment and screening tool), dated 5/1/2021, indicated the resident had minimum difficulty hearing and moderately impaired vision, clear speech, and was to make herself understood, and was able to understand others. The MDS indicated the resident required staff supervision with moving around inside and outside the unit. During an observation of the Station 2 Medication Cart 2, on 04/22/2021 at 8:14 a.m., observed Resident 40's unopened Humalog insulin vial (a medication used to control high blood sugar) with label to be refrigerated. During a concurrent observation and interview, on 4/22/2021 at 8:30 a.m., Licensed Vocational Nurse 5 (LVN 5) stated the medication was unopened and she knows it was supposed to be kept refrigerated. LVN 5 did not know who left it in the medication cart. A review of the facility's policy and procedures titled Storage of Medications, revised in 04/2019, indicated unopened insulin vials and medications requiring refrigeration must be stored in a refrigerator.

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 the storage, preparation, and distribution of food was done under sanitary conditions for 89 residents who are served food from the kitchen, by failing to: 1. Ensure all bread products are labeled with the date when the products were opened. 2. Ensure scoops of ice cream in cups prepared in advance were labeled with date when they were prepared. 3. Ensure dietary staff do not bring a half-eaten donut which was placed on top of a mug below a dough mixer in the Dietary Manager`s (DM) office located inside the kitchen area. 4. Ensure dietary staff do not place an N95 (respiratory protective device) mask lying on a plastic stand below a dough mixer in the Dietary Manager`s office located inside the kitchen area. These deficient practices had the potential to result in contamination of the food, and placed the residents at risk for foodborne illnesses (illnesses caused by the ingestion of contaminated food or beverages). Findings: On 04/19/2021 at 7:58 a.m., during an initial observation tour of the kitchen, and a concurrent interview with Dietary Aide (DA), observed seven (7) cups containing scoops of ice cream, covered with plastic food wrap, with no label as to the date they were prepared, inside a freezer located inside the Dietary Manager's (DM) office. According to DA, the one who prepared those cups should have labeled them with a date to determine when they were prepared as they will be discarded after three days to prevent foodborne illnesses. Also observed in the Dietary Manager`s (DM) office a half-eaten donut on top of a mug and an N95 mask (respiratory protective device), not in bag or plastic container, both placed on top of a plastic stand below a dough mixer. According to DA, DM's office was not where staff`s personal food should be placed. DA also stated the N95 mask was clean and to be used the next day. During the continuation of the kitchen tour, observed a bag of opened mixed wheat and white bread and a bag of bagel with two bagels left inside the walk-in refrigerator. Observed both bags with no indication of when they were both opened. Per DA, the kitchen staff should have labeled the bags with the date open so they would know when to discard them. On 04/19/2021 at 8:43 a.m., DM came to join the kitchen tour. Showed DM the prior observations noted. According to DM, the N95 mask was already contaminated and should not be worn. DM also stated her office was not to be used for storage of personal food. DM also stated that any food that are partially opened should be dated because residents can be potentially be at risk for food-borne illnesses from expired food. A review of the facility`s undated policy and procedures, titled Labeling and Dating of Food, indicated all food will be dated, labeled, and prepared for storage to prevent contamination, deterioration, and dehydration. All products must be clearly labeled with the date when the product was opened. A review of the facility`s policy and procedures, titled Food Preparation and Service, last revised in 07/2014, indicated food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.

CONCERN (E)

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

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: 1. Ensure the medication storage room was free from potentially contaminated items for one out of two sampled medication storage rooms (Medication Storage room [ROOM NUMBER]) reviewed during Medication Storage and Labeling facility task. This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) with the medications, and had the potential for the residents to receive contaminated medications. 2. Ensure that a bowl of uneaten green salad brought by a family member from the day before is kept in the refrigerator, labeled with the resident's name and use by date for one out of one sampled resident (Resident 33). This deficient practice had the potential to compromise the integrity of the food and can place the resident at risk for foodborne illnesses (illness caused by the ingestion of expired and contaminated food). 3. Ensure three out of seven surveyors and a total of 16 visitors were screened for signs and symptoms of COVID-19 infection (a type of common virus that infects humans, typically leading to an upper respiratory infection). This failure had the potential for unnecessary spread of COVID-19 infection from visitors to residents. Findings: a. During an observation of Medication Storage room [ROOM NUMBER], on 04/20/2021 at 12:23 p.m., in the presence of the Director of Nursing (DON), observed pairs of shoes, a jacket, two new backpacks, and a welcome packet inside the shelves of the medication storage room. During an interview, on 4/22/2021 at 4:15 p.m., the DON confirmed that the pairs of shoes, jacket, backpacks, and welcome packet were inside the shelves of the medication storage room. The DON stated, those items should have not placed in the medication storage room because there was chance of contamination of medication. The DON also stated, it was important for infection control. A review of the facility's policy and procedures titled, Storage of Medications, revised in 04/2019, indicated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. b. A review of Resident 33's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and type 2 diabetes mellitus (characterized by high levels of sugar in the blood). A review of Resident 33's Minimum Data Set (MDS - an assessment and care screening tool) dated 02/20/2021, indicated the resident had severe cognitive (mental action or process of acquiring knowledge and understanding) impairment. The MDS also indicated the resident had the ability to make self-understood and the ability to understand others. The MDS indicated the resident required extensive assistance from staff for dressing, toilet use, personal hygiene, and bathing. On 04/19/2021 at 9:18 a.m., during the facility observation tour, observed Resident 33 in bed, alert and awake, and able to participate in interview. While resident was eating, she indicated that the uneaten bowl of salad on the overbed table was brought by her son the day before and it was there since yesterday. On 04/19/2021 at 10:10 a.m., observed Licensed Vocational 4 (LVN) passing medication in another room. Requested LVN 4 to check on the bowl of salad on Resident 33's overbed table. LVN 4 stated that the salad should have been refrigerated, labeled, dated, and discarded if they are not able to ascertain the date it was brought in by family. A review of the facility`s policy and procedures, titled Food Brought by Family/Visitors, revised in 10/2017, included the following implementation guidelines, but not limited to: 1. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food. 2. Perishable foods must be stored in resealable containers with tightly fitting lids in a refrigerator, containers will be labeled with the resident`s name, the item and the use by date. 3. Potentially hazardous food that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded. c. On 4/19/2021, at 7:37 a.m., the facility's receptionist (FR) was observed screening for COVID-19 signs and symptoms of seven surveyors that entered facility. The FR was observed to check four temperatures out of the seven surveyors present. During a concurrent interview and record review, on 4/21/2021, at 10:50 a.m., the FR stated she screened every visitor for COVID 19 symptoms. The FR stated she checked the temperatures of visitors before and after the visits. The FR confirmed that she did not check the temperatures of some of the surveyors and denied entering temperature measurements in the Log Book after the surveyors passed by the lobby. A review of the Log Book indicated, on 4/18/2021, six of 16 visitors did not have temperature measurements and end visit time when they were leaving the facility. During an interview on 4/22/2021, at 9:20 a.m., the Director of Nursing (DON) stated the visitors' temperatures should be checked according to the facility's policy. A review of the facility's policy, dated 4/12/2021, titled, Visitation, Communal Group Activities and Communal Dining, indicated any visitor entering the facility, regardless of their vaccination status, must be screened for fever and COVID-19 symptoms.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0574 (Tag F0574)

Minor procedural issue · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure availability of the State Long Term Care Ombudsman Program (resident advocacy group) by not posting the contact information sign (notice)in the resident dining room and the employee lounge. This deficient practice had the potential to deprive the residents of assistance from resident advocacy groups should unresolved issues arise in the facility. Findings: On 4/20/2021 at 10:06 a.m., during an observation and a Resident Council Meeting interview in the resident dining room, observed there was no Ombudsman (resident advocacy group) contact information sign (notice) posted. Six out of six residents (Residents 74, 24, 71, 80, 61 and 79) stated they did not know where the Ombudsman contact signs were posted. Resident 74 stated the Ombudsman contact information used to be posted in the resident dining room, but when the renovations were done, they did not see it anymore. No Ombudsman contact information signs were posted in the dining room and in the employee lounge. During a concurrent observation and interview, on 4/20/2021 at 11:10 a.m., the Director of Nursing (DON) confirmed there was no Ombudsman contact information sign posted in the resident's big dining room and in the employee lounge. DON stated, the sign should be posted in the resident dining room and the employee lounge. She stated if the sign was not posted, residents and staff would not know how to contact the Ombudsman. A review of the California Health and Safety Code 1422.6, effective 1/1/2001, indicated facility notice should be posted in a conspicuous location in at least 4 areas of the facility- a location accessible to the public, a location for employee breaks, next to telephone for resident use, and a location for communal functions for residents.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most California facilities.
• 34% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• 81 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade C (50/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.

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About This Facility

What is Valley Village's CMS Rating?

CMS assigns VALLEY VILLAGE CARE CENTER an overall rating of 2 out of 5 stars, which is considered 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 Valley Village Staffed?

CMS rates VALLEY VILLAGE CARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 34%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Valley Village?

State health inspectors documented 81 deficiencies at VALLEY VILLAGE CARE CENTER during 2021 to 2025. These included: 80 with potential for harm and 1 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Valley Village?

VALLEY VILLAGE 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 ABRAHAM BAK & MENACHEM GASTWIRTH, a chain that manages multiple nursing homes. With 99 certified beds and approximately 94 residents (about 95% occupancy), it is a smaller facility located in NORTH HOLLYWOOD, California.

How Does Valley Village Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, VALLEY VILLAGE CARE CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Valley Village?

Based on this facility's data, families visiting should ask: "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?"

Is Valley Village Safe?

Based on CMS inspection data, VALLEY VILLAGE CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Valley Village Stick Around?

VALLEY VILLAGE CARE CENTER has a staff turnover rate of 34%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Valley Village Ever Fined?

VALLEY VILLAGE CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Valley Village on Any Federal Watch List?

VALLEY VILLAGE 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: 94
Occupancy: 95.3%
Ownership: For profit - Limited Liability company
Chain: ABRAHAM BAK & MENACHEM GASTWIRTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
81 Deficiencies: -10
Final Score: 50/100

Nearby Alternatives

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

View all in NORTH HOLLYWOOD →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555012