Does VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC have any serious inspection findings?

Yes, VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 104 total deficiencies from recent inspections.

What are the staffing levels at VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has a two-star staffing rating from CMS with 0.40 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

How many beds does VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC have?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has 72 certified beds.

Who owns VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC is a for profit - limited liability company facility and is part of the CRYSTAL SOLORZANO chain.

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC

Q: What is VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC's CMS rating?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Where is VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC located?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC is located in NORTH HOLLYWOOD, CA. It is a Medicare and Medicaid certified skilled nursing facility.

Q: Do nurses at VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC stick around?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has average staff turnover at 39%, which is typical for the nursing home industry.

Q: Was VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC ever fined?

Yes, VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has been fined $50,997 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC on any federal watch list?

No, VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

6120 N. VINELAND AVE, NORTH HOLLYWOOD, CA 91606 · (818) 763-6275

For profit - Limited Liability company 72 Beds CRYSTAL SOLORZANO Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

0/100

#1145 of 1155 in CA

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VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC nursing home in NORTH HOLLYWOOD, CA - Photo 1 of 2

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC nursing home in NORTH HOLLYWOOD, CA - Photo 2 of 2

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Last Inspection: July 2025

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

Overview

Valley Vista Nursing and Transitional Care LLC has received a Trust Grade of F, indicating significant concerns and a poor overall rating. They rank #1145 out of 1155 facilities in California, placing them in the bottom half, and #361 out of 369 in Los Angeles County, suggesting very few local options are worse. The trend is worsening, with issues increasing from 21 in 2024 to 50 in 2025. Staffing is rated 2 out of 5 stars, which is below average, and the turnover rate is 39%, similar to the state average. The facility has incurred $50,997 in fines, which is concerning and suggests ongoing compliance problems. There are specific incidents of concern, including a resident who ingested foreign objects due to insufficient supervision, leading to critical health risks. Additionally, another resident was physically abused by another resident, resulting in injuries and anxiety. There were also serious food safety issues, such as improperly stored roast beef that could make residents ill if consumed. While there is some RN coverage, overall, the facility's significant weaknesses overshadow any strengths, making it a risky choice for families seeking care.

Trust Score: F
In California: #1145/1155
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 39% turnover. Near California's 48% average. Typical for the industry.
Penalties: $50,997 in fines. Higher than 61% of California facilities. Some compliance issues.
Skilled Nurses: Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 104 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 21 issues

2025: 50 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (39%)
9 points below California average of 48%

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 39%

Near California avg (46%)

Typical for the industry

Federal Fines: $50,997

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: CRYSTAL SOLORZANO

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 104 deficiencies on record

1 life-threatening 1 actual harm

Sept 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of four sampled residents (Resident 2 and Resident 3), by failing to develop and implement a care plan for the residents` discharge planning (a process where the facility staff, doctors, the resident and/or the resident's family collaboratively create a plan for after the resident leaves the facility, making sure the resident has the resources needed to stay safe at home or at another facility). This deficient practice had the potential to result in an unreasonable delay with the progress of Resident 2 and Resident 3's plan to be discharged from the facility to a community setting. Findings: 1. During a review of Resident 2's admission Record, dated 9/05/2025, the admission Record indicated the facility admitted the resident on 4/24/2024 with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe due to damage to the lungs and airways), type two diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and atrial fibrillation (a condition where the upper chambers of the heart beat irregularly and too fast). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 7/25/2025, the MDS indicated Resident 2 required substantial assistance with toileting hygiene, showering, and dressing the lower body (a helper does more than half the effort in completing the activity). The MDS indicated Resident 2 required clean up assistance with eating and oral hygiene (a helper only sets up or cleans up as the resident completes the activity). During an interview on 8/28/2025 at 10:13 a.m. with Social Services Director (SSD), SSD stated discharge planning starts when residents are first admitted . SSD stated she will ask where [a] resident wants to be discharged , and SSD will determine what outside agency [resources] they might need in preparation for a resident's discharge. During a concurrent interview and record review on 9/5/2025 at 11:25 a.m. with Director of Nursing (DON), Resident 2's care plan dated 9/5/2025 was reviewed. The DON stated social services is responsible for developing a care plan with interventions related to discharge planning. The DON reviewed Resident 2's care plan and could not locate any focus, goal, or intervention related to discharge planning. The DON stated it is important to develop a care plan for discharge planning so that a patient knows where they are going to go, and there is a plan for a safe discharge. The DON stated if the care plan does not include discharge planning, it can be chaos which can cause stress to the patient. 2.During a review of Resident 3's admission Record, dated 9/05/2025, the admission Record indicated the facility admitted the resident on 6/14/2025 with diagnoses including seizures (a sudden burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness), hypertension (a condition where the blood pressure is consistently too high), and depression (a mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities that were once enjoyable). During a review of Resident 3's History and Physical Examination (H&P - when a doctor obtains a patient's medical history, performs a physical exam, and documents his/her findings in the patient's medical record), dated 6/15/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 6/17/2025, the MDS indicated Resident 3 required substantial assistance with showering and toileting hygiene (a helper does more than half the effort in completing the activity). The MDS indicated Resident 3 required partial assistance with oral hygiene and upper body dressing (a helper does less than half the effort). The MDS indicated Resident 3 required supervision for eating (a helper provides verbal cues or contact assistance as the resident completes the activity). During a concurrent interview and record review on 9/5/2025 at 11:28 a.m. with DON, Resident 3's care plan dated 9/5/2025 was reviewed. The DON stated social services is responsible for developing a care plan with interventions related to discharge planning. The DON reviewed Resident 3's care plan and could not locate any focus, goal, or intervention related to discharge planning. The DON stated it is important to develop a care plan for discharge planning so that a patient knows where they are going to go, and there is a plan for a safe discharge. The DON stated if the care plan does not include discharge planning, it can be chaos which can cause stress to the patient. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2025, the P&P indicated the following: 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. During a review of the facility's policy and procedure (P&P) titled, Social Services, dated 1/2025, the P&P indicated the social worker/social services staff are responsible for.Transitions of Care.[and] Comprehensive Person-Centered Care Planning. The P&P indicated social services are responsible for helping residents with transitions of care services, such as community placement options, home care services, transfer arrangements, etc. During a review of the facility's job description for SSD titled, Job Description, undated, the job description indicated the SSD provides discharge-planning services including referrals, arrangement for follow-up services, transfers to other facilities, and post discharge 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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 1) by failing to document the communications social services had with Resident 1 and the actions taken by social services regarding the resident`s discharge planning. This failure resulted in an incomplete medical record that is not in accordance with the facility's own policies and procedures. Findings:During a review of Resident 1's admission Record, dated 8/14/2025, the admission Record indicated the facility originally admitted the resident on 5/10/2024, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe due to damage to the lungs and airways), chronic kidney disease (a condition where the kidneys become damaged and slowly lose the ability to clean waste and fluids from the blood), and major depressive disorder (a mood disorder that causes persistent feelings of sadness and loss of interest and can interfere with daily living). During a review of Resident 1's History and Physical (H&P - when a doctor obtains a patient's medical history, performs a physical exam, and documents his/her findings in the patient's medical record), dated 7/19/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/5/2025 the MDS indicated Resident 1 was dependent on toileting hygiene, showering, and dressing the lower body part (a helper does all the effort). The MDS indicated Resident 1 required supervision with eating (a helper provides verbal cues and/or contact guard assistance as the resident completes the activity). During an interview on 9/04/2025 at 1:49 p.m. with Resident 1, Resident 1 stated the last time she spoke with a facility staff member about discharge planning was weeks ago. Resident 1 stated she would like to be transferred to a city closer to their family. Resident 1 stated she (Resident 1) is also willing to discuss any little town near her desired location. During a concurrent interview and record review on 9/5/2025 at 11:25 a.m. with Social Services Director (SSD), Resident 1's electronic medical record was reviewed. SSD stated Resident 1 wants to go up north because of her disabled family member. SSD stated it is important to try to accommodate a resident's discharge planning request because it's for their psychosocial well-being. SSD stated it is important for the residents to feel good about where they are going to stay after being discharged from the facility. SSD stated she has been in communications with a marketer contact for up north, and that SSD explained to Resident 1 that the facilities up north might not be able to accept her because they can't care for her needs. SSD stated she is trying to make sure the possible cities of facilities who can accept Resident 1 are at least going in northern direction. When asked to show documentation of the actions that SSD has taken and the communications SSD has made regarding Resident 1's discharge planning, SSD stated: No, there is no progress note. During a concurrent interview and record review on 9/5/2025 at 11:25 a.m. with Director of Nursing (DON), Resident 1's electronic medical record was reviewed. DON stated it is important to document in a patient's medical record because it is a legal document. DON stated, We document what we do for the patient. DON stated that if there is no documentation in the resident's medical record about discharge planning discussion, then it doesn't exist. DON reviewed Resident 1's electronic medical record and could not locate a notation that discharge planning was discussed between social services and Resident 1. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 1/2025, the P&P indicated [a]ll services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. During a review of the facility's policy and procedure (P&P) titled, Social Services, dated 1/2025, the P&P indicated the director of social services.is responsible for.maintaining records related to social services.

Aug 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the call light (an alerting device used to contact nursing personnel for assistance) for one of three sampled residents (Resident 1) was accessible and within reach. This failure had the potential to prevent Resident 1 from being able to contact facility staff for help as needed. Findings: During a review of Resident 1's admission Record, dated 8/14/2025, the admission Record indicated Resident 1's diagnoses included lumbar spondylosis (a condition in which the bones and cartilage of the low back are wearing out over time), neuropathy (a condition where nerves in the body are damaged, leading to pain, weakness, and/or difficulty with balance and coordination), and respiratory failure (a condition where the lungs is unable to adequately exchange oxygen and carbon dioxide, leading to dangerously low oxygen levels and/or high carbon dioxide levels in the blood).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 1 was dependent for eating, toileting, personal hygiene and with dressing (a helper does all of the effort as the resident is unable to complete the activity).During a review of Resident 1's care plan, dated 7/1/2025, the care plan indicated Resident 1 is at risk for falls. The care plan indicated nursing interventions include ensuring the call light is within reach and [to] encourage the resident to use it for assistance as needed.During an observation on 8/13/2025 at 12:16 p.m. of Resident 1 in her room, Certified Nursing Assistant (CNA 1) was observed inside Resident 1's room near her bed. Resident 1 was sleeping.During a concurrent observation and interview on 8/13/2025 at 12:21 p.m. with CNA 1, CNA 1 stated he was inside Resident 1's room maybe 10 minutes ago. When asked where Resident 1's call light was located, CNA 1 initially looked at Resident 1's bed but could not find the call light. CNA 1 then walked toward the head of the bed where CNA 1 found the call light on the floor behind Resident 1's bed frame. CNA 1 stated it is important to have the call light near the resident for emergencies and in case the resident needs help. During an interview on 8/13/2025 at 12:40 p.m. with Licensed Vocational Nurse (LVN 1), who was the assigned nurse for Resident 1, LVN 1 stated the call light needs to be in reach so if patients need something, they can reach you.During an interview on 8/14/2025 at 3:39 p.m. with Director of Nursing (DON), the DON stated when nursing staff are entering their patient's room to check up on them, the professional standards of practice include the nursing staff checking the position of the patients and if their call light is in reach. The DON stated the consequence of not having the call light within reach is that a resident might fall and cannot contact anybody. The DON stated the call light is important for a resident's overall safety.During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised 9/2022, the P&P indicated the facility must ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

CONCERN (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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Based on observation, interview, and record review, the facility failed to ensure the respiratory care for one of three sampled residents (Resident 1) was provided in accordance with professional standards of practice and per the doctor's orders, when Resident 1's nasal cannula (a flexible device that delivers extra oxygen through a tube and into the nose) was found inside Resident 1's mouth. This failure had the potential to decrease Resident 1's oxygen levels, leading to respiratory distress (when a person has difficulty breathing because there is not enough oxygen received in the lungs).Findings: During a review of Resident 1's admission Record, dated 8/14/2025, the admission Record indicated Resident 1's diagnoses included congestive heart failure (a condition where the heart cannot pump enough blood to meet the body's needs, which leads to fluid back up in the body especially in the lungs), pleural effusion (when excess fluid builds up between the lung and the chest wall), and respiratory failure (a condition where the lungs is unable to adequately exchange oxygen and carbon dioxide, leading to dangerously low oxygen levels and/or high carbon dioxide levels in the blood).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 1 was dependent for eating, toileting, personal hygiene and with dressing (a helper does all of the effort as the resident is unable to complete the activity). During a review of Resident 1's care plan, dated 7/1/2025, the care plan indicated Resident 1 has potential for episodes of [shortness of breath] and requires use of oxygen.continuously via nasal cannula. The care plan indicated Resident 1 is at risk for ineffective breathing pattern, and nursing interventions include administer[ing] oxygen as prescribed. During a review of Resident 1's Order Summary Report, dated 8/1/2025, the Order Summary Report indicated the doctor ordered oxygen at 2 liters per minute (measurement of how much oxygen is being administered) for shortness of breath every shift, which may be increased up to 5 liters if necessary. During an observation on 8/13/2025 at 12:16 p.m. of Resident 1 in her room, Certified Nursing Assistant (CNA 1) was observed inside Resident 1's room near her bed. Resident 1 was sleeping. During a concurrent observation and interview on 8/13/2025 at 12:21 p.m. with CNA 1 inside Resident 1's room, CNA 1 stated he was inside Resident 1's room maybe 10 minutes ago. When asked where Resident 1's oxygen nasal cannula was, CNA 1 pointed to Resident 1's mouth. CNA 1 stated it is important for the nasal cannula to be properly placed in Resident 1's nose so that she gets oxygen. CNA 1 stated that if a CNA finds a nasal cannula out of place, the CNA should notify the charge nurse to address. During an interview on 8/13/2025 at 12:40 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated if a nasal cannula is found inside a resident's mouth, the nurse should first check the resident's oxygen saturation (the amount of oxygen that is circulating in the blood), verify if there is a doctor's order for oxygen, and then replace the nasal cannula. LVN 1 stated the consequence of not having the nasal cannula properly placed inside a resident's nose is the possibility of oxygen desaturation (occurs when blood oxygen levels drop below a normal range). During an interview on 8/14/2025 at 3:39 p.m. with Director of Nursing (DON), the DON stated when nursing staff are entering their residents' rooms to check up on them, the professional standards of practice for respiratory care include the nursing staff checking the position of the residents, if the call light is within reach, and if the nasal cannula has correct placement. The DON stated if a CNA finds a nasal cannula outside of a resident's nose, the CNA should notify the charge nurse who will need to assess the resident. The DON stated the consequence of an improper placement of a nasal cannula is that the resident is deprived of oxygen, which can lead to desaturation. DON stated that if there is a doctor's order for oxygen, then it needs to be followed accordingly. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised October 2010, the P&P indicated [o]xygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter. The P&P indicated the nasal cannula is a tube that is placed approximately one-half inch into the resident's nose.

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 maintain a sanitary, orderly, and homelike environment for one of three sample residents (Resident 1) by failing to maintain cleanliness of Resident 1's room and restroom.This failure had the potential to negatively impact Resident 1's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).Findings:During a review of Resident 1's admission Record (AR), the AR indicated facility admitted Resident 1 on 6/26/2025, with diagnoses of depressive disorder (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life), hypertension (high blood pressure), and anxiety disorder (feeling of anxiousness that affects daily life). During a review of Resident 1's History and Physical (H&P,) dated 6/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 7/1/2025, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 required moderate assistance with personal hygiene, toileting hygiene, upper and lower dressing. During a concurrent observation and interview on 7/16/2025 at 1:23p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, black residue was observed on the floor and at the bottom of the window frame, white residue was observed at the bottom of the window, dark red coating was observed on the soap dispenser, broken metal door was observed upon entrance of the restroom. LVN 1 stated, the soap dispenser was rusty (a reddish-brown coating that forms on iron or steel caused by exposure to air and moisture), the metal door frame at the bottom of the bathroom door was separating from the door. LVN 1 further stated the window in Resident 1's room was dirty, and the edge of the sliding door and window was dusty. LVN 1 further stated it is important to keep the resident's room clean so residents can feel comfortable. LVN 1 stated Resident 1's room was not clean and homelike. During an interview on 7/16/2025 at 2:54p.m. with the Director of Nursing (DON,) the DON stated the facility failed to provide a clean and homelike environment to Resident 1. The DON further stated this failure had the potential for Resident 1 to not feel comfortable negatively affecting resident's well-being. During a review of the facility-provided policy and procedure (P&P) titled, Homelike Environment, last reviewed on 1/2025, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary and orderly environment .9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.11. Walls, blinds, and window curtains in residents areas will be cleaned when these surfaces are visibly contaminated or soiled.

Jul 2025 25 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences to two of three sampled residents (Resident 12 and 47) investigated during review of environment facility task by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within residents' reach. This deficient practice had the potential to result in Residents 12 and 47 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect residents' comfort and well-being. Findings: a. During a review of Resident 12's admission Record (AR), the AR indicated the facility admitted Resident 12 on 1/26/2021 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 12's History and Physical (H&P), dated 4/2/2025, the H&P indicated Resident 12 had impaired cognitive functioning ((mental processes that enable people to think, understand, make decisions, and complete tasks). During a review of Resident 12's Minimum Data Set (MDS-a resident assessment tool), dated 6/9/2025, the MDS indicated Resident 12 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 12 required maximal assistance with oral hygiene, toileting hygiene, bathing, upper and lower body dressing. During a review of Resident 12's Care Plan (CP), initiated on 4/12/2025, the CP indicated Resident 12 had activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) related to bed mobility, transfer, walk in room, walk in corridor, locomotion in unit and off unit, dressing, eating, toilet use, personal hygiene, bathing. The CP indicated Resident ADL needs will be met daily with interventions to assist with ADL as needed. During a concurrent observation and interview on 6/30/2025 at 8:57 a.m. with Certified Nurse Assistant (CNA) 2 inside Resident 12's room, Resident 12's call light was observed behind the Resident's bed, away from Resident's reach. CNA 2 stated Resident 12 would not be able to reach the call light behind the bed and the call light should have been placed within Resident 12's reach to make sure the resident can call for assistance during emergencies. During an interview on 7/2/2025 at 10:15 a.m. with Registered Nurse (RN) 1, RN 1 stated call lights should be placed within resident's reach. RN 1 stated failure to place the call light within the resident's reach could potentially delay resident's care and cause accidents such as falls. During an interview on 7/3/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated residents use call light to call staff for assistance so the call light should be placed within resident's reach. The DON stated the failure to place the call light within resident's reach could potentially lead to delay of necessary care. b. During a review of Resident 47's admission Record (AR), the AR indicated the facility admitted Resident 47 on 2/21/2023 and readmitted on [DATE] 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), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), epilepsy (a sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), and depression (mental health illness causing a persistent feeling of sadness, loss of interest, and can interfere with daily life). During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 had moderately impaired cognitive functioning. The MDS also indicated Resident 47 required moderate assistance with toilet transfers, toilet hygiene, showers, upper and lower body dressing, personal hygiene. During a concurrent observation and interview on 6/30/2025 at 9:15 a.m. with CNA 3 inside Resident 47's room, Resident 47's call light was observed behind Resident 47's bed away from Resident's reach. CNA 3 states Resident 47 could not reach the call light behind the bed. CNA 3 stated the call light should be in a place where the resident can reach. CNA 3 stated if the call light is not within residents' reach, then residents will not be able to call for help and will not receive necessary help. During an interview on 7/2/2025 at 10:15 a.m. with Registered Nurse (RN) 1, RN 1 stated call lights should be placed within resident's reach. RN 1 stated failure to place the call light within the resident's reach could potentially delay resident's care and cause accidents such as falls. During a review of the facility-provided policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 01/2025, the P&P indicated, When the resident is in bed or confirmed to a chair be sure the call light is within easy reach of the resident. Report all defective call lights to the nurse supervisor promptly.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) by failing to: 1.Develop and implement a CP for an actual fall for one of two sampled residents (Resident 219) reviewed during the Accidents care area. 2.Develop a CP to address residents' bowel and bladder incontinence (having no or insufficient voluntary control over urination or defecation) management and retraining one of two randomly sampled residents (Resident 119). These deficient practices had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives resulting in a delay in care and services. Findings: a. During a review of Resident 219’s admission Record (AR), the AR indicated the facility admitted the resident on 6/18/2025 with diagnoses that included 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 cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, lack of coordination, and history of falls, depression (persistent feelings of sadness and loss of interest that can interfere with daily living), and anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear). During a review of Resident 219’s Minimum Data Set (MDS – resident assessment tool) dated 6/23/2025, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing; and required substantial / maximal assistance for upper body dressing, personal hygiene, and transferring from the bed to chair. During a review of Resident 219’s History and Physical (H&P), dated 6/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 219’s Care Plan (CP) titled, “The Resident is high risk for falls related to unaware of safety needs,” initiated 6/18/2025, the CP indicated a goal that the resident would be free from falls with interventions that included to follow facility fall protocol. During an observation and interview on 6/30/2025 at 9:25 a.m. with Resident 219 and Licensed Vocational Nurse (LVN) 3, observed Resident 219 sitting in a wheelchair in the hallway outside the resident’s room. Resident 219 stated Resident 219 falls a lot and had fallen in the facility. LVN 3 stated Resident 219 last had a fall on 6/27/2025. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m., LVN 2 reviewed Resident 219’s Progress Notes for 6/2025, in progress (not completed) Post Fall Evaluation dated 6/27/2025, Change of Condition (COC) form dated 6/27/2025, and care plans. LVN 2 stated when a resident has a fall in the facility, the process is to complete a post fall evaluation right away to re-assess the resident’s risk for falls and develop and implement a post fall CP with any new interventions. LVN 2 stated it is important to implement a post fall CP to ensure the resident does not fall again. LVN 2 stated Resident 219 had a fall on 6/27/2025 and Resident 219 did not have a post fall CP, but there should have been one created. LVN 2 stated Registered Nurse (RN) 1 completed the COC form. During a concurrent interview and record review on 7/1/2025 at 1:47 p.m., RN 1 reviewed Resident 219’s Progress Notes for 6/2025, in progress Post Fall Evaluation dated 6/27/2025, COC form dated 6/27/2025, and care plans. RN 1 stated CPs are communication tools for all the staff to follow to provide care for a resident. RN 1 stated every resident has an individualized CP according to their needs. RN 1 stated CPs are also important to re-evaluate the residents’ progress toward the CP goals. RN 1 stated Resident 219 had a fall on 6/27/2025. RN 1 stated Resident 219 should have a post fall CP from 6/27/2025 but did not. RN 1 stated the internet does not function well in the facility and RN 1 was not able to create a CP in the computer. RN 1 stated without a post fall CP Resident 219 could have another fall because new interventions may not be implemented. During a concurrent interview and record review on 7/2/2025 at 2:32 p.m. with the Director of Nursing (DON), the DON reviewed the facility Policy and Procedures (P&P) regarding CPs. The DON stated CPs are resident centered plans of care. The DON stated a post fall CP should be completed right after a resident has a fall to ensure the resident is monitored, new interventions are implemented, and future falls are prevented. The DON stated that when Resident 219 had a fall and there was no post fall CP developed and implemented, the resident could have sustained a fall with injury the very next day. The DON stated the facility P&P was not followed. During a review of the facility provided P&P titled, “Fall and Fall Risk, Managing,” last reviewed 1/2025, the P&P indicated based on previous evaluations 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. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. During a review of the facility provided P&P titled, “Care Plans, Comprehensive,” last reviewed 1/2025, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. c. Build on the residents’ strengths. d. Reflect the resident's expressed wishes regarding care and treatment goals. e. Reflect treatment goals, timetables and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions. Care plan interventions are designed after careful consideration of the relationship between the residents’ problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change. b. During a review of Resident 119’s AR, the AR indicated the facility admitted the resident on 5/27/2025 with diagnoses including anxiety disorder, bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 119’s “H&P,” dated 5/27/2025, the “H&P” indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 119’s MDS dated [DATE], the MDS indicated Resident 119’s cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS further indicated that Resident 119 required moderate assistance with upper body dressing, personal hygiene, bathing, and was dependent on lower body dressing, transferring from the bed to chair and moving from lying to sitting position. During an interview on 7/3/2025 at 12:12 p.m. with the MDS Coordinator (MDSC), MDSC stated bladder and bowel management, and retraining care plan was not initiated for Resident 119. MDSC stated residents’ care plan should be comprehensive and include all aspects of residents’ care. MDSC stated the failure to initiate and implement a comprehensive care plan that would include bladder and bowel retraining program for Resident 119 could potentially result in delay of care, negatively affecting Resident 119’s well-being. During an interview on 7/3/2025 at 12:26p.m. with the DON, the DON stated bowel and bladder management, and retraining care plan should have been initiated for Resident 119. The DON stated comprehensive care plan provides the guiding steps of resident care. The DON stated the failure to initiate the care plan could potentially prevent Resident119 from receiving care leading to increased risk of incontinence and negatively affect Resident 119’s psychosocial well-being. During a review of the facility-provided P&P titled, “Care Plan-Comprehensive,” last reviewed on 01/2025, the P&P indicated, “An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident’s medical, nursing, mental and psychological needs is developed for each resident. 1. Our facility’s Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to the MDS. 3. Each resident’s comprehensive care plan is designed to : a. incorporate identified problem area; b. Incorporate risk factors associated with identified problems; c. Build on the resident’s strengths;…h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program.”

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided meet professional standards of quality in accordance with professional standards and comprehensive care plan for two of two sampled residents (Residents 25 and 31) by failing to ensure: 1. Subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites were rotated (a method to ensure repeated injections are not administered in the same area) for Resident 25. 2. Resident 31's Psychotropic medications (medications that affect the mind, emotions, and behavior) had documented evidence for the diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thoughts). These deficient practices had the potential for Residents 25 and 31 to experience adverse effect (unwanted, unintended result) and negatively affect the residents' well-being Cross Reference with F760 Findings: a. During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted Resident 25 on 8/31/2016 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 25's Care Plan (CP), initiated on 8/23/2024, the CP indicated Resident 25 had diabetes mellitus. The CP interventions indicated to administer diabetes medications as ordered by the doctor. During a review of Resident 25's History and Physical (H&P), dated 10/25/2024, the H&P indicated, Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS-resident assessment tool) dated 5/9/2025, the MDS indicated Resident 25's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS also indicated Resident 25 required supervision with showers, bed to chair transfers, and toilet transfers. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated the following physician's order: -2/9/2025: Insulin Glargine (Lantus SoloStar- a long-acting insulin that provides a consistent level of insulin in the body over approximately 24 hours) Subcutaneous Solution Pen-Injector (a medical device designed for easy and accurate administration of injectable medication) 100 unit per milliliter (unit/ml - a unit of measurement). Inject 90 units subcutaneously in the morning. Rotate Site. Hold if blood sugar (BS-body's main source of energy) is less than 100. During a concurrent interview and record review on 7/2/2015 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 25's Medication Administration Record (MAR), dated 6/2025 was reviewed. The MAR indicated insulin glargine was administered as follows: 6/4/25 06:00 6/4/25 06:27 subcutaneously Abdomen-left upper quadrant (LUQ) 6/5/25 06:00 6/5/25 06:13 subcutaneously Abdomen- LUQ 6/6/25 06:00 6/6/25 05:20 subcutaneously Arm-right 6/7/25 06:00 6/7/25 05:52 subcutaneously Arm-right 6/15/25 06:00 6/15/25 05:18 subcutaneously Abdomen-left lower quadrant (LLQ) 6/16/25 06:00 6/16/25 06:13 subcutaneously Abdomen-LLQ 6/17/25 06:00 6/17/25 06:01 subcutaneously Abdomen-LLQ 6/20/25 06:00 6/20/25 06:33 subcutaneously Abdomen-LLQ 6/21/25 06:00 6/21/25 05:11 subcutaneously Abdomen-LLQ LVN 4 stated the insulin administration sites should have been rotated during each administration. LVN 4 stated the failure to rotate insulin administration sites had the potential for Resident 25 to experience skin problems, adverse effects and affect the absorption of the insulin. During an interview on 7/2/2025 at 3:05 p.m. with Registered Nurse (RN) 1, RN 1 stated licensed staff should have rotated insulin administration sites. RN 1 stated the failure to rotate insulin administration sites had the potential to damage Resident 25's subcutaneous tissue. During an interview on 7/3/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated insulin administration sites should be rotated. The DON stated the failure to rotate insulin administration sites had the potential to cause cellulitis (a skin infection that causes swelling and redness), damage the subcutaneous tissue and affect the absorption of the medication. During a review of the facility provided manufacturer's guideline for Lantus dated 8/2022, the guideline indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis at the injection site. During a review of the facility-provided policy and procedure (P&P) titled, Insulin Administration, last reviewed on 1/2025, the P&P indicated, Injection sites should be rotated, preferably in the same general area (abdomen, thigh, upper arm). b. During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted Resident 31 on 4/25/2025 and readmitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), bipolar disorder, and end stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 31's MDS, dated [DATE], the MDS indicated Resident 31's cognitive functioning was moderately impaired. The MDS also indicated Resident 31 required moderate assistance with oral hygiene, personal hygiene, and maximal assistance with toileting hygiene, showers, and chair to bed transfers. During a review of Resident 31's CP, initiated on 5/15/2025, the CP indicated Resident 31 had behavioral patterns of Schizophrenia manifested by rapid mood cycling as evidenced by sudden shifts in mood from pleasant to extreme anger. The CP also indicated residents were at risk for adverse effects from psychotropic medications. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated the following physician's order: -5/26/2025: Seroquel (Quetiapine Fumarate) Oral Tablet 25 milligram (mg-unit of measurement). Give 12.5mg by mouth two times a day for schizophrenia manifested by rapid mood cycling as evidenced by sudden shifts in mood from pleasant to extreme anger, yelling and screaming. During a concurrent interview and record review on 7/1/2025 at 2:32 p.m. with RN 1, Resident 31's General Acute Care Hospital (GACH) records, dated 5/2025 were reviewed. The GACH records indicated Resident 31's home medications included Seroquel. RN 1 stated Resident 31's facility records do not have documented record of Schizophrenia diagnosis. During an interview on 7/3/2025 at 12:26 p.m. with the DON, the DON stated there should have been documentation from the physician regarding Resident 31's diagnoses of schizophrenia and evaluation for the indication of the psychotropic medication. The DON stated this failure had the potential for Resident 31 to receive unnecessary medication and experience sedation, increasing risk of injury. During a review of the facility-provided P&P titled, Psychotropic Medication Use, last reviewed on 1/2025, the P&P indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition. 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: a. Anti-psychotics. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. During a review of the facility-provided P&P titled, Psychotropic Medication Use, last reviewed on 1/2025, the P&P indicated, An ‘adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. The staff and practitioner strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication.

CONCERN (D)

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

Deficiency F0678 (Tag F0678)

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 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 ensure one of three Certified Nursing Assistants (CNA) (CNA 4) obtained her CPR certification credentialed by the American Red Cross (ARC-an organization providing disaster relief, blood donation services, and health education) or the American Heart Association (AHA-an organization focused on heart disease prevention, research, and education). This deficient practice had the potential to result in a delay for the provision of CPR to residents in emergency situations. Findings: During a review of CNA 4's CPR certificate, the CPR certification indicated a completion date of [DATE]. During a concurrent interview and record review on [DATE] at 9:03 a.m. with the Director of Nursing (DON), reviewed CNA 4's CPR certificate and the facility's policy and procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, the DON stated CNA 4 and CNAs are part of their CPR team. The DON stated the P&P is to make sure all their staff are trained by the ARC or the AHA. The DON stated the residents could potentially have an injury while their staff provides CPR/Basic Life Support (BLS -a lifesaving technique used to save a victim in case of an emergency) to the residents. During a concurrent interview and record review on [DATE] at 1:37 p.m. with the Director of Staff Development (DSD), reviewed CNA 4's CPR certificate, the DSD stated CNA 4's CPR training was not accredited by the ARC or the AHA. The DSD stated she will remove CNA 4 from the schedule and have her retrained for CPR. The DSD stated she missed it when she did the hiring process for CNA 4. The DSD stated it is important that CNA 4's CPR certificate is credentialed by the AHA or ARC to meet legal requirements and follow their policy. During a review of the facility's P&P titled, Emergency Procedure - Cardiopulmonary Resuscitation, last reviewed 1/2025, the P&P indicated the personnel had completed training on the initiation of CPR and basic life support, including defibrillation, for victims of sudden cardiac arrest. The P&P indicated for the preparation for CPR that key clinical staff members who will direct resuscitative efforts, including non-licensed personnel, are to obtain and/or maintain American Red Cross or American Heart Association certification in BLS/CPR. The PNP indicated the CPR team in this facility shall include at least one nurse, one licensed practical nurse/licensed vocational nurse, and two CNAs, all of whom have received training and certification in CPR/BLS.

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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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 interview and record review, the facility failed to ensure residents who were incontinent (having no or insufficient voluntary control) of bowel and bladder received services and assistance for one of one sampled resident (Resident 119) by failing to implement the bowel and bladder retraining program when Resident 119 was identified as a candidate for retraining. This deficient practice had the potential to result in increased risk for urinary or bowel incontinence and negatively affecting Resident 119's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose). Findings: During a review of Resident 119's admission Record (AR), the AR indicated the facility admitted Resident 119 on 5/27/2025 with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 119's History and Physical (H&P), dated 5/27/2025, the H&P indicated Resident 119 had the capacity to understand and make decisions. During a review of Resident 119's Minimum Data Set (MDS-resident assessment tool) dated 6/3/2025, the MDS indicated Resident 119's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS further indicated that Resident 119 was always incontinent of bladder and bowel, and was dependent on lower body dressing, transferring from the bed to chair and moving from lying to sitting position. During a concurrent interview and record review on 7/3/2025 at 12:12 p.m. with MDS Coordinator (MDSC), Resident 119's Bowel and Bladder Program Screener, dated 5/27/25 was reviewed. The Bowel and Bladder Program Screener indicated Resident 119 was a candidate for retraining. MDSC stated the purpose of the retraining program was to encourage and help residents to regain control over bladder and bowel elimination. MDSC stated bowel and bladder retraining program should have been initiated for Resident 119. MDSC stated this failure had the potential for Resident 119 to experience physical decline, develop skin problems, and negatively affect Resident 119's psychosocial well-being. During an interview on 7/3/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated facility failed to place Resident 119 on bowel and bladder retraining program. The DON stated this failure had the potential to increase Resident 119's risk of incontinence, cause skin damage and negatively affect Resident 119's well-being. During a review of the facility-provided policy and procedure (P&P) titled, Urinary Continence and Incontinence, last reviewed on 01/2025, the P&P indicated, 1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. 2. Management of incontinence will follow relevant clinical guidelines. 3. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible.19. The staff will document the results of the toileting trail in the resident's medical record. a. If the resident responds well, the toileting program will be continued.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident (Resident 53) reviewed during Respiratory Care by failing to ensure Resident 53's nasal cannula (a medical device that provides supplemental oxygen therapy) was connected to the oxygen concentrator (a medical device that provides a concentrated source of oxygen). This failure had the potential for Resident 53 to experience shortness of breath, respiratory distress, and negatively affect Resident 53's well-being. Findings: During a review of Resident 53's admission Record (AR), the AR indicated facility admitted Resident 53 on 10/18/2024 and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition when lungs cannot adequately oxygenate the blood leading to hypoxemia [low blood oxygen levels]), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dementia (a progressive state of decline in mental abilities). During a review of Resident 53's Care Plan (CP) titled, Risk for ineffective breathing pattern, initiated on 10/23/2024, the CP interventions indicated to administer oxygen as prescribed. During a review of Resident 53's CP titled, Resident has an impaired gas exchange related to dyspnea and shortness of breath, initiated on 1/15/2025, the CP interventions indicated to administer oxygen and titrate oxygen to keep oxygen saturation greater than (>) 92 percent (%-unit of measurement). During a review of Resident 53's History and Physical (H&P), dated 3/4/2025, the H&P indicated Resident 53 did not have the capacity to understand and make decisions. During a review of Resident 53's Minimum Data Set (MDS-resident assessment tool), dated 6/27/2025, the MDS indicated Resident 53 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 53 was dependent on staff for eating, oral hygiene, toileting hygiene, showers, upper and lower body dressing. During a review of Resident 53's Order Summary Report, the Order Summary Report indicated the following physician's order: -3/20/2025: Oxygen: Oxygen at 2 liters (L-unit of volume measurement) per minute continuously, for shortness of breath may titrate up to 5L if necessary 1L at a time. During a concurrent observation and interview on 6/30/2025 at 1:57 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 53's room, Resident 53 was observed in bed with nasal cannula placed near Resident's nostrils. Nasal cannula tubing was observed disconnected from the concentrator, hanging from Resident 53's bed. LVN 1 stated the oxygen tubbing should always be connected to the oxygen source and it is facility staff's responsibility, including licensed staff and certified nurse assistants, to make sure the connection is intact. LVN 1 stated failure to connect Resident 53's nasal cannula to the oxygen concentrator had the potential for Resident 53 to experience shortness of breath and oxygen desaturation (decrease in the oxygen saturation of the blood). During an interview on 7/3/2025 at 12:35p.m with the Director of Nursing (DON), the DON stated staff should routinely monitor oxygen tubing and make sure tubbing is intact and connected to the concentrator. DON stated failure to connect the nasal canula to the oxygen concentrator had the potential for Resident 53 to experience shortness of breath and respiratory distress. During a concurrent interview and record review on 7/3/2025 at 1:05 p.m. with the MDS Coordinator (MDSC), the facility-provided policy and procedure (P&P) titled, Oxygen Administration, last reviewed on 01/2025, was reviewed. The P&P indicated, Check the tubing connected to the oxygen cylinder to assure that it is free of kinks.Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Check the mask, tank, humidifying jar, etc. , to be sure they are in good working order and are securely fastened. MDSC stated Oxygen Administration policy is the only facility policy addressing the monitoring of the oxygen administration.

CONCERN (D)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to complete a performance review for two of two Certified Nursing Assistants or CNAs (CNA 2 and CNA 3) once every 12 months. This deficient practice had the potential to result in placing residents at risk or reducing care quality. Findings: During a concurrent interview and record review on 7/2/2025 at 8:45 a.m. with the Director of Staff Development (DSD), the DSD stated licensed nurses and CNAs complete an annual competency and performance evaluation based on hire date. During a concurrent interview and record review on 7/2/2025 at 9:11 a.m. with the DSD, reviewed CNA 2's employee file, the DSD stated CNA 2's hire date was 6/29/2018 and her last competency skills check was done on 6/21/2023. The DSD stated the competency skills check for the year 2024 was not done for CNA 2. The DSD stated it should have been done on 6/2024 by the previous DSD. The DSD stated competency is done annually to make sure their nurses are competent with their skills and ensure the right care is provided to their residents. During a concurrent interview and record review on 7/2/2025 at 9:17 a.m. with the DSD, reviewed CNA 3's employee file, the DSD stated CNA 3's hire date was 12/14/2022 and her last competency skills check was done on 10/26/2023. The DSD stated the competency skills check for the year 2024 was not done for CNA 3. During an interview on 7/2/2025 at 9:24 a.m. with the DSD, the DSD stated competency skills check, and performance reviews should be in the employee files and completed. The DSD stated the completion of competency skills is to show proof that their nurses, licensed nurses and CNAs, have the skills and ability to perform patient care, medication administration, lift machine, and do their job description. The DSD stated it should be filed immediately. DSD stated it should have been completed during day 1 and 2 of orientation. The DSD stated if it is not filed, she would not know if it was completed. During an interview on 7/3/2025 at 8:51 a.m. with the Director of Nursing (DON), the DON stated performance reviews are done yearly including CNAs. The DON stated they know what their responsibilities and expectations are based on their job description. The DON stated competency is done yearly and if there was a deficiency they would do another competency. The DON stated this is done to ensure that licensed nurses and CNAs know how to provide the care and treatment they are providing. The DON stated the residents may cause injury to the residents such as transferring residents and may cause injury when transfer and staff can injure themselves when taking care of residents. During a review of the facility's policy and procedure (P&P) titled, Job Descriptions and Performance Evaluations, last reviewed 1/2025, the P&P indicated that each employee will receive a copy of his/her respective job description prior to his/her performance of assigned tasks. The P&P indicated the primary purpose of the facility's job description and performance evaluations is to provide uniform guidelines for the implementation of job requirements and the evaluation of the standards of job performance. The P&P indicated the objectives of the facility's job descriptions and performance evaluations are to: a. Clarify who is responsible for particular duties within their facility; b. Assist employees in understanding the essential functions, responsibilities, working conditions, qualifications, and specific physical requirements of their positions; c. Prevent misunderstanding about job responsibilities and how each job is evaluated; e. Provide a basis for job evaluation, wage and salary increases, promotions, demotions, transfers, etc. and to improve the quality of work performance.

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 residents were free of unnecessary medication for one of one sampled residents (Residents 31) by failing to monitor Resident 31's hemoglobin (a protein in red blood cells that carry oxygen) levels to ensure Epogen (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] by creating more blood cells) was indicated for Resident 31 prior to the administration of the medication. This deficient practice had the potential for Resident 31 to experience adverse (unwanted, unintended result) cardiovascular (heart and blood vessels) reactions and stroke (loss of blood flow to a part of the brain). Cross Reference with F755 Findings: During a review of Resident 31's admission Record (AR), the AR indicated the facility admitted Resident 31 on 4/25/2025 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and anemia. During a review of Resident 31's Minimum Data Set (MDS-resident assessment tool), dated 4/30/2025, the MDS indicated Resident 31's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was moderately impaired. The MDS also indicated Resident 31 required moderate assistance with oral hygiene, personal hygiene, and maximal assistance with toileting hygiene, showers, and chair to bed transfers. During a review of Resident 31's Order Summary Report, the Order Summary Report indicated the following physician's order: -5/27/2025: Epogen (Epoetin Alfa) Injection Solution 10000 unit/milliliter (unit/ml-unit of measurement). Inject 1 dose subcutaneously (beneath the skin) one time a day every Tuesday for anemia. Hold if hemoglobin is greater (>) than 11. During a concurrent interview and record review on 7/2/2015 at 3:05 p.m. with Registered Nurse (RN) 1, Resident 31's Medication Administration Record (MAR), dated 6/2025 was reviewed. The MAR indicated, on 6/3/2025 for the 9 a.m. administration time and 6/10/2025 for the 9 a.m. administration time, there was a licensed staff initials in the box for Resident 31's Epogen Injection Solution, indicating the medication was administered. RN 1 stated Epogen should not have been administered without monitoring of the hemoglobin levels. RN 1 stated Resident 31's hemoglobin levels should have been monitored every week prior to medication administration. RN 1 stated the failure to monitor hemoglobin levels could potentially cause Resident 31 to receive Epogen when hemoglobin level was high and the medication was not indicated. RN 1 stated this failure had the potential for Resident 31 to experience liver problems. During an interview on 7/2/2025 at 3:35 p.m. with the Director of Nursing (DON), the DON stated Resident 31's hemoglobin level should have been monitored every week prior to administration of Epogen. The DON stated the failure to monitor hemoglobin levels prior to administering Epogen had the potential to cause polycythemia (high hemoglobin concentration in the blood) in Resident 31 negatively affecting her well-being. During a review of the facility provided manufacturer's guideline for Epogen dated 9/2017, the guideline indicated to monitor hemoglobin levels at least weekly until stable, then monitor at least monthly for CKD patients. The manufacturer's guideline also indicated there is a greater risk for adverse cardiovascular reactions, and stroke when Epogen is administered to target a hemoglobin level of greater than 11grams/deciliter (g/dL-unit of volume measurement). During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 01/2025, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed.

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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Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (% - out of one hundred). Two (2) medication errors out of 29 total opportunities contributed to an overall medication error rate of 6.9% affecting one (1) of five (5) residents observed for medication administration (Resident 36). The medication errors resulted when the facility failed to: 1.Ensure Licensed Vocational Nurse (LVN) 5 administered medication per the physician prescribed orders when LVN 5 omitted (did not administer) amiodarone (medication to prevent and treat certain types of serious heart rhythm problems) and famotidine (a medication that reduces stomach acid production) on 7/2/2025 during the 9 a.m. medication pass observation. 2.Ensure LVN 5 did not document the administration of omitted medications amiodarone and famotidine in Resident 36's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) on 7/2/2025 during the 9 a.m. medication pass observation. These deficient practices had the potential to result in a delay of care and treatment, mismanagement of resident's care, and miscommunication among caregivers. Cross Reference to F755 Findings: During a review of Resident 36's admission Record (AR), the AR indicated the facility originally admitted the resident on 8/16/2024 and most recently admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), dysphagia (difficulty swallowing), hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), presence of cardiac pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm), and presence of gastrostomy tube [GT or G-tube, a tube that is inserted into the stomach). During a review of Resident 36's Minimum Data Set (MDS - resident assessment tool), dated 5/7/2025, the MDS indicated the resident usually was able to understand others and usually was able to make themself understood. The MDS further indicated the resident was dependent on staff for dressing, personal and oral hygiene, toileting, bathing, and mobility. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 1.Amiodarone HCl Oral Tablet 100 milligrams (mg, a unit of measurement) Give 100 mg via G-Tube two times a day for arrhythmia (an irregular heart rhythm) hold (do not give) for heart rate (HR) less than (<) 60 beats per minute (BPM), dated 2/18/2025. 2.Arginine (a supplement that helps the body produce proteins) Oral Packet, give 1 packet via G-Tube two times a day for supplement, dated 2/18/2025. 3.Buspirone (an anti-anxiety medication) HCl Oral Tablet 5 mg, give 1 tablet via G-Tube two times a day for anxiety manifested by (m/b) physical restlessness as evidenced by (AEB) thrashing back and forth in bed, dated 5/26/2025. 4.Apixaban (medication used to treat and prevent blood clots [gel-like clumps of blood]) Oral Tablet five (5) mg, give 1 tablet via G-Tube two times a day for deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), monitor for bleeding, dated 02/18/2025. 5.Clonazepam (medication to prevent and treat anxiety disorders) Oral Tablet 1 mg, give 1 tablet via G-Tube two times a day for anxiety with agitation m/b physical restlessness AEB trashing back and forth in bed, dated 02/18/2025. 6.Risperidone (medication used to treat mental disorders) Oral Tablet, give 1.5 mg via G-Tube two times a day for psychosis m/b disrobing, self-harm behaviors AEB throwing self on floor 7.Sennoside (medication used to treat constipation) Oral Tablet 8.6 mg, give two tablets via G-Tube two times a day for severe constipation if no bowel movement for 4 days. Hold for loose stools, dated 02/18/2025. 8.Famotidine (used to prevent and treat heartburn due to acid indigestion Oral Tablet 20 mg, give 20 mg via G-Tube every 12 hours for gastrointestinal (the organs and system involved in digestion) prophylaxis, dated 02/18/2025. During a Medication Administration Observation on 7/2/2025 at 8 a.m., with LVN 5, observed LVN 5 prepare Resident 36's medications at Station 1 Medication Cart. Observed LVN 5 removed amiodarone from the bubble pack (a package that contains multiple sealed compartments with medication), reviewed the physician's order, and then stated the amiodarone was already given by the night shift nurse. Observed LVN 5 place the amiodarone in the medication waste bin. Observed LVN 5 then prepared cups for water flush, and the following supplement and medications to administer via GT: 1.Arginine one oral powder packet 2.Buspirone, one 5 mg tablet 3.Apixaban, one 5 mg tablet 4.Clonazepam, one 1 mg tablet 5.Risperidone one 1.5 mg tablet 6.Sennoside, two 8.6 mg tablets LVN 5 entered Resident 36's room and administered the water flushes and arginine, buspirone, apixaban, clonazepam, risperidone, and sennoside to the resident via GT. LVN 5 exited Resident 36's room and stated LVN 5 would now document the administration of Resident 36's medication in the MAR on the computer. LVN 5 stated LVN 5 administered the supplement and five 9 a.m. medications to Resident 36. During a follow-up concurrent interview and record review on 7/2/2025 at 11:19 a.m. with LVN 5, LVN 5 reviewed Resident 36's MAR for 7/2/2025 and physician orders and noted the following: -Resident 36 had an order for famotidine to be administered during the 9 a.m. medication pass. LVN 5 did not administer famotidine to Resident 36. LVN 5 documented in the MAR that LVN 5 administered famotidine to Resident 36. -Resident 36 had an order for amiodarone to be administered during the 9 a.m. medication pass. LVN 5 did not administer amiodarone to Resident 36. LVN 5 documented in the MAR that LVN 5 administered amiodarone to Resident 36. There was no documented evidence that the night shift administered amiodarone to Resident 36. LVN 5 further stated that LVN 5 did not administer amiodarone because LVN 5 was confused. LVN 5 stated LVN 5 did not administer famotidine because the medication was not in the Station 1 Medication Cart. LVN 5 stated LVN 5 accidentally documented that LVN 5 administered amiodarone and famotidine to Resident 36. LVN 5 stated that when LVN 5 was confused and did not find the medication in the medication cart, LVN 5 should have gone to a supervisor, but LVN 5 did not. LVN 5 stated when LVN 5 documented the administration of amiodarone and famotidine in Resident 36's MAR, the medication was considered given. LVN 5 stated if an administration is documented, then it is considered done. LVN 5 stated Resident 36's MAR was not accurate. LVN 5 stated it was important for the care of the resident to administer all resident medications per the physician's orders. LVN 5 stated LVN 5 made a mistake and would administer the famotidine and amiodarone to Resident 36. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. Registered Nurse (RN) 1 reviewed the facility policy and procedure (P&P) regarding medication administration and documentation. RN 1 stated the medication administration process is to administer medications per the physician's orders and then document in the MAR. RN 1 stated LVN 5 probably just clicked and clicked to document in the MAR, but LVN 5 did not administer all the medication. RN 1 stated it was a medication error when LVN 5 did not administer amiodarone and famotidine to Resident 36 and documented the medication as administered. RN 1 stated when Resident 36 did not receive amiodarone there was a potential that the resident would have atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots) or other heart issues. RN 1 stated when Resident 36 did not receive famotidine there was a potential that Resident 36 would have abdominal pain. RN 1 stated LVN 5 did not follow the facility P&Ps. During a review of the facility P&P titled, Administering Medications, last reviewed 1/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or 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. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: The date and time the medication was administered. During a review of the facility P&P titled, Adverse Consequences and Medication Errors, last reviewed 1/2025, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include: -Omission - a drug is ordered but not administered. -Wrong time.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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) for one of one sampled resident (Resident 25) by failing to ensure subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites were rotated (a method to ensure repeated injections are not administered in the same area). Cross Reference F658. Findings: During a review of Resident 25's admission Record (AR), the AR indicated the facility admitted Resident 25 on 8/31/2016 and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing, and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 25's History and Physical (H&P), dated 10/25/2024, the H&P indicated, Resident 25 had the capacity to understand and make decisions. During a review of Resident 25's Minimum Data Set (MDS-resident assessment tool), dated 5/9/2025, the MDS indicated Resident 25's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS also indicated Resident 25 required supervision with showers, bed to chair transfers, and toilet transfers. During a review of Resident 25's Order Summary Report, the Order Summary Report indicated the following physician's order: -2/9/2025: Insulin Glargine (Lantus SoloStar- a long-acting insulin that provides a consistent level of insulin in the body over approximately 24 hours) Subcutaneous Solution Pen-Injector (a medical device designed for easy and accurate administration of injectable medication) 100 unit per milliliter (unit/ml - a unit of measurement). Inject 90 units subcutaneously in the morning. Rotate Site. Hold if blood sugar (BS-body's main source of energy) is less than 100. During a concurrent interview and record review on 7/2/2015 at 2:50 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 25's Medication Administration Record (MAR), dated 6/2025 was reviewed. The MAR indicated, the MAR indicated the insulin glargine was administered as follows: 6/4/25 06:00 6/4/25 06:27 subcutaneously Abdomen-left upper quadrant (LUQ) 6/5/25 06:00 6/5/25 06:13 subcutaneously Abdomen- LUQ 6/6/25 06:00 6/6/25 05:20 subcutaneously Arm-right 6/7/25 06:00 6/7/25 05:52 subcutaneously Arm-right 6/15/25 06:00 6/15/25 05:18 subcutaneously Abdomen-left lower quadrant (LLQ) 6/16/25 06:00 6/16/25 06:13 subcutaneously Abdomen-LLQ 6/17/25 06:00 6/17/25 06:01 subcutaneously Abdomen-LLQ 6/20/25 06:00 6/20/25 06:33 subcutaneously Abdomen-LLQ 6/21/25 06:00 6/21/25 05:11 subcutaneously Abdomen-LLQ LVN 4 stated the insulin administration sites should have been rotated during each administration. LVN 4 stated the failure to rotate insulin administration sites had the potential for Resident 25 to experience skin problems, adverse effects and affect the absorption of the insulin. During an interview on 7/2/2025 at 3:05 p.m. with Registered Nurse (RN) 1, RN 1 stated licensed staff should have rotated insulin administration sites. RN 1 stated the failure to rotate insulin administration sites was considered a medication error and had the potential to damage Resident 25's subcutaneous tissue. During an interview on 7/3/2025 at 12:26 p.m. with the Director of Nursing (DON), the DON stated insulin administration sites should be rotated. The DON stated the failure to rotate insulin administration sites was a medication error and had the potential to cause cellulitis (a skin infection that causes swelling and redness), damage the subcutaneous tissue and affect the absorption of the medication. During a review of the facility provided manufacturer's guideline for Lantus dated 8/2022, the guideline indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis at the injection site. During a review of the facility-provided policy and procedure (P&P) titled, Insulin Administration, last reviewed on 01/2025, the P&P indicated, Injection sites should be rotated, preferably in the same general area (abdomen, thigh, upper arm). During a review of the facility-provided policy and procedure (P&P) titled, Medication Administration, last reviewed on 01/2025, the P&P indicated, Medications must be administered in accordance with the orders, including any required time frame. During a review of the facility-provided policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed on 01/2025, the P&P indicated, A ‘medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.

CONCERN (D)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure resident receive and consume foods in the appropriate nutritive content as prescribed by a physician to support the resident treatment and plan of care when one of two sampled resident (Resident 17) during a review of dining observation task, who was on a fortified diet (a diet that includes foods with added nutrients, like vitamins and minerals, that weren't naturally present in those foods) received fortified soup for lunches on 6/30/2025 and 7/1/2025. This deficient practice had the potential to cause weight loss for Resident 17. Findings: During a review of Resident 17's admission Record (AR), the AR indicates the facility admitted Resident 17 on 8/11/2004 and readmitted the resident on 1/14/2021 with diagnoses including type two (2) diabetes mellitus (DM2-a disorder characterized by difficulty in blood sugar control and poor wound healing), gastroesophageal reflux disease (GERD- when stomach acid frequently flows back into the esophagus, causing heartburn and other issues), and essential (primary) hypertension (HTN-high blood pressure). During a review of Resident 17's Care plan created on 11/18/2024 and revised on 3/11/2025, the Care plan for risk for altered nutritional status due to therapeutic diet with interventions that included dietary supplements as ordered, provide substitutes per request and determine food preferences. During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 4/9/2025, the MDS indicated able to understand and able to be understood. The MDS indicated Resident 17 was independent (completes the activity by themselves with no assistance from a helper) with eating, oral hygiene, toileting, showering, upper body and lower body dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 17's Care plan created on 4/9/2025, the Care plan for risk for dehydration and malnutrition due to weight loss and poor oral intake with interventions that included encourage to take supplements, give fortified soup for lunch and dinner and ice cream for lunch and dinner. During a review of Resident 17's Order Summary Report (OSR) dated 4/7/2025, the OSR indicated mighty shake (a nutritional shake designed to provide extra calories and protein) two times a day at lunch and dinner. During a review of Resident 17's OSR dated 4/10/2025, the OSR indicated consistent carbohydrates (CCHO), no added salt diet (NAS), regular texture, regular thin consistency, fortified soup for lunch and dinner, and add ice cream for lunch and dinner. During a review of Resident 17's OSR dated 5/21/2025, the OSR indicated Mirtazapine 15 milligrams (mg- a unit of measurement) by mouth at bedtime for depression mood behavior poor oral intake less than 50 percent (%). During a review of Resident 17's IDT Conference Record Weight Management dated 6/4/2025, the IDT indicated diet supplements as 4 ounces (oz- unit of measurement) mighty shake chocolate at lunch and dinner, on ice cream, fortified soup, at lunch and dinner. During a concurrent observation and interview on 6/30/2025 at 12:43 p.m. during the dining observation with Resident 17, Resident 17 stated she likes rice and soup, and she was not given soup. During a concurrent observation and interview on 7/1/2025 at 12:37 p.m. during the dining observation with Resident 17, Resident 17 stated she received a grill cheese sandwich, shake, ice cream, mashed potatoes, Cesar salad, spinach and dessert. Resident 17 stated she usually gets soup but did not get soup. During a concurrent observation and interview on 7/1/2025 at 12:44 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated there is no soup on Resident 17's tray. During a concurrent observation and interview on 7/1/2025 at 12:46 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there is no soup on Resident 17's tray. LVN 1 stated Resident 17 has an order to receive fortified soup, it is for added vitamins. LVN 1 stated if Resident 17 is not getting the fortified soup, Resident 17 can have a potential for a deficiency in vitamins. During an interview on 7/1/2025 at 3:33 p.m. with the Dietary Supervisor (DS), the DS stated fortified soup is for someone who is losing weight, so staff adds margarine, dry milk, whole milk, and gravies, to add more calories to help with the weight gain. The DS stated if the resident is ordered the fortified soup but is not given it can be a potential for Resident 17 to continue to lose weight. During a review of the facility's Policy and Procedures (P&P) titled, Therapeutic Diets, last reviewed on 1/2025, the P&P indicated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or alter the texture of the diet. During a review of the facility's P&P titled, Fortification of Food: Increasing Calories and/or Protein in the Diet, last reviewed on 1/2025, the P&P indicated the enrichment of foods will be done on an individual basis for the resident who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calories and/or protein density of the foods commonly consumed by the residents to promote improvement in their nutrition status. Identification of the residents in need of fortification will be done by the Dietitian or the FNS Director. The doctor will then order Fortified Diet. Residents considered will have demonstrated an inability to consume the amounts of foods required to prevent significant weight loss, skin breakdown, and/or loss of muscle mass. Calories and/or protein will be added to selected foods. The Dietitian of FNS Director will select the fortification method from the list provided for foods commonly or agreed upon to be consumed, or the RDs for Healthcare fortified guide will be used. Any number of techniques may be chosen for a given resident. Adding protein/calories indicated instant protein powder and instant calories/protein powders can be purchased. During a review of the facility provided standardized recipe titled, Super Soup, reviewed on 1/2025, indicated the following ingredients included soup and Multimix protein powder. Multimix adds 60 calories and 6 grams of protein per 2 tablespoons.

CONCERN (D)

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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure the indwelling urinary catheter (a flexible tube placed in the bladder to drain urine) drainage bag (a urine collection bag connected to the catheter) was maintained off the floor for one of one sampled residents (Resident 20) reviewed during the Urinary Catheter or Urinary Tract Infections (UTI, an infection in the bladder/urinary tract) care area. This deficient practice had the potential to spread infections and illnesses among residents and staff. 2. Ensure food items were not left inside the clean linen storage. This deficient practice had the potential to result in infection risk and cross-contamination. Findings: a. During a review of Resident 20’s admission Record (AR), the AR indicated the facility originally admitted the resident on 3/17/2025 and most recently re-admitted the resident on 5/1/2025 with diagnoses that included end stage renal disease (ESRD -irreversible kidney failure), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and sepsis (a life-threatening blood infection). During a review of Resident 20’s Minimum Data Set (MDS – resident assessment tool), dated 6/6/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated Resident 20 was dependent on staff for eating, bathing, dressing, toileting, personal and oral hygiene, and transferring from the bed to chair. During a review of Resident 20’s Order Summary Report, the Order Summary Report indicated a physician’s order for the following: -Catheter, may change indwelling catheter drainage bag if leaking or disconnected as needed for indwelling catheter care, dated 6/18/2025. -Catheter care every shift, dated 6/18/2025. During a review of Resident 20’s Care Plan (CP) regarding the indwelling urinary catheter, initiated 6/19/2025, the CP indicated interventions to use proper precaution for infection control and to use proper handwashing technique at all times. During a concurrent observation and interview on 6/30/2025 at 10:15 a.m., observed Resident 20 lying in bed. Observed an indwelling urinary catheter drainage bag hanging off the right side of the bed frame. Observed the drainage bag was resting on the floor. Observed Licensed Vocational Nurse (LVN) 3 entered Resident 20’s room and assessed the drainage bag and stated the drainage bag was on the floor. LVN 3 stated it was not okay for the drainage bag to be on the floor because bacteria can get on the bag from the floor, travel up the tubing to the resident’s urethra (part of the body that transmits urine from the bladder to the exterior of the body during urination), and cause an infection. Observed LVN 3 raised the resident’s bed, and the drainage bag no longer touched the floor. During a concurrent observation and interview on 7/2/2025 at 11:45 a.m. with LVN 3, LVN 3 entered Resident 20’s room to perform indwelling catheter care. Observed Resident 20’s indwelling catheter drainage bag resting on the floor. LVN 3 stated that when the resident’s bed is all the way down, the catheter drainage bag rests on the floor, so the bed should not be in the very lowest position, but it was, and the drainage bag was on the ground. LVN 3 stated facility staff are educated to keep the drainage bags off the floor. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility Policy and Procedure (P&P) regarding indwelling catheters and infection control. RN 1 stated catheter drainage bags should not be on the ground because it is an infection control risk. RN 1 stated the bed must be kept high enough to keep the drainage bag off the ground to keep bacteria from entering the resident’s body and potentially resulting in an infection. RN 1 stated when Resident 20’s indwelling catheter drainage bag was on the ground, the facility P&P was not followed. During a review of the facility provided Procedure titled, “Catheter-Care, Urinary,” last reviewed 1/2025, the Procedure indicated the purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor. Observe for other signs and symptoms of urinary tract infection or urinary retention. During a review of the facility provided P&P titled, “Infection Control Guidelines for All Nursing Procedures,” last reviewed 1/2025, the P&P indicated the purpose was to provide guidelines for general infection control while caring for residents. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues. b. During a concurrent observation and interview on 7/3/2025 at 9:24 a.m. with the Maintenance Supervisor (MS), inside the clean linen closet, the MS stated they store the clean linens, beddings, towels, gowns, and residents' personal clothes when their vendor delivers them, and they store it here in the clean linen closet. The MS stated there is a bagel, a banana, and a bottle of Gatorade (a sports drink). The MS stated these items belong to his assistant. The MS stated he has already told his assistant not to store food items in the clean linen closet because it is to be kept clean. During an interview on 7/3/2025 at 12:28 p.m. with the DON, the DON stated the food items should not be stored in the clean linen storage. The DON stated it invites insects and would not be sanitary to be kept there, and residents’ clothes would be infected. During a review of the facility’s policy and procedure (P&P) titled, “Storage Areas, Environmental Services,” last reviewed 1/2025, the P&P indicated that housekeeping and laundry department storage areas shall be maintained in a clean and safe manner. The P&P indicated all housekeeping and laundry storage areas shall be kept free from accumulation of trash, rubbish, oily, rags, paper, etc., at all times.

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

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 rights to formulate an Advance Directive (AD, a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) for three of five sampled residents (Resident 20, 219, and 119) reviewed under the AD care area by failing to provide written information concerning the right to formulate an AD. This deficient practice had the potential to violate the residents' right to have their wishes honored regarding health care decisions. Findings: a. During a review of Resident 20’s admission Record (AR), the AR indicated the facility originally admitted the resident on 3/17/2025 and most recently re-admitted the resident on 5/1/2025 with diagnoses that included End Stage Renal Disease (ESRD -irreversible kidney failure), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), and sepsis (a life-threatening blood infection). During a review of Resident 20’s Minimum Data Set (MDS – resident assessment tool) dated 6/6/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident was dependent on staff for eating, bathing, dressing, toileting, personal and oral hygiene, and transferring from the bed to chair. During a review of Resident 20’s in progress (not completed) status Social Service History and Initial Assessment Form, dated 6/13/2025, the form did not indicate if the resident had an AD or if the resident or resident representative (RR) wanted information on advanced care planning. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 20’s 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) dated 5/28/2025. LVN 2 stated the POLST indicated an incomplete area for information regarding the AD, and did not indicate that the AD was discussed with the resident or resident representative. LVN 2 stated the Social Services Director (SSD) would have more information about the AD. During a concurrent interview and record review on 7/2/2025 at 9:09 a.m. with the SSD, the SSD reviewed Resident 20’s in progress Social Service History and Initial Assessment Form, dated 6/13/2025. The SSD stated the AD is a document that gives information on a resident’s wishes regarding medical decisions. The SSD stated the AD gives a resident representative the ability to make decisions if the resident has a change of condition and can no longer make decisions for themselves. The SSD stated the facility AD process is to speak with the resident or RR upon admission and ask if the resident has an AD or if the resident would like to formulate an AD. The SSD stated written information is provided regarding the resident’s right to formulate an AD and the AD Acknowledgment form should be signed by the resident or RR. The SSD stated Resident 20 did not have a complete AD Acknowledgment form. The SSD stated the Social Service History and Initial Assessment Form was not completed and there was no documented evidence that the AD was discussed with Resident 20 or their RR. The SSD stated if there was no documentation that information was discussed with the resident or RR regarding the AD, then it was not done. The SSD stated the facility process was not followed for Resident 20 and there was a potential for the resident’s wishes not being followed because the facility was not aware of the resident’s wishes. During an interview on 7/2/2025 at 11:25 a.m. with Registered Nurse (RN) 1, RN 1 stated upon admission the AD Acknowledgment form should be completed to indicate a resident was given information regarding the right to appoint another person as a decision maker when the resident is not able to make decisions for themself. RN 1 stated the SSD or a nurse will follow up to obtain the AD as needed. RN 1 stated if the AD Acknowledgment form is not completed it indicates the resident was not given information on the AD. RN 1 stated failing to provide information regarding the AD indicates a lack of communication between the resident and facility that can potentially lead to the facility not following the resident’s wishes. b. During a review of Resident 219’s AR, the AR indicated the facility admitted the resident on 6/18/2025 with diagnoses that included 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 cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, and anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear). During a review of Resident 219’s MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing; and required substantial / maximal assistance for upper body dressing, personal hygiene, and transferring from the bed to chair. During a review of Resident 219’s History and Physical (H&P), dated 6/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During an interview on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 stated Resident 219 did not have an AD, did not have a completed AD Acknowledgment form, and the SSD would have more information about the AD. During a concurrent interview and record review on 7/2/2025 at 9:09 a.m. with the SSD, the SSD reviewed Resident 219’s Progress Notes dated 6/2025. The SSD stated the AD is a document that gives information on a resident’s wishes regarding medical decisions. The SSD stated the AD gives a resident representative the ability to make decisions if the resident has a change of condition and can no longer make decisions for themself. The SSD stated the facility AD process is to speak with the resident or RR upon admission and ask if the resident has an AD or if the resident would like to formulate an AD. The SSD stated written information is provided regarding the resident’s right to formulate an AD and the AD Acknowledgment form should be signed by the resident or RR. The SSD stated Resident 219 did not have a complete AD Acknowledgment form. The SSD stated there was no documented evidence that the AD was discussed with Resident 219. The SSD stated if there was no documentation that information was discussed with the resident regarding the AD, then it was not done. The SSD stated the facility process was not followed for Resident 219 and there was a potential for the resident’s wishes not being followed because the facility was not aware of the resident’s wishes. During an interview on 7/2/2025 at 11:25 a.m. with RN 1, RN 1 stated upon admission the AD Acknowledgment form should be completed to indicate a resident was given information regarding the right to appoint another person as a decision maker when the resident is not able to make decisions for themself. RN 1 stated the SSD or a nurse will follow up to obtain the AD as needed. RN 1 stated if the AD Acknowledgment form is not completed it indicates the resident was not given information on the AD. RN 1 stated failing to provide information regarding the AD indicates a lack of communication between the resident and facility that can potentially lead to the facility not following the resident’s wishes. c. During a review of Resident 119’s AR, the AR indicated the facility admitted the resident on 5/27/2025 with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). During a review of Resident 119’s “H&P,” dated 5/27/2025, the “H&P” indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 119’s MDS dated [DATE], the MDS indicated Resident 119’s cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS further indicated that Resident 119 required moderate assistance with upper body dressing, personal hygiene, bathing, and was dependent on lower body dressing, transferring from the bed to chair and moving from lying to sitting position. During a concurrent interview and record review on 7/2/2025 at 9:55a.m. with the SSD, Resident 119’s “Social Service Assessment and Initial History,” dated 5/28/25 was reviewed. The record indicated the AD was not discussed with Resident 119. SSD stated Resident 119 did not have a complete AD Acknowledgment form to indicate that Resident 119 was provided information on AD. The SSD stated this failure had the potential for facility not to follow Resident 119’s wishes and negatively affect Resident 119’s well-being. During an interview on 7/2/2025 at 11:25 a.m. with Registered Nurse (RN) 1, RN 1 stated failing to provide information regarding the AD indicated lack of communication between the resident and facility that could potentially lead to the facility not following the resident’s wishes. During a review of the facility provided Policy and Procedure (P&P) titled, “Advance Directives,” last reviewed 1/2025, the P&P indicated Advance directives will be respected in accordance with state law and facility policy. Prior to or upon admission of a resident to the facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care. including the right to accept or refuse medical or surgical treatment, and the right to formulate ADs. Prior to or upon the admission of a resident the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. During a review of the facility provided P&P titled, “Resident Rights,” last reviewed 1/2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to choose a physician and treatment and participate in decisions and care planning.

CONCERN (E)

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

Deficiency F0605 (Tag F0605)

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 from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for three of five sampled resident (Residents 219, 36, and 31) reviewed under the Unnecessary Medications, Chemical Restraints / Psychotropic Medications care area by failing to: 1. Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of psychotropic medication for Resident 219. 2. Provide ongoing re-evaluation of the need for psychotropic medication by failing to monitor for measurable behaviors and adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status) of bupropion (an antidepressant medication used to treat depression [persistent feelings of sadness and loss of interest that can interfere with daily living]), diazepam (a medication used to relieve symptoms of anxiety [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear]), and duloxetine (a medication to treat depression and anxiety) for Resident 219. 3. Ensure as needed (PRN) diazepam was prescribed for a specific, measurable behavioral manifestation for Resident 219. 4. Provide ongoing re-evaluation of the need for psychotropic medication by failing to ensure PRN diazepam was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed) for Resident 219. 5. Monitor for measurable behaviors of Risperdal (an antipsychotic medication-a drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) from 2/18/2025 to 2/28/2025 for Resident 36. 6. Provide ongoing re-evaluation for the indications for use of Risperdal and Klonopin (a psychotropic medication used for anxiety [a feeling of fear, dread, and uneasiness]) when the Behavior Summary Side Effects sheet (a document that outlines information about psychotropic medications which includes focus on indications for use, side effects, dosage, and frequency) was not completed for the months 2/2025, 3/2025, 5/2025, and 6/2025 for Resident 36. 7. Monitor for measurable behaviors and adverse effects of Seroquel (an antipsychotic medication used to treat mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thoughts]and bipolar disorder [mood swings that range from the lows of depression to elevated periods of emotional highs]) for Resident 31. These deficient practices had the potential to result in the administration of unnecessary psychotropic medication resulting in chemical restraints and placed residents at risk for decline in physical functioning, isolation (a state of reduced social interaction and lack of meaningful connections with others), and injury from falls. Findings: 1. During a review of Resident 219’s admission Record (AR), the AR indicated the facility admitted the resident on 6/18/2025 with diagnoses that included 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 cerebrovascular infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, lack of coordination, history of falls, depression, and anxiety disorder. During a review of Resident 219’s Minimum Data Set (MDS – resident assessment tool) dated 6/23/2025, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing; and required substantial / maximal assistance for upper body dressing, personal hygiene, and transferring from the bed to chair. The MDS indicated that the resident was administered the following high-risk medications (drugs that can cause significant patient harm if used incorrectly): antianxiety and antidepressant. During a review of Resident 219’s History and Physical (H&P), dated 6/19/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 219’s Order Recap Summary, the Order Recap Summary indicated the following physician’s orders: -Bupropion HCl extended release (SR) oral tablet SR 12 hour 150 milligrams (mg, a unit of measurement), give one tablet by mouth one time a day for depression manifested by (M/B) negative statements about health. Informed consent obtained from medical doctor, dated 6/18/2025. -Diazepam oral tablet five mg, give one tablet by mouth every 12 hours PRN for anxiety, dated 6/18/2025. -Duloxetine HCl oral capsule delayed release particles 60 mg, give one capsule by mouth one time a day for depression M/B reduced social interaction, dated 6/18/2025. During an observation and interview on 6/30/2025 at 9:25 a.m., observed Resident 219 sitting in the wheelchair in the hallway near the resident’s room. Resident 219 stated the facility nurse’s do not tell Resident 219 what medications the resident is taking. Resident 219 stated the resident fell while in the facility. 1.a. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 219’s physician orders and medication administration record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. During a concurrent interview and record review on 7/3/2025 at 8:09 a.m. with the MDS Coordinator (MDSC), the MDSC reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. The MDSC stated psychotropic medications affect the brain and behavior of residents. The MDSC stated the facility process for the administration of psychotropic medication was the following: 1.Clarify with the resident that the resident understands the medications prescribed and the physician will obtain informed consent. 2.The consent form is then completed for each psychotropic medication. 3.The resident will be monitored every shift for potential side effects of the medication. 4.The resident will be monitored every shift for behavioral manifestations. 5.Monitoring is documented every shift in the MAR, and behaviors are tallied to ensure the medication is effective. The MDSC further stated it was important for the physician to get informed consent from the resident because psychotropic medications are considered high risk medications with potential for adverse effects like tardive dyskinesia (a movement disorder that causes a range of repetitive muscle movements in the face, neck, arms, and legs), sedation, and overall decline in the medical condition. The MDSC stated there was no documented evidence that informed consent was obtained prior to the administration of Resident 219’s diazepam or duloxetine. The MDSC stated that when residents are administered psychotropic medication without their consent, it could be considered a chemical restraint because the medication modifies a resident’s behavior and may restrict their free will. The MDSC stated the admitting nurse did not follow the facility P&P when informed consent was not obtained potentially resulting in the resident taking medications, they were not aware of and that could potentially affect their medical and mental health. During a concurrent interview and record review on 7/3/2025 at 9 a.m. with the Director of Nursing (DON), the DON reviewed the facility P&P regarding psychotropic medication. The DON stated that informed consent must be obtained for the administration of psychotropic medication because there are side effects to the medications. The DON stated psychotropics change a resident’s behavior and it is important to get the residents consent because residents have the right to refuse any treatment, including medications that affect behavior. The DON stated the facility cannot administer medications if a resident does not want the medication. The DON stated when informed consent was not obtained from Resident 219’s diazepam and duloxetine; the facility P&P was not followed and there was a potential for Resident 219 to be considered chemically restrained and to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Residents have the right to decline treatment with psychotropic medications. During a review of the facility provided policy and procedure (P&P) titled, “Psychoactive Medication Informed Consent,” reviewed 1/2025, the P&P indicated it is the policy of the facility to ensure that an informed consent is obtained for each resident's psychoactive medication. The purpose of the policy is to ensure that informed consent has been obtained and verified prior to initiation of psychotropic medication use. Fundamental Information: resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. Procedure: 1.Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring that the required material information has been provided. 2.If the resident or resident's representative cannot sign the form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. Medical Records: a. The signed written consent must be recorded in the resident's medical record. b. Before initiating treatment with psychotherapeutic drugs, facility staff shall verify that the resident's health record contains written informed consent with the required signatures. During a review of the facility provided P&P titled, “Resident Rights,” reviewed 1/2025, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: Choose a physician and treatment and participate in decisions and care planning. 1.b During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 reviewed Resident 219’s physician orders and MAR for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. LVN 2 stated that because of the adverse effects, the goal for psychotropic medication administration is to have a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued) to avoid unnecessary medication in residents. LVN 2 stated psychotropic medication is prescribed with specific, measurable behavioral manifestations to monitor to evaluate for an increase or decrease in the resident’s behavior. LVN 2 stated if behaviors decrease then the facility can attempt a GDR. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. RN 1 stated psychotropic medication needs to be monitored for adverse effects and the specific behaviors for the drug administration. RN 1 stated it was important to monitor to know if the medication was working. RN 1 stated if a medication is no longer needed, then the goal is to do a GDR because higher levels of psychotropic medication can cause harm to a resident. RN 1 reviewed Resident 219’s MAR and noted the following: -Bupropion was not monitored for the specific behavior of negative statements about health. -Duloxetine was not monitored for the specific behavior of reduced social interaction. -And, bupropion, duloxetine, and diazepam were not monitored for potential side effects. During a concurrent interview and record review on 7/3/2025 at 8:09 a.m. with the MDSC, the MDSC reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. The MDSC stated psychotropic medications affect the brain and behavior of residents. The MDSC stated the facility process for the administration of psychotropic medication was the following: 1.Clarify with the resident that the resident understands the medications prescribed and the physician will obtain informed consent. 2.The consent form is then completed for each psychotropic medication. 3.The resident will be monitored every shift for potential side effects of the medication. 4.The resident will be monitored every shift for behavioral manifestations. 5.Monitoring is documented every shift in the MAR, and behaviors are tallied to ensure the medication is effective. The MDSC further stated the overall goal is that the residents will be able to do activities of daily living on the minimum dosage of psychotropic medications to minimize the side effects. The MDSC stated that when there is no monitoring of psychotropic medication then there is no way to know how the medication is affecting the resident. The MDSC stated without monitoring there is a risk that a resident would be overmedicated potentially resulting in harm from falls. The MDSC stated there was no documented evidence that Resident 219 was monitored for behaviors or the potential side effects for the administration of diazepam, duloxetine, or bupropion. The MDSC stated the facility P&P was not followed. During a concurrent interview and record review on 7/3/2025 at 9 a.m. with the DON, the DON reviewed the facility P&P regarding psychotropic medication. The DON stated psychotropics change a resident’s behavior. The DON stated when there was no monitoring for Resident 219’s diazepam, duloxetine, and bupropion; the facility P&P was not followed and there was a potential for Resident 219 to be considered chemically restrained and to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Psychotropic medication management includes adequate monitoring for efficacy and adverse consequences; and preventing, identifying and responding to adverse consequences. Residents on psychotropic medication receive GDR in an effort to discontinue the medication. Residents receiving psychotropic medications are monitored for adverse consequences. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. During a review of the facility provided P&P titled, “Adverse Consequences and Medication Errors,” reviewed 1/2025, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. An adverse consequence refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. The staff and practitioners strive to minimize adverse consequences by: -Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. Residents receiving medication are monitored for adverse consequences. Adverse consequences are promptly identified and reported. When a resident receives a new medication order, review the following: -The dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. 1.c. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 reviewed Resident 219’s physician orders and MAR for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. LVN 2 stated that because of the adverse effects, the goal for psychotropic medication administration is to have a GDR to avoid unnecessary medication in residents. LVN 2 stated psychotropic medication is prescribed with specific, measurable behavioral manifestations to monitor to evaluate for an increase or decrease in the resident’s behavior. LVN 2 stated if behaviors decrease then the facility can attempt a GDR. LVN 2 stated Resident 219’s diazepam was ordered for anxiety. LVN 2 stated anxiety is not a specific behavioral manifestation. LVN 2 stated the medication nurses should have clarified with the physician and updated the order to include Resident 219’s behavior of verbalizing that the resident felt anxious, but they did not. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with RN 1, RN 1 reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. RN 1 stated anxiety is a psychiatric diagnosis and not behavior. RN 1 stated residents display behaviors of anxiety like shortness of breath or verbalizing fear. RN 1 stated if a specific behavior is not included in the physician’s order, then the admitting nurse should clarify with the physician. RN 1 stated Resident 219’s order for PRN diazepam did not include a specific behavioral manifestation for administration, but it should have. RN 1 stated when Resident 219’s PRN diazepam order did not include a specific behavior, the facility P&P was not followed with a potential to result in the medication causing harm in the resident. During an interview on 7/2/2025 at 2:32 p.m. with the DON, the DON stated psychotropics have a high risk for side effects like over sedation resulting in resident falls. The DON stated psychotropics should be administered and monitored for specific behaviors to know if the residents have a continued need for the medication. The DON stated the behavior monitoring data is used for a GDR with a goal of decreasing and discontinuing medication. The DON stated Resident 219’s physician order for PRN diazepam indicates to give the medication for anxiety. The DON stated anxiety is not a specific behavior. During a follow-up concurrent interview and record review on 7/3/2025 at 9 a.m. with the DON, the DON reviewed the facility P&P regarding psychotropic medication. The DON stated when Resident 219’s diazepam was not ordered with a specific behavioral manifestation; the facility P&P was not followed and there was a potential for Resident 219 to be considered chemically restrained and to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Psychotropic medication management includes adequate monitoring for efficacy and adverse consequences. Residents on psychotropic medication receive GDR in an effort to discontinue the medication. Psychotropic medications are not prescribed or given on a PRN basis unless the medication is necessary to treat a specific diagnosed condition that is documented in the clinical record. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. During a review of the facility provided P&P titled, “Adverse Consequences and Medication Errors,” reviewed 1/2025, the P&P indicated the interdisciplinary team monitors medication usage in order to prevent and detect medication-related problems such as adverse drug reactions (ADRs) and side effects. The staff and practitioners strive to minimize adverse consequences by: -Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. -Defining appropriate indications for use. 1.d. During a concurrent interview and record review on 7/1/2025 at 12:22 p.m. with LVN 2, LVN 2 reviewed Resident 219’s physician orders and MAR for 6/2025. LVN 2 stated psychotropic medications are high-risk medications that can cause adverse effects in residents like confusion, lethargy, and dizziness potentially resulting in resident falls with injury. LVN 2 stated that because of the adverse effects, the goal for psychotropic medication administration is to have a GDR to avoid unnecessary medication in residents. LVN 2 stated all PRN psychotropic medication should be prescribed with a stop date when the physician will reassess the need for the high-risk medication. LVN 2 stated Resident 219’s PRN diazepam was not prescribed with a stop date, but it should have been. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. with RN 1, RN 1 reviewed the facility P&P regarding psychotropic medication, Resident 219’s physician orders, and MAR for 6/2025. RN 1 stated PRN psychotropic medications are ordered with a 14 day stop date and then the resident needs to be re-evaluated because the medication may no longer be needed. RN 1 stated if a resident no longer needs psychotropic medication, the medication should no longer be administered due to the increased risk for harm from side effects. RN 1 stated Resident 219’s PRN diazepam order did not have a stop date, and the facility P&P was not followed with a potential to result in the medication causing falls resulting in harm to the resident. During a concurrent interview and record review on 7/3/2025 at 9 a.m. with the DON, the DON reviewed the facility P&P regarding psychotropic medication. The DON stated when PRN diazepam was not ordered with an end date for Resident 219’s diazepam, the facility P&P was not followed and there was a potential for Resident 219 to have received unnecessary medications potentially resulting in side effects causing injury. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects the brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. PRN orders for psychotropic medications that are not antipsychotics: if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 2. During a review of Resident 36’s AR, the AR indicated the facility originally admitted the resident on 8/16/2024 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety disorder (an abnormal condition characterized by persistent and excessive worries that interfere with daily activities), and respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 36’s H&P, dated 2/19/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 36’s MDS, dated [DATE], the MDS indicated the resident had adequate hearing and unclear speech, usually made self-understood, and had the ability to understand others. The MDS indicated the helper does all the effort for the resident’s activities of daily living including oral hygiene, toileting hygiene, shower/bathing self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated that the resident was taking high-risk drug classes (medications at risk of side effects that can adversely affect health, safety, and quality of life) including antipsychotic and antianxiety medications. During a review of Resident 36’s Order Summary Report, the Order Summary Report indicated: - Klonopin oral tablet, one (1) milligram (mg-a unit of measurement), give 1 tablet via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (g-tube) two times a day for anxiety with agitation manifested by physical restlessness as evidenced by trashing back and forth in bed, dated 2/18/2025. - Risperdal oral tablet, give 1.5 mg via g-tube two times a day for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) manifested by disrobing, self-harm behaviors as evidenced by throwing self on floor, dated 2/18/2025. - Monitor for anxiety with agitation manifested by physical restlessness as evidenced by trashing back and forth in bed and tally by hashmark every shift for clonazepam (Klonopin), dated 2/18/2025. - Monitor psychosis manifested by disrobing, self-harm behaviors as evidenced by trashing back and forth in bed and tally by hashmark every shift, dated 3/1/2025. During a concurrent interview and record review on 7/3/2025 at 9:37 a.m., with the MDSC, reviewed Resident 36’s Behavior Summary Side Effects sheet and Medication Administration Record for the month of 2/2025 to 6/2025. The MDSC stated the Behavior Summary Side Effects documented for the month of 4/2025 only for Klonopin and Risperdal. The MDSC stated the MAR indicated the total behavior exhibited by Resident 36: Total behavior tally for Klonopin: - 2/2025 - 0 - 3/2025 - 4 - 4/2025 - 0 - 5/2025 - 10 - 6/2025 - 42 Total behavior tally for Risperdal: - 3/2025 - 0 - 4/2025 - 0 - 5/2025 - 0 - 6/2025 – 0 During a concurrent interview and record review on 7/3/2025 at 10:10 a.m. with the MDSC, reviewed Resident 36’s Order Summary Report, the MDSC stated there was no order for behavior monitoring for the use of Risperdal from 2/18/2025 to 2/28/2025. The MDSC stated the behavior monitoring was ordered on 3/1/2025. The MDSC stated once the licensed nurse receives the order for Risperdal it should coincide with the monitoring for behavior and side effects. The MDSC stated the behavior is monitored to evaluate if the medication is effective for Resident 36. The MDSC stated this could be a risk for overmedicating Resident 36 and could have adverse effects such as drowsiness, confusion, and tardive dyskinesia (a neurological movement disorder characterized by involuntary, repetitive, and sometimes disfiguring muscle movements, particularly in the face, mouth, tongue, and limbs). During an interview on 7/3/2025 at 12:25 p.m. with the DON, the DON stated the 11 p.m. to 7 a.m. shift licensed nurse would be responsible in completing the behavior summary effect sheet. The DON stated this document provides information if Resident 36’s behavior has increased or decreased, and they could do a gradual dose reduction of the medication. The DON stated there should be a monitoring of the resident’s behavior for the use of psychotropic medications because this is part of medication management and gradual dose reduction. During a review of the facility provided P&P titled, “Psychotropic Medication Use,” reviewed 1/2025, the P&P indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: anti-depressants and anti-anxiety medication. Psychotropic medication management includes adequate monitoring for e[TRUNCATED]

CONCERN (E)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications by failing to ensure Licensed Vocational Nurse (LVN) 5 did not use a syringe (a small hallow tube without a needle, fitted with a sliding plunger) to push (the act of depressing the plunger in a syringe to apply force in order to advance medications through the gastrostomy tube [GT or g-tube, a tube that is inserted into the stomach) medications through the GT for one (1) of 1 sampled resident (Resident 36) reviewed during the Tube Feeding care area. This deficient practice placed Resident 36 at increased risk for abdominal distention (when air or fluid accumulate in the stomach causing expansion), nausea (an urge to vomit), and vomiting. Findings: During a review of Resident 36's admission Record (AR), the AR indicated the facility originally admitted the resident on 8/16/2024 and most recently admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), dysphagia (difficulty swallowing), hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), presence of cardiac pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm), and presence of GT. During a review of Resident 36's Minimum Data Set (MDS - resident assessment tool), dated 5/7/2025, the MDS indicated the resident usually was able to understand others and usually was able to make themself understood. The MDS further indicated the resident was dependent on staff for dressing, personal and oral hygiene, toileting, bathing, and mobility. During a review of Resident 36's Order Summary Report, the Order Summary Report indicated the following physician orders: 1.Arginine (a supplement that helps the body produce proteins) Oral Packet, give 1 packet via G-Tube two times a day for supplement, dated 2/18/2025. 2.Buspirone (an anti-anxiety medication) HCl Oral Tablet 5 mg, give 1 tablet via G-Tube two times a day for anxiety manifested by (m/b) physical restlessness as evidenced by (AEB) thrashing back and forth in bed, dated 5/26/2025. 3.Apixaban (medication used to treat and prevent blood clots [gel-like clumps of blood]) Oral Tablet five (5) mg, give 1 tablet via G-Tube two times a day for deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), monitor for bleeding, dated 02/18/2025. 4.Clonazepam (medication to prevent and treat anxiety disorders) Oral Tablet 1 mg, give 1 tablet via G-Tube two times a day for anxiety with agitation m/b physical restlessness AEB trashing back and forth in bed, dated 02/18/2025. 5.Risperidone (medication used to treat mental disorders) Oral Tablet, give 1.5 mg via G-Tube two times a day for psychosis m/b disrobing, self-harm behaviors AEB throwing self on floor. 6.Sennoside (medication used to treat constipation) Oral Tablet 8.6 mg, give two tablets via G-Tube two times a day for severe constipation if no bowel movement for 4 days. Hold for loose stools, dated 02/18/2025. During a Medication Administration Observation on 7/2/2025 at 8 a.m., with LVN 5, observed LVN 5 prepare Resident 36's medications at Station 1 Medication Cart. Observed LVN 5 prepare cups for water flush, and the following supplement and medications to administer via GT: 1.Arginine one oral powder packet 2.Buspirone, one 5 mg tablet 3.Apixaban, one 5 mg tablet 4.Clonazepam, one 1 mg tablet 5.Risperidone one 1.5 mg tablet 6.Sennoside, two 8.6 mg tablets Observed LVN 5 entered Resident 36's room with the medications and water flush in cups, placed the medications and water on the resident's nightstand, and assessed the resident's GT. LVN 5 was then observed to suction (draw the medication into the syringe tube) the supplement and five medications into a syringe, place the syringe tip onto the GT and apply pressure to the plunger to advance the medications by push method. LVN 5 was observed suctioning 30 milliliters (mL, a unit of measurement) of water into the syringe and then push the 30 mL of water into the GT before and after each medication administration. LVN 5 exited Resident 36's room and stated LVN 5 used the push method to administer the GT medication and water. LVN 5 stated it was okay to slowly push medication. LVN 5 stated using the gravity method (the act of removing the plunger, pouring medication into the syringe, and allowing the medication to flow without applying force) is the preferred method to administer medications by GT because it is more natural and ensures force is not applied to the GT. LVN 5 stated LVN 5 did not attempt to use the gravity method before using the push method to administer Resident 36's medication because the resident's GT has been clogged in the past and LVN 5 assumed the GT may be clogged. LVN 5 stated Resident 36's GT was not clogged. LVN 5 stated LVN 5 should have attempted to use the gravity method, but LVN 5 forgot to. During a concurrent interview and record review on 7/2/2025 at 2:32 with LVN 2 and the Director of Nursing (DON), the policy and procedures (P&P) regarding GT medication administration were reviewed. The DON stated the facility policy is to administer GT medication by gravity. The DON stated the plunger should be remove and medication should be poured into the syringe. LVN 2 stated if a nurse needs to use the slow push method, there must be a physician's order. LVN 2 stated even if there is a physician's order to use the slow push method, the nurse should attempt to use the gravity method first. LVN 2 stated it was important to use the gravity method because gravity simulates the natural process of digestion. LVN 2 stated the gravity method is preferable as to not upset the resident's stomach. LVN 2 stated LVN 5 did not follow the facility P&P to use the gravity method of GT medication administration. A review of the facility P&P titled, Administering Medications through an Enteral Tube last reviewed 1/2024, The P&P indicated to attach the syringe to the GT without the plunger to the end of the GT tubing and administer medication by gravity. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion, open the clamp and deliver medication slowly.

CONCERN (E)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled residents (Resident 51) reviewed under the Dialysis care area by failing to ensure adequate communication with the HD Center regarding no documented assessments done before and after Resident 51's hemodialysis sessions. This deficient practice placed Resident 51 at risk for a delay in care and services and a delay in detecting complications resulting from HD. Findings: During a review of Resident 51's admission Record, the admission Record indicated the facility admitted the resident on 2/21/2024 with diagnoses that included end stage renal disease (the kidneys cease functioning on a permanent basis), dependence on renal dialysis, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 51's Minimum Data Set (MDS - resident assessment tool), dated 5/8/2025, the MDS indicated the resident was able to understand others and was able to make themself understood. The MDS further indicated the resident required supervision with eating, oral and personal hygiene, bathing, dressing, and toileting. During a review of Resident 51's Order Summary Report, the Order Summary Report indicated an order for HD at Hemodialysis Center (HD Center) 1, on Tuesday/Thursday/Saturday at 7:30 a.m., dated 1/1/2025. During a review of Resident 51's Care Plan (CP) regarding hemodialysis, initiated 10/29/2024, the CP indicated a goal that the resident will have immediate interventions should any signs or symptoms of complications from HD occur. During a concurrent interview and record review on 7/1/2025 at 1:14 p.m., Licensed Vocational Nurse (LVN) 2 reviewed Resident 51's Dialysis Assessment forms for 6/2025, Progress Notes for 6/2025, and Vital Signs (measurements of the body's most basic functions including blood pressure, heart rate, respiratory rate, and temperature) forms for 6/2025. LVN 2 stated the facility process for HD residents is an assessment is completed by the licensed nurse (LN) prior to sending the residents to HD to ensure the resident is stable. LVN 2 stated when residents return from HD, the licensed nurse immediately completes a post HD assessment because the residents are at risk for being lethargic, bleeding, or a change in the vital signs. LVN 2 stated it is important to catch any change of condition quickly to treat and minimize the effects of high blood pressure or bleeding. MDSN 1 stated the Dialysis Assessment form documents that the licensed nurse completed pre and post HD assessments of the resident. LVN 2 stated the HD center also completes the Dialysis Assessment form to communicate the resident's weight before and after HD, lab values, and any medications administered at the center. LVN 2 stated the LN is responsible to contact the HD center if the form is not completed. LVN 2 stated Resident 51 has HD three times a week. LVN 2 reviewed Resident 51's Dialysis Assessment forms, Progress Notes, and vital signs and noted the following: On 6/10/2025 there was no documented evidence of a post HD assessment being completed. There was no documented communication from HD Center 1. On 6/17/2025 there was no documented evidence of a post HD assessment being completed. On 6/19/2025 there was no documented evidence of a pre or post HD assessment being completed. On 6/21/2025 there was no documented evidence of a post HD assessment being completed. On 6/24/2025 there was no documented evidence of a post HD assessment being completed. On 6/26/2025 there was no documented evidence of a post HD assessment being completed. LVN 2 stated when pre and post HD assessments were not completed for Resident 51, and the HD Center was not followed up with by the LNs, there was a potential for harm because the resident may have undetected bleeding or high blood pressure that resulting in hospitalization. During a concurrent interview and record review on 7/1/2025 at 2:23 p.m. with Registered Nurse (RN) 1, RN 1 reviewed the facility policy and procedures (P&P) regarding HD. RN 1 stated the facility process is to monitor residents right when the resident returns from HD because there may be bleeding from the HD access site (a way to reach the blood for dialysis) or the resident may have lost too much fluid resulting in abnormal blood pressure. RN 1 stated it is a big risk to not assess and monitor residents before and after HD. RN 1 stated when the Dialysis form was not completed, the LN's did not follow the facility P&P to monitor HD residents. During a concurrent interview and record review on 7/2/2025 at 11:45 a.m. with LVN 3, LVN 3 reviewed the Dialysis Assessment form dated 6/24/2025 and stated LVN 3 cared for Resident 51 on 6/24/2025 and forgot to document monitoring post HD. During a concurrent interview and record review on 7/2/2025 at 12 p.m. with LVN 5, LVN 5 reviewed the Dialysis Assessment form dated 6/26/2025 and stated LVN 5 cared for Resident 51 on 6/26/2025 and forgot to document monitoring before HD. LVN 5 stated in nursing if it was not documented then it was not done. During a review of the facility provided P&P titled, End-Stage Renal Disease, Care of Resident with, last reviewed 1/2024, the P&P indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes: the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. Signs and symptoms of worsening condition and/or complications of ESRD. How to intervene and recognize medical emergencies. During a review of the facility provided P&P titled, Hemodialysis Catheters - Access and Care of, last reviewed 1/2024, the P&P indicated care immediately following HD includes to apply pressure if there is bleeding at the HD site and contact emergency services and HD center. This is a medical emergency. Do not leave the residents alone until emergency services arrive. The nurse should document in the resident's medical record observations post-dialysis.

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 two of five sampled residents (Resident 36 and 31), by failing to: 1.Ensure Licensed Vocational Nurse (LVN) 5 administered medication per the physician prescribed orders when LVN 5 omitted (did not administer) amiodarone (medication to prevent and treat certain types of serious heart rhythm problems) and famotidine (a medication that reduces stomach acid production) on 7/2/2025 during the 9 a.m. medication pass observation for Resident 36. 2.Ensure LVN 5 did not document the administration of omitted medications amiodarone and famotidine in the resident's medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) on 7/2/2025 during the 9 a.m. medication pass observation for Resident 36. 3.Monitor hemoglobin (a protein in red blood cells that carry oxygen) levels before the administration of Epogen (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] by creating more blood cells for Resident 31. These deficient practices had the potential to result in a delay of care and treatment, mismanagement of residents' care, and miscommunication among caregivers. Cross Reference to F757 and F759 Findings: 1.During a review of Resident 36’s admission Record (AR), the AR indicated the facility originally admitted the resident on 8/16/2024 and most recently admitted the resident on 11/8/2024 with diagnoses that included metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), dysphagia (difficulty swallowing), hypertensive heart disease with heart failure (refers to heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), depression (persistent feelings of sadness and loss of interest that can interfere with daily living), presence of cardiac pacemaker (a small battery-operated device that helps the heart beat in a regular rhythm), and presence of gastrostomy tube [GT or G-tube, a tube that is inserted into the stomach). During a review of Resident 36’s Minimum Data Set (MDS – resident assessment tool) dated 5/7/2025, the MDS indicated the resident usually was able to understand others and usually was able to make themself understood. The MDS further indicated the resident was dependent on staff for dressing, personal and oral hygiene, toileting, bathing, and mobility. During a review of Resident 36’s Order Summary Report, the Order Summary Report indicated the following physician orders: 1.Amiodarone HCl Oral Tablet 100 milligrams (mg, a unit of measurement) Give 100 mg via G-Tube two times a day for arrhythmia (an irregular heart rhythm) hold (do not give) for heart rate (HR) less than (<) 60 beats per minute (BPM), dated 2/18/2025. 2.Arginine (a supplement that helps the body produce proteins) Oral Packet, give 1 packet via G-Tube two times a day for supplement, dated 2/18/2025. 3.Buspirone (an anti-anxiety medication) HCl Oral Tablet 5 mg, give 1 tablet via G-Tube two times a day for anxiety manifested by (m/b) physical restlessness as evidenced by (AEB) thrashing back and forth in bed, dated 5/26/2025. 4.Apixaban (medication used to treat and prevent blood clots [gel-like clumps of blood]) Oral Tablet five (5) mg, give 1 tablet via G-Tube two times a day for deep vein thrombosis (a serious condition where a blood clot forms in a deep vein), monitor for bleeding, dated 02/18/2025. 5.Clonazepam (medication to prevent and treat anxiety disorders) Oral Tablet 1 mg, give 1 tablet via G-Tube two times a day for anxiety with agitation m/b physical restlessness AEB trashing back and forth in bed, dated 02/18/2025. 6.Risperidone (medication used to treat mental disorders) Oral Tablet, give 1.5 mg via G-Tube two times a day for psychosis m/b disrobing, self-harm behaviors AEB throwing self on floor. 7.Sennoside (medication used to treat constipation) Oral Tablet 8.6 mg, give two tablets via G-Tube two times a day for severe constipation if no bowel movement for 4 days. Hold for loose stools, dated 02/18/2025. 8.Famotidine (used to prevent and treat heartburn due to acid indigestion Oral Tablet 20 mg, give 20 mg via G-Tube every 12 hours for gastrointestinal (the organs and system involved in digestion) prophylaxis, dated 02/18/2025. During a Medication Administration Observation on 7/2/2025 at 8 a.m., with LVN 5, observed LVN 5 prepare Resident 36’s medications at Station 1 Medication Cart. Observed LVN 5 removed amiodarone from the bubble pack (a package that contains multiple sealed compartments with medication), reviewed the physician’s order, and then stated the amiodarone was already given by the night shift nurse. Observed LVN 5 place the amiodarone in the medication waste bin. Observed LVN 5 then prepared cups for water flush, and the following supplement and medications to administer via GT: 1.Arginine one oral powder packet 2.Buspirone, one 5 mg tablet 3.Apixaban, one 5 mg tablet 4.Clonazepam, one 1 mg tablet 5.Risperidone one 1.5 mg tablet 6.Sennoside, two 8.6 mg tablets LVN 5 entered Resident 36’s room and administered the water flushes and arginine, buspirone, apixaban, clonazepam, risperidone, and sennoside to the resident via GT. LVN 5 exited Resident 36’s room and stated LVN 5 would now document the administration of Resident 36’s medication in the MAR on the computer. LVN 5 stated LVN 5 administered the supplement and five 9 a.m. medications to Resident 36. During a follow-up concurrent interview and record review on 7/2/2025 at 11:19 a.m. with LVN 5, LVN 5 reviewed Resident 36’s MAR for 7/2/2025 and physician orders and noted the following: -Resident 36 had an order for famotidine to be administered during the 9 a.m. medication pass. LVN 5 did not administer famotidine to Resident 36. LVN 5 documented in the MAR that LVN 5 administered famotidine to Resident 36. -Resident 36 had an order for amiodarone to be administered during the 9 a.m. medication pass. LVN 5 did not administer amiodarone to Resident 36. LVN 5 documented in the MAR that LVN 5 administered amiodarone to Resident 36. There was no documented evidence that the night shift administered amiodarone to Resident 36. LVN 5 further stated that LVN 5 did not administer amiodarone because LVN 5 was confused. LVN 5 stated LVN 5 did not administer famotidine because the medication was not in the Station 1 Medication Cart. LVN 5 stated LVN 5 accidentally documented that LVN 5 administered amiodarone and famotidine to Resident 36. LVN 5 stated that when LVN 5 was confused and did not find the medication in the medication cart, LVN 5 should have gone to a supervisor, but LVN 5 did not. LVN 5 stated when LVN 5 documented the administration of amiodarone and famotidine in Resident 36’s MAR, the medication was considered given. LVN 5 stated if an administration is documented, then it is considered done. LVN 5 stated Resident 36’s MAR was not accurate. LVN 5 stated it was important for the care of the resident to administer all resident medications per the physician’s orders. LVN 5 stated LVN 5 made a mistake and would administer the famotidine and amiodarone to Resident 36. During a concurrent interview and record review on 7/2/2025 at 1:40 p.m. Registered Nurse (RN) 1 reviewed the facility policy and procedure (P&P) regarding medication administration and documentation. RN 1 stated the medication administration process is to administer medications per the physician’s orders and then document in the MAR. RN 1 stated LVN 5 probably just clicked and clicked to document in the MAR, but LVN 5 did not administer all the medication. RN 1 stated it was a medication error when LVN 5 did not administer amiodarone and famotidine to Resident 36 and documented the medication as administered. RN 1 stated when Resident 36 did not receive amiodarone there was a potential that the resident would have atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots) or other heart issues. RN 1 stated when Resident 36 did not receive famotidine there was a potential that Resident 36 would have abdominal pain. RN 1 stated LVN 5 did not follow the facility P&Ps. During a review of the facility P&P titled, “Administering Medications,” last reviewed 1/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (I) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). If a drug is withheld, refused, or 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. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: The date and time the medication was administered. During a review of the facility P&P titled, “Adverse Consequences and Medication Errors,” last reviewed 1/2025, the P&P indicated a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medications errors include: -Omission - a drug is ordered but not administered. -Wrong time. 2. During a review of Resident 31’s AR, the AR indicated the facility admitted Resident 31 on 4/25/2025 and readmitted on [DATE] with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and anemia. During a review of Resident 31’s MDS dated [DATE], the MDS indicated Resident 31’s cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was moderately impaired. The MDS also indicated Resident 31 required moderate assistance with oral hygiene, personal hygiene, and maximal assistance with toileting hygiene, showers, and chair to bed transfers. During a review of Resident 31’s Order Summary Report, the Order Summary Report indicated the following physician’s order: -5/27/2025: Epogen (Epoetin Alfa) Injection Solution 10000 unit/milliliter (unit/ml-unit of measurement). Inject 1 dose subcutaneously (beneath the skin) one time a day every Tuesday for anemia. Hold if hemoglobin is greater (>) than 11. During a concurrent interview and record review on 7/2/2015 at 3:05 p.m. with RN 1, Resident 31’s MAR, dated 6/2025 was reviewed. The MAR indicated, on 6/3/2025 for the 9 a.m. administration time and 6/10/2025 for the 9 a.m. administration time, there were licensed staff initials in the box for Resident 31’s Epogen Injection Solution, indicating the medication was administered. RN 1 stated Resident 31’s hemoglobin levels have not been monitored since resident’s admission to the facility. RN 1 stated Epogen should not have been administered without checking hemoglobin levels and there was a potential for Resident 31 to receive Epogen when Resident’s hemoglobin level was >11. RN 1 stated Resident 31’s hemoglobin levels should have been monitored every week prior to medication administration. RN 1 stated the failure to monitor hemoglobin levels could potentially cause Resident 31 to experience liver problems. During an interview on 7/2/2025 at 3:35 p.m. with the Director of Nursing (DON), the DON stated Resident 31’s hemoglobin level should have been monitored every week prior to administration of Epogen. The DON stated the failure to monitor hemoglobin levels prior to administering Epogen had the potential to cause polycythemia (high hemoglobin concentration in the blood) in Resident 31 negatively affecting resident’s well-being. During a review of the facility provided manufacturer’s guideline for Epogen dated 9/2017, the guideline indicated to monitor hemoglobin levels at least weekly until stable, then monitor at least monthly for CKD patients. The manufacturer’s guideline also indicated there is a greater risk for adverse cardiovascular reactions, and stroke when Epogen is administered to target a hemoglobin level of greater than 11grams/deciliter (g/dL-unit of volume measurement). During a review of the facility-provided P&P titled, “Administering Medications,” last reviewed on 01/2025, the P&P indicated, “Medications shall be administered in a safe and timely manner, and as prescribed.

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 residents when [NAME] 1 did not level the number eight (8) scoop (1/2 cup [c, a unit of measurement]) for serving egg noodles. This failure had the potential to result in excess food served resulting to increased nutrient intake of 64 of 69 resident who received egg noodles causing unintended weight gain and ineffective therapeutic diet provisions of 16 of 20 residents on consistent carbohydrate diet (CCHO, a diet with the same amount of carbohydrate [macronutrient found in many foods and drinks, including sugars, starches, and fiber] each meal to manage high blood sugar). Findings: During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled, Menus, dated 6/30/2025, the spreadsheet indicated residents on regular diet (diet with no restriction) and CCHO would include the following foods on the tray: -Swedish meatballs two (2) pieces -Gravy 1-2 ounces (oz, a unit of measurement) -Egg noodles 1/2 cup (c, a household measurement) -Fresh zucchini and carrots 1/2 c -Orange slice 1 -Wheat rolls 1 pc -Margarine 1 teaspoon -Raspberry parfait 2x2 1/2 inch (regular diet) -Diet gelatin with 1 tablespoon of whip cream (for CCHO diet) -Milk 2 oz During an observation on 6/30/2025 at 12:10 p.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate), observed [NAME] 1 using number 8 scoop to portion the egg noodles to the plate and it was overflowing. During a concurrent observation and interview on 6/30/2025 with the Dietary Supervisor (DS) at the trayline area, observed [NAME] 1 portioning egg noodles using number 8 scoop. The DS stated [NAME] 1 used number 8 scoop in portioning egg noodles, it was not leveled, and it should be leveled. The DS stated [NAME] 1 gave too much egg noodles on the trays that could potentially cause unintended weight gain to the residents. During a review of the facility's policies and procedures (P&P) titled, Food Preparation, dated 1/5/2025, the P&P indicated, PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. During a review of the facility's P&P titled, Portion Sizes, dated 1/5/2025, the P&P indicated POLICY: Various portion sizes of food served will be available to better meet the needs of the residents. PROCEDURE: The small or large portion servings will be served as printed on the cook's spreadsheets for every meal. During a review of the facility's standardized recipe titled, RECIPE: EGG NOODLES, dated 2024, the recipe indicated portion size: 1/2 cup.

CONCERN (E)

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

Deficiency F0805 (Tag F0805)

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 in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) pasta was too dry, puree vegetables were watery, and puree meat did not hold its shape on the plate. These failures had the potential to result in difficulty in swallowing, chewing, decrease in food intake and nutrient intake to 9 of 9 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Menus, dated 6/30/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: -Puree Swedish meatballs 1/2 cup (c., household measurement) with gravy -Puree egg noodles 1/2 c -Puree fresh zucchini and carrots 1/3 c. -Puree orange slice 1-2/3 teaspoon -Puree wheat roll 1/4 c -Puree raspberry parfait 1/3 c -Milk 4 ounces (oz, a unit of measurement) -Puree pound cake with fresh strawberries 1/2 c/1 tablespoon During an observation on 6/30/2025 at 11:58 a.m. of puree food preparation, observed [NAME] 1 used a blender. During an observation on 6/30/2025 at 12:00 p.m. of puree food preparation, observed [NAME] 1 pouring thickener in the puree vegetable without measuring it. During an observation on 6/30/2025 at 12:10 p.m. of puree pasta, observed puree pasta had particles and puree Swedish meatballs did not hold its shape when plated on the plate. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 6/30/2025 at 1:03 p.m. with the Dietary Supervisor (DS), observed the puree meat did not hold its shape on the plate and was flat, puree fresh zucchini and carrots had liquid coming out on the side and puree egg noodles were dry. The DS stated a puree diet should be presentable, not too watery but not too dry and food should hold its shape on the plate. The DS stated the puree Swedish meatballs did not hold it shape on the plate and the puree zucchini and carrots had liquid coming out on the side. The DS further stated the puree egg noodle was not pudding like consistency because it was a little dry. The DS stated residents would have a hard time swallowing resulting in choking as a potential outcome and the food presentation was affected. The DS stated the residents would not eat the food and would lead to weight loss as a potential outcome. During a review of the facility's policies and procedures titled, Menu Planning, dated 1/2025, the P&P indicated Procedures: (1) The facilities' diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. (4) Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. During a review of the facility's P&P titled, Diet Manual, dated 2020, the P&P indicated, This diet manual is designed to meet the specific needs of intermediary and long-term care facilities. Objectives: (1) To provide a realistic approach to diets in order to make them adaptable and flexible to the individual needs and cultural background of the residents. (2) To meet the most recent Recommended Dietary Allowances. The RDA's were used as a basis for determining the adequacy of the diets. It must be recognized that all these allowances were developed for the maintenance of good nutrition in healthy individuals. A resident may require more or less of these nutrients. (3) To have a common language of communication among Food and Nutrition Services, Nursing, Physicians, Residents and their families. During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed and avoided and sample menus the facility have) titled Regular Pureed Diet dated 2020, the diet manual indicated The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. Detailed procedure of pureeing food is in Binder #1, misc. section. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft, and smooth state such as pudding, ice cream, applesauce, mashed potato, etc. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Meats dated 2024, the recipe indicated (5) The finished pureed item should be smooth and free of lumps, hold it shape, while not being firm or sticky, and should not weep. The finished puree item must pass IDDSI level 5 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests). During a review of the facility's standardized recipe title Recipe: Pureed (IDSSI Level 4) Vegetables dated 2024, the recipe indicated (5) The finished pureed item should be smooth and free of lumps, hold it shape, while not being firm or sticky, and should not weep. The finished puree item must pass IDDSI level 5 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests). During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test.

CONCERN (E)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one (1) of 1 sampled resident (Resident 40) food allergy, food preferences and intolerances were honored when orange slices, cheese quesadilla and pasta were served at lunch on 6/30/2025. Resident 40 was allergic to oranges, had intolerances to milk and milk products and disliked pasta. This deficient practice resulted in Resident 40 being served orange slices, cheese quesadilla, and pasta which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]), diarrhea, dehydration, low food intake resulting to weight loss and/or death for Resident 40. Findings: During a review of Resident 40's admission Record, the admission Record indicated the facility initially admitted Resident 40 on 5/10/2025 and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, a lung disease characterized by long term poor air flow to your lungs), pleural effusion (buildup of excess fluid between the lung and chest wall) and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter through the heart in an emergency situation). During a review of Resident 40's Minimum Data Sheet (MDS - a federally mandated resident assessment tool) dated 5/9/2025, the MDS indicated Resident 40's understood others and made self understood. The MDS indicated Resident 40 needed supervision and touching assistance when eating (helper provides verbal cues and or touching/steadying and/or contact guard assistance as a resident completes the activity. Assistance maybe provided throughout the activity or intermittently). During a review of the facility's report titled Order Listing Report dated 5/21/2025, the report indicated resident was on No Added Salt (NAS, a diet with no salt packets on the tray), regular texture, thin consistency, offer vegetarian menu, no tomatoes, green leafy vegetables, grapefruit and cranberry. During an interview on 6/30/2025 at 10 AM with Resident 40, Resident 40 stated the food was inedible and she has lifelong allergies to blueberries, oranges, and tomatoes and had been given tomato sauce on her tray from the kitchen. Resident 40 stated her tongue swells up and she could not breathe as an allergic reaction. Resident 40 stated she gets gastroparesis and could not have beef, chicken, ham, or lamb because her body could not break it down. During a review of Resident 40's diet ticket dated 6/30/2025, the diet ticket indicated Resident 40 dislikes tomato products, turkey, cranberry juice, olives, spinach, milk, broccoli, milk products, beef, chicken, ham, chocolate, pasta, Brussel sprouts, and tofu. During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Menus, dated 6/30/2025, the spreadsheet indicated residents on regular diet (diet with no restriction) and CCHO would include the following foods on the tray: -Swedish meatballs two (2) pieces -Gravy 1-2 ounces (oz, a unit of measurement) -Egg noodles 1/2 cup (c, a household measurement) -Fresh zucchini and carrots 1/2 c -Orange slice 1 -Wheat rolls 1 pc -Margarine 1 teaspoon -Raspberry parfait 2x2 1/2 inch (regular diet) -Diet gelatin with 1 tablespoon of whip cream (for CCHO diet) -Milk 2 oz During an observation on 6/30/2025 at 12:35 p.m. of Resident 40's food tray, observed egg noodles, quesadilla, carrots, zucchini, and orange slice on the plate. During a review of allergy report dated 7/1/2025, the allergy report indicated Resident 40 is allergic to eggs, olives, orange, tomato, and turkey During an interview on 7/1/2025 at 10:23 a.m. with the Dietary Supervisor (DS), the DS stated the process of catering food preferences and allergies upon resident's admission were as follows: 1.Introduce herself to the residents and ask what their food preferences. 2.Ask for residents' likes and dislikes 3.Ask for food allergies 4.Enter all the information on the computer to prepare the diet ticket 5.Diet tickets contain the residents' diet, diet consistency, beverages, special devices, dislikes, likes, dining room information and which table they would be seated. 6.Enter food allergies on the right corner of the ticket. During an interview on 7/1/2025 at 10:29 a.m. with the DS, the DS stated she was familiar with Resident 40's food allergies and that he is allergic to beef, turkey, tuna, milk, orange products, peanut butter, peanuts, vegetables. The DS stated Resident 40's diet ticket did not indicate food allergies, and she received orange slice yesterday on her tray and it was not okay. The DS stated Resident 40 received pasta and quesadilla which has milk product, and it was not okay as it was part of Resident 40's dislikes and intolerances. The DS stated it was important to take note of Resident 40's allergies in the diet ticket because of the Resident 40's at risk of being sick and resident could die as a potential outcome. During an interview on 7/1/2025 at 10:40 a.m. with the DS, the DS stated there was a difference between dislikes and food preferences and defined dislikes as foods residents did not want to eat. The DS further stated food allergies is when a resident had certain reaction to food upon consumption. The DS stated the kitchen should not be treating food allergies and food preferences the same for Resident 40 as she could have a reaction to food she received on her tray even if it is an ingredient. The DS stated the right thing to do was to enter the food allergies in the allergy section of the diet ticket rather than the dislike section. During an interview on 7/1/2025 at 12:42 p.m. with Resident 40, Resident 40 stated she is allergic to beer, wine, blueberries, tomatoes, papaya and oranges. Resident 40 she has intolerances when consuming milk and milk products, whole grain breads, cheerios containing high fiber. Resident 40 stated he dislike bacon, sausage, turkey, chicken. Resident 40 stated she did not take her tray yesterday because she cannot have it and that kitchen staff were aware that she could not have certain food items, but they sent it anyway. Resident 40 stated she felt that they did not care, and she got used to just not eating the food and order from outside. During a review of the facility's Policies and Procedures (P&P) titled Food Allergies and Intolerances dated 1/2025, the P&P indicated Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). General Guidelines: 1.Food allergies are immune system responses to allergens (foods). [NAME] antibodies to foods attach to mast cells in body tissue (e.g., skin, nose, throat, lungs, and gastrointestinal tract) and basophils in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine, an anti-inflammatory compound. 2.Food Intolerances are unpleasant reactions to specific foods that are not life threatening but can necessitate avoidance of triggering foods. For example, lactose intolerance is the inability to digest milk sugars due to a deficiency in the enzyme lactase. Lactose intolerance causes gas, bloating, cramping and diarrhea. Assessments and Interventions: (4) Meals for residents with severe food allergies are specially prepared so that cross-contamination with allergies does not occur. (5) Residents with food intolerances and allergies are offered appropriate substitutions for food that they cannot eat. During a review of the facility's P&P titled Resident Food Preferences, dated 1/2025, the P&P indicated Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be offered with the residents' or representative's consent. Policy and Interpretation: 1.Upon the resident's admission (or within twenty-four (24) hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. 2.When possible, staff will interview the residents directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3.The food service department will offer a variety of foods at each meal, as well as access to nourishing snacks throughout the day and night.

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: 1.Kitchen equipment and utensils were not maintained in their proper condition, smooth and easy to clean. a. Vegetables reach-in freezer had ice buildup. b. Reach-in freezer shelves by the preparation area were cracked and stained with amber discoloration. c. Walk-in refrigerator blue shelves were cracked and chipped. 2.Four (4) of 4 cans were stored with non-dented cans. 3.Kitchen equipment and kitchen areas were not cleaned and sanitized. a. Ice machine internal parts had dry hard water buildup and black residues. b. The resident's refrigerator had green dirt. 4.Staff did not perform hand hygiene when washing soiled dishes then cleaning and touching clean resident's carts. These failures 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 64 of 69 medically compromised residents who received food and ice from the kitchen. Findings: 1.a. During an observation on 6/30/2025 at 8:36 a.m. of the reach-in freezer, observed ice buildup by the door and shelves of the reach-in freezer. During an interview on 6/30/2025 at 8:47 a.m. with the Dietary Supervisor (DS), the DS stated there was an issue with the freezer and it was producing a lot of ice buildup. The DS stated they installed a metal plate so the inside freezer air would not go out. The DS stated the cause of the ice buildup was the air coming in from the outside and it builds condensation causing ice-buildup. The DS stated there was still a small gap in the freezer and it was not okay as the food could spoil if the air from the outside was coming in. The DS stated residents could get sick of stomachache, and the quality of food and freshness would be affected. During a review of the facility's Policy and Procedure (P&P) titled Sanitation dated 1/2025, the P&P indicated, POLICY: The Food and Nutrition Services Department shall have equipment of the type and, in the amount, necessary for the proper preparation, serving and storing of food. (4) Employees are to alert the FNS Director immediately to any equipment needing repair. (5) The FNS Director (an/or cook in his absence) will report any equipment needing repair to the maintenance man. (6) The maintenance department will assist Food and Nutrition Service as necessary in maintaining equipment and in doing janitorial duties which the Food and Nutrition employees cannot do and maintain maintenance records on all equipment. b. During an observation on 6/30/2025 at 8:40 a.m. of the meat freezer by the preparation area, observed the shelves were cracked with amber discoloration. During concurrent observation and interview on 6/30/2025 at 8:55 a.m. of the meat freezer with the DS, the DS stated the freezer shelves were not in good condition as they were broken, cracked, a had yellowish discoloration and needed to be replaced. The DS stated the stain did not come off and it was not okay as it could grow bacteria in the cracks of the shelves. The DS stated the residents could get sick of stomachache and crack shelves could be a potential hazard for the food of the residents. c. During an observation on 6/30/2025 at 9:04 a.m. of the walk-in refrigerator racks, observed two (2) of 2 racks were chipped and not smooth. During an interview on 6/30/2025 at 9:11 a.m. with the DS, the DS stated the racks in the walk-in refrigerator were cracked and not smooth and it was the same problem with the shelves in the freezer. The DS stated bacteria could grow in the cracks of the racks and could contaminate food. The DS stated resident could get sick as a potential outcome. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 1/2025, the P&P indicated, (9) Periodically inspect shelves and replace if coating is chipped away exposing metal shelves. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 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. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 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 3-391 - 3-306. 2.During a concurrent observation and interview on 6/30/2025 at 9:15 a.m. of the dry storage area, observed 4 of 4 dented cans stored with non-dented cans. The DS stated they have a designated dented cans area so their staff would not use it. The DS stated the dented cans were smashed and it was dangerous for residents' consumption and the residents could die upon consumption of food from the dented cans as a potential outcome. During a review of the facility's P&P titled, Food Storage-Dented Cans, dated 1/2025, the P&P indicated, Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from retaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victims to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 3.a. During an observation on 6/30/2025 at 11:09 a.m., of the ice machine, white dirt particles observed inside the ice machine. During a concurrent observation and interview on 6/30/2025 at 11:13 p.m. with the DS, observed the ice machine internal parts had white and black dirt particles. The DS stated the last time the outside company cleaned the ice machine was on 6/11/2025. However, the white particles were hard water buildup and there was also black dirt when wiped using a paper towel. The DS stated it was not okay to have dirt in the ice machine because was it would turn into mold so the ice bin would have to be emptied, and the ice would be thrown out. The DS stated the bacteria could grow on ice and residents could get sick upon ice consumption as a potential outcome. During a review of the facility's P&P titled, Ice Machine Cleaning Procedures, dated 1/2025, the P&P indicated Policy: The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer recommendations, and the date recorded when cleaned. During a review of the facility's manufacturer's guidelines of the ice machine titled, Maintenance, undated, the guidelines indicated, Clean and sanitize the ice machine every six months for efficient operation. If ice machines require more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. An extremely must be taken apart for cleaning and sanitizing. b. During a concurrent observation and interview on 7/1/2025 at 10:45 a.m. of the resident's refrigerator inside the staff lounge with the DS, the DS stated the green dirt looked like paint and it needed to be cleaned as residents could get sick due to cross-contamination. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 1/2025, the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 4.During a concurrent observation and interview on 7/1/2025 at 10 a.m. during the dishwashing process with Dietary Aide 1 (DA 1), observed DA 1 loaded the rack with the soiled dishes then proceeded to clean the carts using the sanitizer then touched the clean carts without changing her gloves. DA 1 stated the dishwashing area was dirty and the cart was clean, and she should have changed her gloves or washed her hands to prevent dirt from the soiled dishes to the clean carts. During an interview on 7/1/2025 at 10:06 a.m. with the DS, the DS stated handwashing must be done every time a staff member finished a task and when changing task to avoid cross-contamination. The DS stated DA 1 should have washed her hands because she worked from the dirty dishes then going to a clean surface. The DS stated residents could get sick due to cross contamination as a potential outcome. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 1/2025, the P&P indicated This facility considers hand hygiene the primary means to prevent the spread of infection. (7) Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. (g) before handling clean or soiled dressings, gauze pads, etc. During a review of Food Code 2022, dated 1/18/2023, the Food Code indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure the reach-in freezer was maintained according to manufacturer's guidelines where there was a gap causing air to come in the reach in freezer resulting in ice buildup of 1 of 2 reach-in freezer. This deficient practice had the potential to result in danger zone temperatures (a range of temperatures in which food-borne bacteria could grow) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in 64 of 69 medically compromised residents who stored food in the resident's refrigerator and freezer. Findings: During an observation on 6/30/2025 at 8:36 a.m. of the reach-in freezer, observed ice buildup by the door and shelves of the reach-in freezer. During an interview on 6/30/2025 at 8:47 a.m. with the Dietary Supervisor (DS), the DS stated there was an issue with the freezer and it was producing a lot of ice buildup. The DS stated they installed a metal plate so the inside freezer air would not go out. The DS stated the cause of ice buildup was the air coming in from the outside and it builds condensation causing ice-buildup. The DS stated there was still a small gap in the freezer and it was not okay as the food could spoil if the air from the outside is coming in. The DS stated residents could get sick of stomachache, and the quality of food and freshness would be affected. During an interview on 7/1/2025 at 1:53 p.m. with the Maintenance Supervisor (MS), the MS stated that they had an issue with the kitchen reach-in freezer with the air from the outside was coming in the freezer. MS stated the freezer door would not stick well and he was supposed to change the gaskets. However, the administrator decided to place a metal plate between the door so it could close properly and there would not be hot air coming in. The MS stated it was the administrator's decision to do it. During an interview on 7/1/2025 at 2:02 p.m. with the Administrator (ADM), the ADM stated there was an issue with the reach in freezer in the kitchen as it was not latching properly and he discussed it with the MS and decided to buy a metal and install it so there would not be defrosting happening. The ADM stated they did not call the manufacturer to check for the solution. ADM stated he was not aware that there was still an issue of ice-buildup. During a review of the facility's Policy and Procedure (P&P) titled, Sanitation, dated 1/2025, the P&P indicated, POLICY: The Food and Nutrition Services Department shall have equipment of the type and, in the amount, necessary for the proper preparation, serving and storing of food. (4) Employees are to alert the FNS Director immediately to any equipment needing repair. (5) The FNS Director (an/or cook in his absence) will report any equipment needing repair to the maintenance man. (6) The maintenance department will assist Food and Nutrition Service as necessary in maintaining equipment and in doing janitorial duties which the Food and Nutrition employees cannot do and maintain maintenance records on all equipment. During a review of the facility's log titled, Daily Maintenance Communication Log, dated 4/1/2025, the log indicated, maintenance department was aware of the freezer was still having issues of ice buildup around the door.

CONCERN (E)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when four (4) flies (a type of insect) were observed in the kitchen during trayline (an area where foods were assembled from the steamtable to resident's plate). This failure had the potential to result in 64 of 69 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During a concurrent observation and interview on 6/30/2025 at 12:43 p.m. with the Dietary Supervisor (DS), two (2) flies were flying around the trayline area and landed on the pan. The DS stated the flies probably came in from the outside when the staff opened the door and they needed to place a fly curtain to avoid flies from coming in the kitchen when they open the door. During an observation on 6/30/2025 at 12:58 p.m., observed one (1) fly landed on the blender. During an interview on 6/30/2025 at 1:12 p.m. with the DS, the DS stated there were flies flying around the kitchen because it came in when the staff brought the ice and it was important to have a kitchen free from flies to avoid cross-contamination of food. The DS stated flies could bring bacteria to food and residents could get sick of stomach issues as a potential outcome of consuming contaminated food. During a concurrent observation and interview on 7/1/2025 at 10:40 a.m. with the DS in the preparation area, observed one fly flying around the preparation area by the preparation sink. The DS stated they needed to have a fly-free kitchen to prevent cross-contamination. During a review of facility's policies and procedures (P&P) titled, Pest Control, reviewed 1/2025, the P&P indicated, Our facility shall maintain an effective pest control program. (1) This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 6.501.111 Controlling Pests. The premises shall be maintained free of insects, rodents and other pests shall be controlled to eliminate their presence on the premises by: a. Routinely inspecting incoming shipments of food and supplies. b. Routinely inspecting the premises for evidence of pests. c. Using methods, if pests are found, such as trapping devices or other means of pest control specified under SS 7-202.12, 7-206.12, and 7-206.13. d. Eliminating harborage conditions.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · 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 at least 80 square feet (sq. ft. - a unit of measurement) per resident in multiple resident bedrooms for 24 of 24 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the safety and quality of life for the residents. Findings: During a concurrent observation and interview on 6/30/2025 at 9:10 a.m., Resident 50 sleeping in bed, wheelchair at the end of bed with space for movement for staff and residents. Certified Nursing Assistant (CNA) 9 stated Resident 50 goes to dialysis every Tuesday, Thursday, and Saturday and had no concerns with the space in the rooms. During an interview on 6/30/2025 at 10:45 a.m. with Resident 50, Resident 50 stated has no concerns with space in the room. During a concurrent observation and interview on 6/30/2025 at 9:20 a.m., inside room [ROOM NUMBER], three beds in the room and bed B with an oversized bed with ample space for movement of residents. Resident 56 stated he had no issues with the room space. During an observation on 6/30/2025 at 10:15 a.m., inside room [ROOM NUMBER], Resident 42 in the room, sitting up in wheelchair and able to self-propel past bed A and bed B with Resident 20 lying in bed with no concerns identified regarding space in the room. During an interview on 7/2/2025 at 1:14 p.m. with CNA 5, CNA 5 stated was assigned to rooms 20, 22, 5C, and 6A and had provided showers to three residents today. CNA 5 stated she had enough space to provide care, 22B likes to move the table and 6A can move beds and roommates bed able to move, and she puts it back after. During an interview on 7/2/2025 at 1:21 p.m. with CNA 6, CNA 6 stated she was assigned to rooms [ROOM NUMBER]C. CNA 6 stated she had enough room to provide care. CNA 6 stated 26B requires a lift machine and she has enough space to maneuver the machine. During an interview on 7/2/2025 at 1:40 p.m. with Registered Nurse (RN) 1, RN 1 stated she assist with care with CNAs such as pulling a resident up in bed or refusing to shower and talk to the resident and inform that responsibility and getting what they need. RN 1 stated she has enough space to provide care to the residents and has no concerns with the space. During a concurrent interview and record review on 7/3/2025 at 8:56 a.m., reviewed facility's room waiver letter, dated 6/30/2025, the Director of Nursing (DON) stated the room waiver request is for rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, and 27, for a total of 24 rooms. The DON stated the request for a waiver does not meet the required 80 sq. ft. per resident in multiple bedrooms. The DON stated their policy is 80 sq ft for double rooms. During a review of the facility's room waiver letter request, dated 6/30/2025, the letter indicated that the rooms slightly fall short of the minimum square footage requirement, but the needs of the residents are fully accommodated. The residents are able to move about the room freely; bathrooms and closets are easily accessible and all required furniture is provided for each resident. Delivery of care is unimpeded in any way. Furthermore, the residents can be quickly and safely evacuated in the event of emergency. The rooms are in accordance with the special needs of the residents and would not have an adverse effect on the resident's health and safety or impede the ability of any of the residents in the rooms to attain his or her highest practicable wellbeing. The letter indicated the following measurements in square footage for the residents' rooms: - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 223.25 sq. ft., three beds, 19.10 feet by 11.9 feet - room [ROOM NUMBER]: 229.1 sq. ft., three beds, 19.87 feet by 11.54 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.5 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 230.8 sq. ft., three beds, 19.9 feet by 11.6 feet - room [ROOM NUMBER]: 227.3 sq. ft., three beds, 19.6 feet by 11.6 feet - room [ROOM NUMBER]: 233.04 sq. ft., three beds, 19.10 feet by 11.5 feet - room [ROOM NUMBER]: 227.3 sq. ft., three beds, 19.6 feet by 11.6 feet - room [ROOM NUMBER]: 228.8 sq. ft., three beds, 19.9 feet by 11.5 feet - room [ROOM NUMBER]: 227.3 sq. ft., three beds, 19.6 feet by 11.5 feet - room [ROOM NUMBER]: 228.8 sq. ft., three beds, 19.9 feet by 11.5 feet - room [ROOM NUMBER]: 226.53 sq. ft., three beds, 19.6 feet by 11.6 feet During a review of the facility's policy and procedure titled, Bedrooms, last reviewed 1/2025, the P&P indicated that all residents are provided with clean, comfortable, and safe bedrooms that meet federal and state requirements. The P&P indicated that bedrooms accommodate no more than two residents at a time. The P&P indicated bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. The P&P indicated Note: Individual variations on this may be permitted by federal authorities if it is demonstrated that the variation is in accordance with special needs of the resident and will not adversely affect the resident's health and safety.

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the Posted Nursing Staffing information was accurate. This deficient practice had the potential to result in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents. Findings: During a concurrent observation and interview on 6/24/2025 at 7:42 a.m. of the posted nursing staffing information with the Minimum Data Set Coordinator (MDS), the MDS stated the posted nursing staffing information is posted in the front lobby. The MDS stated that the posted nursing staffing information is dated 6/19/2025 and should be dated for 6/24/2025. During a concurrent observation and interview on 6/24/2025 at 1:16 p.m. of the posted nursing staffing information with the Director of Staff Development (DSD), the DSD stated she is the one that is in charge of doing the nursing staffing hours. The DSD reviewed the posted nursing staffing information and stated the nursing staffing information is dated 6/19/2025 it should be dated for today 6/24/2025 with today ' s staffing information. The DSD stated the nursing staffing hours should be posted in the morning within 2 hours of the start of the shift, should be posted prior to 9 a.m. The DSD stated the potential for not having the accurate posted nursing staffing information would be it would be the wrong information for everyone in the facility and the nursing staffing information will not be accurate, and the patient hours will not be accurate. The DSD stated it is also the residents and visitors ' right to know the staffing hours. During a review of the facility ' s Policy and Procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, last revised on 1/2025, the P&P indicated our facility will post on a daily basis for each shift, the nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct-care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location designated by the Administrator.

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop a baseline care plan for one of two sampled residents (Resident 3) within 48 hours of Resident 3's admission. This failure had the potential to cause a delay of care for Resident 3 and negatively Resident 3's well-being. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 11/18/2021 and readmitted Resident on 6/12/2025 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anxiety disorder (feeling of anxiousness that affects daily life), and schizophrenia (a mental illness that is characterized by disturbances in thoughts). During a review of Resident 3's History and Physical (H&P), dated 6/12/2025, the H&P indicated Resident 3 had impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). During an interview on 6/18/2025 at 12:58p.m. with the Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 3's baseline care plan was not completed within 48 hours of admission. LVN 2 stated Resident 3's comprehensive care plan was not updated after readmission as of 6/18/2025. LVN 3 stated the failure had the potential to jeopardize Resident 3's safety and cause a delay of care During a review of the facility-provided policy and procedure (P&P) titled, Care Plans-Baseline, last reviewed on 1/2025, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident

CONCERN (E) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the residents' physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Administer treatments as ordered by the physician for Residents 1 and 2. 2. Follow physician order for Resident 1's blood sugar (BS-body's main source of energy) monitoring. These failures had the potential to delay residents' care and negatively affect their well-being. Findings: 1. a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/26/2021 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/9/2025, the MDS indicated Resident 1 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). During a review of Resident 1's Care Plan (CP) for wound management, initiated on 4/2/2025, the CP interventions indicated to provide wound care treatment as ordered. -5/17/2025: Left anterior medial toe, Normal Saline (NS-saltwater solution used to wound care), pat dry, Betadine (a medication used to prevent infections in open wounds and cuts), cover with dry dressing every day shift for redness on the nail. During a concurrent interview and record review on 6/18/2025 at 2:56 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Treatment Administration Record (TAR), dated 6/2025 was reviewed. The TAR indicated on 6/15/2025 for 7 a.m. administration time, there was no licensed staff initials in the box for Resident 1's treatment orders for Betadine, to demonstrate the treatment was administered. LVN 1 stated there was no documentation on the TAR dated 6/2025 that indicated Resident 1 received the left medial toe Betadine treatment on 6/15/2025. LVN 1 stated this failure had the potential to negatively affect Resident 1's care and potentially cause wound infection or delay of wound healing. During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 1/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame 24. Topical medications used in treatments are recorded on the resident's treatment record (TAR). 1.b. During a review of Resident 1's CP for elevated blood sugar (BS), initiated on 6/4/2025, the CP interventions indicated to monitor blood sugar levels regularly. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order: -6/11/2025: Call provider immediately if resident is hypoglycemic (blood sugar less than 70 milligram (mg-unit of measurement)/deciliter (dL-unit of measurement)). Call provider as soon as possible when: (1) blood glucose (BS-blood sugar) values are regularly 70-100 mg/dl (for possible regimen adjustment); (2) blood glucose values are greater than (>) 250 mg/dL more than once in a 24-hour period; (3) blood glucose values are > 300 mg/dL more than once over two consecutive days; (4) reading is too high for glucometer (a medical device used to measure the amount of sugar in a blood sample. Four times a day for DM every 6 hours. During a concurrent interview and record review on 6/18/2025 at 2:56 p.m. with LVN 1, Resident 1's Medication Administration Record (MAR), dated 6/2025 was reviewed. The MAR indicated Resident 1's BS was as follows: -6/12/2025 at 12 p.m. BS:256 -6/12/2025 at 5 p.m. BS:297 -6/12/2025 at 9 p.m. BS:324 -6/14/2025 at 9 a.m. BS:292 -6/14/2025 at 12 p.m. BS:314 -6/14/2025 at 9 p.m. BS:283 -6/15/2025 at 9 a.m. BS:274 -6/15/2025 at 12 p.m. BS:260 -6/15/2025 at 5 p.m. BS:310 -6/15/2025 at 9 p.m. BS:269 -6/16/2025 at 12 p.m. BS:285 -6/16/2025 at 5 p.m. BS:278 -6/17/2025 at 5 p.m. BS:376 -6/17/2025 at 9 p.m. BS:399 -6/18/2025 at 9 a.m. BS:482 -6/18/2025 at 12 p.m. BS:400 The LVN 1 stated there was no record of MD communication for 6/12/2025, 6/14/2025 to 6/18/2025 to indicate that MD was notified of Resident 1's BS levels. The LVN 1 stated this failure to notify the MD could negatively affect Resident 1's health and potentially cause hospitalization. During an interview on 6/18/2025 at 4:04 p.m. with Registered Nurse (RN) 1, RN 1 stated MD should have been notified of Resident 1's BS levels on 6/12/2025, 6/14/2025-6/18/202. RN stated this failure had the potential for Resident 1 to experience loss of consciousness and brain damage. During a review of the facility-provided policy and procedure (P&P) titled, Diabetes-Clinical Protocol last reviewed on 1/2025, the P&P indicated, The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia. 2. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/9/2022 and readmitted on [DATE] with diagnoses including anxiety disorder (feeling of anxiousness that affects daily life), alcoholic cirrhosis of liver (liver disease caused by alcohol use leading to scarring and potential liver failure), and splenomegaly (enlarged spleen). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognitive functioning. During a review of Resident 2's CP, initiated on 6/11/2025, the CP indicated Resident 2 had left great toe cellulitis (bacterial infection of the skin). During a review of Resident 2's Order Summary Report, the report indicated the following physician's order: -6/12/2025: Mupirocin External Ointment (an antibiotic ointment used to treat bacterial skin infection) 2 percent (%-unit of measurement). Apply to left medial first toe topically every day shift for 21 days. During a concurrent interview and record review on 6/18/2025 at 2:56 p.m. with LVN 1, Resident 2's TAR, dated 6/2025 was reviewed. The TAR indicated on 6/15/2025 for 7 a.m. administration time, there was no licensed staff initial in the box for Resident 's Mupirocin External Ointment, to demonstrate the treatment was administered. LVN 1 stated there was no documentation on the TAR dated 6/2025 that indicated Resident 2 received 's Mupirocin External Ointment on 6/15/2025. LVN 1 stated this failure had the potential to negatively affect Resident 2's care and potentially delay of wound healing and complication of wound infection. During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 1/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame 24. Topical medications used in treatments are recorded on the resident's treatment record (TAR).

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for two of three sampled residents (Resident 2 and Resident 3). On 5/31/2025 at 9 p.m., Resident 2 and Resident 3 had a verbal altercation (an angry argument or disagreement expressed through words) in the smoking patio that led to a physical altercation (a confrontation or fight involving physical contact or force) where Resident 3 grabbed Resident 2 by the neck to choke Resident 2. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 3 while under the care of the facility. Resident 2 stated when Resident 3 grabbed her (Resident 2) neck, Resident 2 ended up landing on the right side of her (Resident 2) body with her (Resident 2) chair on the ground. The incident made Resident 2 feel shocked (emotionally or physically disturbed; upset), scared, and experienced pain on her (Resident 2) right knee with a pain intensity of five out of 10 on the pain scale (a scale used to measure pain, typically from 0 to 10, where 0 represents no pain and 10 represents the worst possible pain). Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility initially admitted Resident 2 on 4/27/2020 and readmitted on [DATE] with diagnoses including osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time) and hypertension (high blood pressure, which is when the force of blood against the artery walls is too high). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/31/2025, the MDS indicated Resident 2 had moderately impaired thought process (when individuals experience noticeable decline in cognitive abilities, such as memory, language, and problem-solving) and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 2's History and Physical Examination, dated 10/29/2024, the History and Physical Examination indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Change in Condition (a noticeable alteration in a resident's health or physical state) Evaluation, dated 5/31/2025, the Change in Condition Evaluation indicated Resident 2 claimed an allegation of abuse. The Change in Condition Evaluation indicated Resident 2 stated Resident 3 caused Resident 2 to fall at the smoking patio. During a review of Resident 2's Post Fall Evaluation, dated 5/31/2025, the Post Fall Evaluation indicated Resident 2 alleged another resident (Resident 3) caused her (Resident 2) to fall at the smoking patio. During a review of Resident 2's Pain Assessment, dated 5/31/2025, the Pain Assessment indicated Resident 2 verbalized complaints of pain with a pain intensity of five out of 10 on the pain scale. The Pain Assessment indicated Resident 2 had mild pain in her right knee. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/5/2025, with diagnoses including encephalopathy (brain is not working right due to some kind of injury or disease) and chronic obstructive pulmonary disease (airflow obstruction, making it difficult to breathe). During a review of Resident 3's History and Physical Examination, dated 5/26/2025, the History and Physical Examination indicated Resident 3 had the capacity to make decisions for ADLs. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had moderately impaired thought processes and required moderate assistance from staff to complete ADLs. The MDS indicated Resident 3 required supervision during sit to lying, chair/bed to chair transfer, toilet transfer, shower transfer, walking 10 feet, and walking 50 feet with two turns. During a review of Resident 3's Change in Condition Evaluation, dated 5/31/2025, the Change in Condition Evaluation indicated Resident 2 stated Resident 3 caused her (Resident 2) to fall at the smoking patio. During a review of Resident 4's admission Record, the admission Record indicated the facility initially admitted Resident 4 on 8/31/2016 and readmitted on [DATE] with a diagnosis of hypertension and chronic obstructive pulmonary disease. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had intact thought process (a person's thinking is logical, sequential, and goal-directed, without excessive or disorganized rambling or shifting between topics) and was able to perform ADLs independently. During a review of Resident 4's History and Physical Examination, dated 10/25/2024, the History and Physical Examination indicated Resident 4 had the capacity to understand and make decisions. During an interview on 6/2/2025 at 3:57 p.m. with Resident 2, Resident 2 stated in the smoking patio Resident 3 sat on a wheelchair across her (Resident 2) table and kept asking Resident 2 for a cigarette. Resident 2 stated she (Resident 2) did not have any cigarettes to give and refused to share her (Resident 2) cigarettes. Resident 2 stated Resident 3 grabbed her (Resident 2) by the neck choking her (Resident 2) while sitting and she (Resident 2) fell on her (Resident 2) right side and ended up breaking her headphones. Resident 2 stated that she was shocked and scared at what happened. Resident 2 stated facility staff was not present during the incident. Resident 2 stated Resident 4 witnessed the incident (Resident 3 grabbing Resident 2's neck). During an interview on 6/2/2025 at 4 p.m. with Resident 4, Resident 4 stated on 5/31/2025 around 8 p.m. to 9 p.m., he (Resident 4) saw Resident 3 called Resident 2 a derogatory term and told Resident 2 to give her (Resident 3) a cigarette. Resident 4 stated he observed Resident 3 got up from her wheelchair, jumped on Resident 2, grabbed Resident 2's neck, and Resident 2 fell. Resident 4 stated he observed Resident 3 left the smoking patio after the incident. Resident 4 further stated after witnessing the incident, he (Resident 4) went to the nurses' station to ask for help, but no staff was found. During an interview on 6/3/2025 at 3:20 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Certified Nursing Assistant (CNA) 4 reported that Resident 2 was on the floor in the smoking patio. LVN 5 stated that he went to the smoking patio right away and assessed Resident 2. LVN 5 stated Resident 2 complained of five out of 10 pain intensity on the pain scale on her right knee. LVN 5 stated Resident 2 mentioned that Resident 3 pushed her to the floor. LVN 5 stated Resident 2 was upset because her headphones broke and wanted them to be replaced. During an interview on 6/3/2025 at 4:10 p.m. with CNA 4, CNA 4 stated she (CNA 4) was in the hallway pushing another resident (name not indicated) in the wheelchair and heard a noise. CNA 4 stated she (CNA 4) saw Resident 3 rushing back into her room by pushing her (Resident 3) wheelchair. CNA 4 stated she (CNA 4) thought something happened and went right away to the smoking patio. CNA 4 stated she (CNA 4) found Resident 2 lying on the floor in the smoking patio. CNA 4 stated she left the smoking patio and reported the incident to LVN 5. During an interview on 6/4/2025 at 2:17 p.m. with the Administrator, the Administrator stated Resident 3 caused physical harm to Resident 2 and was considered as a physical abuse. The Administrator stated if there was a staff present in the smoking patio, the staff could have made a difference to prevent the incident. During an interview on 6/4/2025 at 2:55 p.m. with the Director of Nursing (DON), the DON stated staff should be present for resident safety if there are residents in the smoking patio. During a review of the facility's policy and procedure titled, Abuse Prevention Program, last reviewed on 1/2025, the policy and procedure indicated, Our residents have the right to be free from abuse This includes but is not limited to . verbal, . physical abuse As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including, but not necessarily limited to . other residents

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one out of three sampled residents (Resident 1) by failing to ensure Resident 1's care plan was developed and implemented after the physician gave an order for Resident 1 to self-administer medication. This deficient practice 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: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 11/5/2024 and readmitted on [DATE] with a diagnosis of hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1 had a moderately impaired thought process (difficulty with thinking, learning, and remembering) and required maximal assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's Self-Administration of Medication, dated 5/27/2025, the Self-Administration of Medication indicated Resident 1 was fully capable of storing medications in a secure location, capable of opening/closing medication containers, can accurately tell time to know when medications need to be taken, understands that skipping/choosing not to take a medication dose is a refusal of medication and he/she must notify staff when refusal has occurred. The Self-Administration of Medication indicated Resident 1 was fully capable of administering inhalants or inhalers. During a review of Resident 1's Physician Order, dated 5/27/2025, the Physician Order indicated Resident 1 may self-administer inhalers. During a review of Resident 1's care plans, the care plans did not indicate a care plan for Resident 1's self-administration of medication. During a concurrent interview and record review on 6/2/2025 at 12:19 p.m. with the Director of Nursing (DON), Resident 1's care plans were reviewed and did not indicate a care plan for Resident 1's self-administration of medication. The DON stated care plan must be updated to meet Resident 1's physical and psychological functional needs. During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed 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. During a review of the facility's P&P titled, Self-Administration of Medications, last reviewed 1/2025, the P&P indicated if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.

May 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop and implementa comprehensive, person-centered care plan with measurable objectives and interventions for one of four sampled residents (Resident 2) when the facility did not create and implement a care plan that addressed Resident 2's refusal of indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) care. This deficient practice placed Resident 2 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 4/19/2025 with diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and retention of urine. During a review of Resident 2's History and Physical (H&P), dated 4/20/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired. The MDS indicated Resident 2 was dependent on facility staff on toileting hygiene. The Bladder and Bowel section in the MDS indicated Resident 2 had an indwelling catheter. During a review of Resident 2's Progress Notes, dated 5/15/2025, the Progress Notes indicated Licensed Vocational Nurse (LVN) 5 documented Resident 2 refused the disposable brief change three times. During a concurrent interview and record review on 5/20/2025 at 2:38 p.m. with the MDS Nurse (MDSN), Resident 2's care plans were reviewed and the MDSN stated care plans were designed to guide the facility staff on the care provided for the residents. The MDSN stated Resident 2's Care Plans did not indicate a care plan was created addressing the resident's refusal of urinary catheter care and toileting hygiene care. The MDSN stated without a care plan, Resident 2's needs will not be addressed. During an interview on 5/20/2025 at 3:45 p.m. with the Director of Nursing (DON), the DON stated resident care plans were designed to address the residents' problems. The DON stated care plans should be specific and resident centered. The DON stated a Change of Condition (COC) form would be initiated for a resident that refused care. The DON stated a care plan was not initiated after Resident 2 refused toileting and indwelling catheter care. The DON stated the facility failed to ensure care plans were created to address Resident 2's refusal of care. During a review of the facility's policy and procedure (P&P) titled, Care Plans - Comprehensive, last reviewed on 1/2025, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The P&P indicated each resident's comprehensive care plan is designed to incorporate identified problem areas .incorporate risk factors associated with identified problems . The P&P indicated assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, last reviewed on 1/2025, the P&P indicated the nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there has been . f. refusal of treatment or medications (two or more consecutive times).

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) with indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to: 1. Ensure Resident 2's indwelling urinary catheter had an order. 2. Ensure Resident 2 was monitored for the presence of urinary tract infection (UTI- an infection in the bladder/urinary tract). 3. Ensure licensed nurses provided and documented Resident 2's urinary catheter care. These deficient practices had the potential to cause Resident 2 urinary catheter-associated complications including UTI, discomfort, and pain. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 4/19/2025 with diagnoses including epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]), Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and retention of urine. During a review of Resident 2's History and Physical (H&P), dated 4/20/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated Resident 2's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired. The MDS indicated Resident 2 was dependent on facility staff on toileting hygiene. The Bladder and Bowel section indicated Resident 2 had an indwelling catheter. During a review of Resident 2's Care Plan on urinary catheter, initiated on 5/10/2025, the Care Plan indicated the resident had a Foley (a brand name of an indwelling urinary device) catheter related to urinary retention. The Care Plan interventions indicated urinary catheter care every shift, provide good perineal care during episodes of bowel elimination, and observe urine for signs and symptoms of infection such as foul odor, abnormal urine color, and presence of blood. The interventionsindicated to notify the Attending Physician (MD) promptly. During a review of Resident 2's Care Plan on infection, initiated on 5/12/2025, the Care Plan indicated the resident was at risk for infection related to contributing factors and diagnoses of history of UTI and use of indwelling catheter for urinary elimination. The Care Plan interventions indicated to evaluate for urinary complaint, to evaluate urine characteristics, manage indwelling catheters to minimize risk of infection, and to monitor for signs and symptoms of infection. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2 on 5/20/2025 at 10:24 a.m., Resident 2's Physician Orders, dated 5/20/2025, were reviewed and LVN 2 stated Resident 2 had no urinary catheter order when the resident was readmitted from General Acute Care Hospital (GACH) 1 on 5/14/2025. LVN 2 stated a physician's order for urinary catheter and urinary catheter care and monitoring was required to reflect in Resident 2's Treatment Administration Record (TAR). Resident 2's TAR, dated 5/1/2025 to 5/31/2025, was reviewed and LVN 2 stated Resident 2's TARindicated there was no urinary catheter care and monitoring provided for Resident 2. Resident 2's Care Plan for Foley catheter related to urinary retention, initiated 5/10/2025, was reviewed and LVN 2 stated Resident 2's care plan interventions were not followed. LVN 2 stated Resident 2 had the potential to develop UTI. During an interview on 5/20/2025 at 3:45 p.m. with the Director of Nursing (DON), the DON stated Resident 2 was readmitted from GACH 1 with an indwelling urinary catheter. The DON stated Resident 2's urinary catheter, catheter care, and monitoring were not documented in the resident's medical records. The DON stated the facility failed to ensure residents with indwelling urinary catheter were assessed and monitored. The DON stated the facility failed to document the assessments and monitoring done for Resident 2. The DON stated Resident 2 had the potential to develop UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed on 1/2025, the P&P indicated the purpose .to prevent catheter-associated urinary tract infections. The P&P indicated to observe the resident for complications associated with urinary catheters . b. check the urine for unusual appearance, c. notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed . e. observe for other signs and symptoms of urinary tract infection or urinary retention. During a review of the facility's P&P titled, Charting and Documentation, last reviewed on 1/2025, the P&Pindicated documentation of procedures and treatments shall include care-specific details and shall include . the date and time the procedure or treatment was provided, the assessment and any unusual findings obtained during the procedure or treatment, and how the resident tolerated the procedure or treatment.

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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Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's oxygen tubing was dated when it was changed. 2. Ensure Resident 1's oxygen tubing was kept inside an oxygen supplies bag when not in use. 3. Ensure Resident 1's oxygen tubing was not touching unclean surfaces. These deficient practices had the potential for Resident 1 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/5/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), systemic lupus erythematosus (a disease where the immune system of the body mistakenly attacks healthy tissues and organs, leading to inflammation and damage), and type two diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During a review of Resident 1's Physician Order, dated 4/30/2025, the Physician Order indicated oxygen at two liters per minute (unit of measurement) every shift. During a review of Resident 1's Physician Order, dated 5/4/2025, the Physician Order indicated oxygen tubing and humidifier change one time a day every Sunday. During a concurrent observation and interview on 5/21/2025 at 9:16 a.m. with the Quality Assurance Nurse (QAN) inside Resident 1's room, Resident 1's nasal cannula (also known as oxygen cannula, a medical device that delivers supplemental oxygen through the nose) tubing touched the floor while connected to the resident and oxygen concentrator (a medical device that gives a person extra oxygen). The QAN stated Resident 1's nasal cannula did not have a date when it was last changed. Resident 1's other oxygen mask and tubing was on top of an overbed table. The QAN stated Resident 1's oxygen equipment should be dated and stored in a dated plastic bag when not in use. The QAN stated the oxygen nasal cannula tubing and mask should not touch the floor or any unclean surfaces. The QAN stated Resident 1 had the potential to acquire infections from unclean and contaminated oxygen equipment such as the nasal cannulas. During an interview on 5/21/2025 at 9:35 a.m. with the Director of Nursing (DON), the DON stated oxygen cannulas, oxygen masks, and oxygen supply bags should be changed every seven days. The DON stated Resident 1's oxygen supplies should be dated to indicate when the supplies were last changed. The DON stated Resident 1's oxygen cannulas should be inside the dated oxygen supply bag when not in use. The DON stated Resident 1's undated oxygen supplies that were touching unclean surfaces had the potential to cause Resident 1's respiratory infection. The DON stated the facility failed to ensure Resident 1's oxygen supplies were dated and did not touch unclean surfaces. During a review of the facility's policy and procedure (P&P) titled Departmental (Respiratory Therapy) Prevention of Infection, last reviewed on 1/2025, the P&Pindicated the purpose was to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The Infection Control Considerations Related to Oxygen Administration section indicated . 7. Change the oxygen cannula and tubing every seven days or as needed, 8. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. The P&P indicated to store the circuit in a plastic bag, marked with date and resident's name.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 1's cephalexin oral tablet (a medication, taken by mouth, used to treat bacterial infections) 500 milligrams (mg - unit of measurement) was administered at the scheduled time on multiple dates. This deficient practice placed Resident 1 at risk for untreated infections and had the potential for the development of multidrug-resistant organisms (MDRO - bacteria that becomes resistant to multiple types of antibiotics [a medication that inhibit the growth of bacteria], making them harder to treat). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/5/2024 with diagnoses including chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), systemic lupus erythematosus (a disease where the immune system of the body mistakenly attacks healthy tissues and organs, leading to inflammation and damage), and type two diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/9/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During a review of Resident 1's Progress Notes, dated 5/3/2025, the Progress Notes indicated Resident 1 returned from the General Acute Care Hospital (GACH) 1 with a diagnosis of bladder infection. During a review of Resident 1's Physician Orders, dated 5/5/2025, the Physician Orders indicated to discontinue Macrobid oral capsule (a medication, taken by mouth, used to treat bacterial infections) 100 mg two times a day for bladder infection. During a review of Resident 1's Physician Orders, dated 5/5/2025, the Physician Orders indicated cephalexin oral tablet 500 mg four times a day for seven days for bladder infection. During a concurrent interview and record review on 5/20/2025 at 2:38 p.m. with the MDS Nurse (MDSN), Resident 1's Medication Administration History, dated 5/5/2025 to 5/11/2025, was reviewed and the Medication Administration History indicated Resident 1 was scheduled to receive cephalexin 500 mg at 9 a.m., 12 p.m., 5 p.m., and 9 p.m. every day. The MDSN stated Resident 1's cephalexin 500 mg may be given one hour before or one hour after the medication's scheduled administration time. The Medication Administration History indicated Resident 1 received the scheduled cephalexin 500 mg late on the following dates and times: a. On 5/5/2025 at 2 p.m., one hour after the allowed administration time. b. On 5/5/2025 at 6:47 p.m., 47 minutes after the allowed administration time. c. On 5/7/2025 at 6:55 p.m., 55 minutes after the allowed administration time. d. On 5/8/2025 at 1:43 p.m., 43 minutes after the allowed administration time. e. On 5/8/2025, Resident 1's scheduled medication at 5 p.m. and 9 p.m. were both administered at 11:37 p.m. f. On 5/9/2025 at 2:21 p.m., one hour and 21 minutes after the allowed administration time. g. On 5/9/2025 at 7:33 p.m., one hour and 33 minutes after the allowed administration time. The next dose was administered at 8:08 p.m., 35 minutes after the last dose was administered. h. On 5/10/2025 at 1:38 p.m., 38 minutes after the allowed administration time. The MDSN stated late administration of Resident 1's medication had the potential for the bacteria to become resistant to the medication and lead to ineffective treatment of Resident 1's infection. During an interview on 5/20/2025 at 3:45 p.m. with the Director of Nursing (DON), the DON stated medications should be administered within the allowed administration time, which was one hour before or one hour after the scheduled administration time. The DON stated Resident 1's cephalexin was not administered on time on multiple dates and times. The DON stated Resident 1's medication not administered on time had the potential to be ineffective in treating the resident's infection. The DON stated the facility failed to ensure Resident 1's medication was administered on time as ordered by the physician. During an interview on 5/20/2025 at 4:15 p.m. with the facility's Pharmacist (Pharm) 1, Pharm 1 stated a medication such as cephalexin 500 mg administered with a short interval between the doses or two doses administered at the same time, had the potential to cause a resident abdominal pain and diarrhea. During a review of the current facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 1/2025, the P&P 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 Medications must be administered within one hour of their prescribed time If a drug (medication) is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record (MAR) space provided for that drug and dose.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report within two hours an incident of an alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for two of three sampled residents (Resident 1 and 2). The abuse incident happened on 5/1/2025 at 7:30 p.m. and was reported to the State Survey Agency on 5/2/2025. This deficient practice had the potential to result in unidentified abuse in the facility and placed Resident 1 and Resident 2 at risk of further abuse. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/23/2024 with the following diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (feeling of anxiousness that affects daily life), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 3/26/2025, the MDS indicated the resident had impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). During an interview on 5/16/2025 at 9:40a.m. with Resident 1, Resident 1 stated Resident 2 approached her (unable to provide date of the incident) in the smoking patio (designated outdoor smoking area) and stated Resident 1's dress was open in the back. Resident 1 stated Resident 2 hit Resident 1's arm. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with the following diagnoses including depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thoughts), anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had intact cognitive functioning. MDS indicated Resident 2 required moderate assistance to wheel self at least 50 feet (ft, unit of distance measurement). During a review of Resident 2's Care Plan (CP), initiated on 5/2/2025, the CP indicated Resident 2 claimed she was hit in the face by another resident. The CP also indicated Resident 2 was at risk for emotional distress. During an interview on 5/16/2025 at 9:27a.m. with Resident 2, Resident 2 stated she approached Resident 1 in the smoking patio to tell her that her dress was open when Resident 1 hit her face. Resident 2 stated Resident 1 tried to throw a slipper at her when AA 1 caught the slipper and helped her back inside the facility. Resident 2 stated on 5/2/2025, she informed the Administrator Resident 1 hit her in the smoking patio. During an interview on 5/16/2025 a.m. with Activities Aide (AA) 1, AA 1 stated on 5/1/2025 at approximately 7:30 p.m., he heard Resident 1 and Resident 2 screaming at each other in the smoking patio. AA 1 stated Residents' speech was unintelligible. AA 1 stated Resident 2 approached Resident 1 near the entrance of the smoking patio and attempted to put her arm around Resident 1's shoulder, while Resident 1. AA 1 stated he approached Residents (Resident 1 and Resident 2) and moved Resident 2 away from Resident 1 before Resident 2 could touch Resident 1. AA 1 stated he stopped Resident 1 from throwing her slipper at Resident 2. AA 1 stated he assisted Resident 2 inside the facility and left her in her wheelchair near the nursing station. AA 1 stated he did report the incident to the facility staff. During an interview on 5/16/2025 at 2:30 p.m. with the Administrator, the Administrator stated on 5/2/2025, at approximately 9:30 a.m., Resident 2 approached the Administrator and reported that on 5/1/2025 Resident 1 swung her arm at Resident 2. The Administrator stated he was not notified of the incident by the facility staff. The Administrator stated AA 1 should have reported the incident to the Administrator or supervisor. The Administrator stated the failure to report the incident had the potential to cause psychological and physical distress for Residents 1 and 2 and place Residents (Resident 1 and Resident 2) at risk of abuse. The Administrator stated he reported the abuse allegation to the State Survey Agency on 5/2/2025 approximately an hour after Resident 2 reported the incident to him (Administrator). During a review of the facility's policy and procedure (P&P) titled, Reporting Abuse to Facility Management, last reviewed on 1/2025, the P&P indicated, It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse .To help with recognition of incidents of abuse, the following definitions of abuse are provided: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability . 4. Employees, facility consultants and /or Attending Physicians must immediately report any suspected abuse or incident of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse supervisor on duty.

May 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for one of three sampled residents (Resident 1) to address Resident 1's: 1. Use of Clozapine (a medication primarily indicated for the treatment of schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions]). 2. The use of Ativan (a medication used to treat anxiety [a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome]). 3. Change of condition (COC- when there is a sudden change in a resident's condition) when on 4/30/2025 Resident 1 exhibited increased agitation (a condition in which a person is unable to relax and be still), restlessness manifested by striking out staff and making multiple attempts to get out of bed. These deficient practices had the potential to negatively affect the delivery of care and services, delayed interventions, and inappropriate psychotropic (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings or behavior) medication management. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 4/29/2025 with diagnoses that included schizophrenia, mood affective disorder (a mental health condition characterized by persistent and intense changes in mood, energy levels, and behavior), and epilepsy (a brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical discharge in the brain that can cause temporary changes in brain function, behavior, and body movements]). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/1/2025, the MDS indicated Resident 1 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 1 needed partial or moderate assistance from staff with oral hygiene and toileting hygiene and substantial or maximal assistance from staff with shower or bathing, and dressing. During a review of Resident 1's Physician's Order, dated 4/29/2025, the Physician's Order indicated Clozapine oral tablet 100 milligrams (mg- a unit of measurement), give 250 mg by mouth at bedtime for mood disorder manifested by rapid mood cycling as evidenced by (AEB) sudden shifts in mood from pleasant to extreme anger AEB yelling or screaming. During a review of Resident 1's Physician's Order, dated 4/30/2025, the Physician's Order indicated Ativan oral tablet one (1) mg, give one tablet by mouth every eight (8) hours as needed for anxiety, restlessness and agitation for 14 days manifested by striking out staff and getting out of bed multiple times. During a review of Resident 1's COC Evaluation Form, dated 4/30/2025, timed at 8:41 a.m., the COC indicated that on 4/30/2025 at 7:00 a.m. Resident 1 was observed with increased agitation and restlessness manifested by striking out staff and trying to get out of bed multiple times without assistance. The COC indicated that Resident 1's physician was notified at 8:42 a.m. and received a new order for Ativan one mg by mouth every eight hours as needed. During an interview on 5/7/2025 at 2:42 p.m., with the Director of Nursing (DON), the DON stated medication changes or changes in condition require a comprehensive care plan. The care plan should include measurable objectives and address the resident's level of functioning. The DON stated that Resident 1 had a COC on 4/30/2025 due to increased agitation, including pacing in the hallways, for which Ativan was ordered. The DON confirmed that there were no care plans developed addressing Resident 1's behavioral changes, the use of Ativan and the use of Clozapine. The DON stated that a care plan should have been developed following the COC on 4/30/2025. The DON stated the care plan should have been person-centered, addressing the manifestations of Resident 1's behavior and outlining appropriate monitoring. The DON further stated separate care plans should have been created for the use of Ativan and Clozapine. The DON stated that the absence of care plans creates a risk that staff may miss necessary interventions, making it difficult to address Resident 1's needs. During a review of the facility's Policy and Procedure (P&P) titled, Care Plan-Comprehensive, last reviewed on 1/2025, the P&P indicated an individualized comprehensive care plan that includes measurable objective and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.

CONCERN (D) 📢 Someone Reported This

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

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

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 medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when: 1. The facility failed to accurately document Resident 1 ' s monitoring for mood disorder on the medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). 2. The facility failed to accurately document Resident 1 ' s side effect of the inability to sit still for clozapine (a medication used to treat severely ill patients with schizophrenia [a mental illness that is characterized by disturbances in thought]). These deficient practices resulted in inaccurate documentation of Resident 1 ' s records. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/29/2025 with diagnoses that included schizophrenia, epilepsy (a brain disorder characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), essential (primary) hypertension (HTN - high blood pressure). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 5/1/2025, the MDS indicated Resident 1 had the ability to usually be understood and had the ability to understand. The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) with showering, upper body dressing, lower body dressing and putting on and taking off footwear. During a review of Resident 1 ' s Physician ' s Order, dated 4/29/2025, the Physician ' s Order indicated: - Clozapine oral tablet 100 milligram (mg - a unit of measurement) give 250 mg by mouth at bedtime for mood disorder manifested by (m/b) rapid mood cycling as evidence by (AEB) sudden shifts in mood from pleasant to extreme anger AEB yelling and screaming. - Monitor for mood disorder m/b rapid mood cycling AEB sudden shifts in mood from pleasant to extreme anger AEB yelling and screaming and tally up hashmark every shift for clozapine. - Inability to sit still (clozapine) every shift document if monitored, document - NO in the absence of side effects + YES in the presence of side effects, if present notify the doctor (MD) and document in progress notes. During a review of Resident 1 ' s Change in Condition (COC) Evaluation, dated 4/30/2025,at 8:41 a.m., the COC indicated Resident 1 had increased agitation and restlessness mood behavior striking out at staff and trying to get out of bed multiple times. During a review of Resident 1 ' s MAR, dated April 2025, the MAR for monitoring mood disorder m/b rapid mood cycling AEB sudden shifts in mood from pleasant to extreme anger AEB yelling and screaming and tally up hashmark every shift for clozapine indicated: - 4/30/2025 evening shift, tally III, indicated NO, behaviors - 4/30/2025 night shift, tally III, indicated NO, behaviors. During a review of Resident 1 ' s MAR, dated April 2025, the MAR for inability to sit still (clozapine) every shift document if monitored, document - NO in the absence of side effects + YES in the presence of side effects, if present notify the MD and document in progress notes indicated: - 4/30/2025 day shift, + - 4/30/2025 evening shift, + - 4/30/2025 night shift, + During a review of Resident 1 ' s MAR, dated May 2025, the MAR for monitoring for mood disorder m/b rapid mood cycling AEB sudden shifts in mood from pleasant to extreme anger AEB yelling and screaming and tally up hashmark every shift for clozapine indicated on 5/1/2025 the evening shift, tally I, indicated NO, behavior. During a review of Resident 1 ' s MAR, dated May 2025, the MAR for inability to sit still (clozapine) every shift document if monitored, document - NO in the absence of side effects + YES in the presence of side effects, if present notify the MD and document in progress notes indicated: - 5/1/2025 day shift, + - 5/1/2025 evening shift, + During a concurrent interview and record review, on 5/7/2025, at 11:03 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 1 ' s MAR, dated April 2025 and May 2025, was reviewed and LVN 3 stated he documented + on 4/30/2025 and 5/1/2025 on the inability to sit still MAR because Resident 1 was not sitting still. LVN 3 stated he did not notify the MD of this side effect. LVN 3 statedbased on the inability to sit still MAR, the MD must be notified when documenting + because it indicates that the resident is having a side effect to the medication. LVN 3 stated Resident 1 was not showing signs of side effects to the medication and LVN 3 documented inaccurately, therefore there was no need to contact the MD. LVN 3 stated he should have documented - on the MAR. LVN 3 stated if facility staff are documenting improperly, it may appear that the resident is having these side effects, and the MD is not being notified. During a concurrent interview and record review, on 5/7/2025, at 2:42 p.m., with the Director of Nursing (DON), Resident 1 ' s MARs, dated April 2025 and May 2025, were reviewed and the DON stated the staff tally the number of indicated behaviors per shift on the MAR for monitoring mood disorder. The DON stated the MAR for 4/1/2025 evening and night shift both have three tallies of behaviors but indicate there was no behavior. The DON stated the MAR for 5/1/2025 indicated there is one tally, and it indicated no behavior. The DON stated this is inaccurate documentation andshould indicate yes because the resident was having the behavior. The DON stated the MAR for the inability to sit still means the resident is showing side effects of restlessness from clozapine. The DON reviewed the MAR for 4/30/2025 and 5/1/2025 and stated the MAR indicated Resident 1 was having side effects to the medication and the MD should have been contacted. The DON stated if the MD is not being notified of the side effects of the medication, the resident can be in danger and the side effects should be addressed right away becausethe resident is having a reaction to the medication and the MD needs to be made aware to provide orders. The DON stated if LVN 3 is inaccurately documenting there is potential for the documentation to appear that the resident is having side effects, and no interventions are being done. During a review of the facility ' s Policy and Procedure (P&P) titled, Charting and Documentation, last reviewed on 1/2025, the P&P indicated the documentation in the medical record will be objective, complete and accurate.

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure vital signs (measurements that indicate the status of a person's body's vital functions and are used to assess overall health) were taken prior to discharging Resident 1 home on 4/18/2025, as indicated in the facility's policy. This deficient practice had the potential for delay in Resident 1's care and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 2/3/2025, with diagnoses that included other idiopathic peripheral autonomic neuropathy (nerve damage in the autonomic nervous system (network of nerves) where the cause is unknown, that can affect functions like pulse rate [number of times your heart beats in one minute] and blood pressure [the force of your blood pushing against the walls of your arteries as your heart pumps blood throughout your body]), unspecified (unconfirmed) epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). The admission Record indicated the facility discharged Resident 1 home on 4/18/2025, at 1 p.m. During a review of Resident 1'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 3/3/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS – a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required moderate assistance from staff for oral hygiene, toileting and personal hygiene. During a review of Resident 1's Progress Notes, dated 4/17/2025, timed at 3 p.m. the Progress Notes indicated Resident 1 requested to be discharge home in the morning (4/18/2025) with Family Member 1 (FM 1). During a review of Resident 1's Physician Order, dated 4/17/2025, timed at 3:21 p.m., the Physician order indicated to discharge Resident 1 home in the morning (4/18/2025) per Resident 1's request. During a review of Resident 1's Progress Notes, dated 4/18/2025 timed at 12:51 p.m. the Progress Notes indicated Resident 1 was discharge home and left the facility at 12:15 p.m., with FM 1. During a review of Resident 1's Transfer/Discharge Report, dated 4/18/2025, the Transfer/Discharge Report indicated latest vital signs (basic measurements of how your body is functioning) as follows: 1. Blood pressure - 131/79 millimeters of mercury (mmHg-unit of pressure) on 4/18/2025. 2. Pulse rate – 78 beats per minute (bpm) on 4/17/2025. 3. Temperature -98.2 degrees Fahrenheit on 4/17/2025. 4. Respirations (the number of breaths a person takes in one minute) 18 breathes per minute (bpm) on 4/17/2025. During a concurrent interview and record review on 4/23/2024, at 10:25 a.m., with the Director of Nursing (DON), Resident 1's Transfer/Discharge Report, dated 4/18/2025 and Weights and Vital Summary, dated 4/17/2025, to 4/18/2025, was reviewed. The Weights and Vitals Summary indicated latest vital signs as follows: 1. Blood pressure 131/79 mmHg on 4/18/2025 at 8:39 a.m. 2. Pulse rate -78 bpm on 4/17/2025 at 7:17 p.m. 3. Temperature-98.2 F on 4/17/2025 at 7:17 p.m. 4. Respirations-18 bpm on 4/17/2025 at 7:17 p.m. 5. Saturations 98 percent (%-by a hundred) on 4/17/2025 at 7:17 p.m. The DON stated complete set of vital signs should be taken before discharging Resident 1 home. The DON stated the nurse should have rechecked vital signs of Resident 1 before sending Resident 1 home. The DON stated the importance of checking vital signs before discharge was to know the current status of Resident 1. During a concurrent interview and record review on 4/23/2025, at 12:03 p.m., with the DON, facility's policy and procedure (P&P), titled, Discharging the Resident, dated 12/2016 and last reviewed on 1/2025, the P&P indicated, Assess and document resident's condition at discharge, including skin assessment, if medical condition allows. Documentation The following information should be record in the resident's medical record: .3. All assessment data obtained during the procedure, if applicable.

Apr 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

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 sanitary, orderly, and homelike environment for one of three sample residents (Resident 1) by failing to maintain cleanliness of Resident 1's floor. This failure had the potential to spread infection and negatively impact Resident 1's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose). Cross Reference F880 Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), systemic lupus erythematosus (a condition that can affect various parts of the body including the skin, joints, kidneys, and other organs, causing pain and inflammation), legal blindness (severe visual impairment), schizophrenia (a mental illness that is characterized by disturbances in thoughts), epilepsy (a neurological condition characterized by recurrent, sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), and contracture of the left hand (a stiffening/shortening at any joint, that reduces the joint's range of motion( full movement potential of a joint)). During a review of Resident 1's History and Physical (H&P), dated 11/5/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Care Plan (CP), dated 11/7/2024, the CP indicated Resident 1 was blind and was dependent on staff. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 required moderate assistance with toilet transfers, toilet hygiene, and maximal assistance with lower body dressing. The MDS indicated Resident 1 was always incontinent (having no or insufficient voluntary control) of urine and bowel movements. During a concurrent observation and interview on 4/2/2025 at 11:05 a.m. with Certified Nurse Assistant (CNA) 1 in Resident 1's room, food remains and utensils were observed on the floor next to the right side of Resident 1's bed. CNA 1 stated a plastic spoon with brown residue, a glass jar with brown residue, an upside-down brown plate, orange peels, and cut orange was observed on the floor next to the right side of Resident 1's bed. CNA 1 stated there were ants inside the glass jar and on the floor next to the right side of Resident 1's bed. CNA 1 stated it is important to keep Resident 1's room clean and prevent infection. During a concurrent observation and interview on 4/2/2025 at 11:25 a.m with CNA 1 in Resident 1's room, brown residue was observed on Resident 1's bedside commode. CNA 1 stated there was a dried fecal residue on the bedside commode. CNA 1 stated the bedside commode should have been cleaned to prevent spread of infection. During an interview on 4/3/2025 at 4:02 p.m. with the Director of Nursing (DON), the DON stated resident rooms should be kept clean and sanitary. The DON stated the facility failed to keep Resident 1's room clean, provide homelike environment, and maintain infection control measures which could potentially become a hazard to Resident 1's health. During a review of the facility-provided policy and procedure (P&P) titled, Quality of Life-Homelike Environment, last reviewed on 1/2025, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. Clean, sanitary and orderly environment

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement resident-centered care plan for one of three sampled residents (Resident 1). This deficient practice could have delayed in providing Resident 1's care needs. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), systemic lupus erythematosus (a condition that can affect various parts of the body including the skin, joints, kidneys, and other organs, causing pain and inflammation), legal blindness (severe visual impairment), schizophrenia (a mental illness that is characterized by disturbances in thoughts), epilepsy (a neurological condition characterized by recurrent, sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), and contracture of the left hand (a stiffening/shortening at any joint, that reduces the joint's range of motion( full movement potential of a joint)). During a review of Resident 1's History and Physical (H&P), dated 11/5/2024, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Care Plan (CP), dated 12/5/2024, the CP indicated Resident 1 was non-compliant with weight management. The CP indicated Resident 1 would not suffer any consequences related to Resident 1's choices. The CP interventions included notifying physician of Resident 1's non-compliance with weight management. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 was independent with eating and required supervision for oral hygiene. During an interview with Resident 1 on 4/2/2025 at 10:48 a.m., Resident 1 stated she had lost more than 50 pounds (lb-unit of measurement) since admission to the facility. Resident 1 stated her weight was measured upon admission. Resident 1 stated she refused monthly weight measurements. During a concurrent interview and record review on 4/3/25 at 9:21 a.m. with the Dietary Supervisor (DS), Resident 1' Monthly Weights Measurement Record was reviewed. The Monthly Weights Measurement Record indicated Resident 1's admitting weight on 11/5/2024 was 212 pounds (lb-unit of measurement), and in 4/2024 Resident 1's weight was 211 lbs. No weight measurements were recorded on 12/2024 to 3/2025. The DS stated Resident 1 refused to have her weights measured between 12/2024 to 3/2025 which were indicated on the Monthly Weights Measurement Record by an asterisk (*) marked for 12/2024 to 3/2025. During an interview on 4/3/2025 at 4:02 p.m. with the Director of Nursing (DON), the DON stated licensed staff were responsible for communicating Resident 1's noncompliance with weight measurement to the physician. The DON stated facility could not provide documented evidence of physician communication regarding Resident 1's weight measurement refusal. The DON stated the facility failed to implement Resident 1's care plan. The DON stated Resident 1 could have potentially experienced a change in her condition and weight loss that was not identified. The DON stated facility did not have a policy addressing resident's care plan implementation.

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 residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to teh interrelation of social factors and indivudial thoughts and behavior) needs for one of three sampled residents (Resident 1) by failing to: 1. Administer medications and treatments as ordered by the physician. 2. Provide Resident 1 with enough Oxygen supply to last during clinic appointments. These deficient practices had the potential to place Resident 1 at risk for unrelieved shortness of breath, respiratory complications, and negatively affect Resident 1's life. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), systemic lupus erythematosus (a condition that can affect various parts of the body including the skin, joints, kidneys, and other organs, causing pain and inflammation), legal blindness (severe visual impairment), schizophrenia (a mental illness that is characterized by disturbances in thoughts), epilepsy (a neurological condition characterized by recurrent, sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), and contracture of the left hand (a stiffening/shortening at any joint, that reduces the joint's range of motion( full movement potential of a joint)). During a review of Resident 1's History and Physical (H&P), dated 11/5/2024, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Care Plan (CP), initiated on 11/5/2024, the CP indicated Resident 1 had the potential for episodes of shortness of breath and required use of oxygen. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 required moderate assistance with toilet transfers, toilet hygiene, and maximal assistance with lower body dressing. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order: -1/20/2025: Aquaphor External Ointment (medication used to create a barrier on the skin, help to heal and protect dry, cracked or irritated skin) Apply to nostril (nose) area topically every day shift for skin maintenance of dry skin apply to each nostril area. -3/2/2025: Albuterol Sulfate (medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases) Inhalation Nebulization (the process of converting liquid mediation into a fine mist or aerosol, allowing it to be inhaled directly into the lungs for treatment of respiratory conditions) Solution 5 milligram/milliliter (mg/ml-a unit of measurement) 0.5 percent (% - per hundred) 1 unit inhale orally via nebulizer (medical device that converts liquid medication into a fine mist, which is then inhaled into the lungs) four times a day for COPD. -3/2/2025: Symbicort Inhalation (medication used to reduce inflammation and open the airways to help improve breathing and prevent symptoms such as shortens of breath) Aerosol (a suspension of tiny solid or liquid particles in a gas, typically air 160-4.5 microgram/ACT (mcg/ACT-a unit of measurement) 2 puffs inhale orally two times a day for COPD and rinse mouth after use. During an interview on 4/2/2015 at 10:48 a.m. with Resident 1, Resident 1 stated feeling frustrated because she was not receiving timely breathing treatments and skin treatment as ordered by the physician. During a concurrent interview and record review on 4/2/2025 at 10:04 a.m. with LVN 1, Resident 1's Treatment Administration Record (TAR), dated 3/025 was reviewed. The TAR indicated on 3/9/2025, 3/16/2025, 3/23/2025, 3/30/3035, there were no licensed staff initials in the box for Resident 1's Administer Aquaphor External Ointment, to demonstrate the treatments were administered. LVN 1 stated there was no documentation on the TAR dated 3/2025 that indicated Resident 1 received the Administer Aquaphor External Ointment on 3/9/2025, 3/16/2025, 3/23/2025, and 3/30/3035. During a concurrent interview and record review on 4/3/1015 at 3:36 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication Administration Record (MAR), dated 3/2025 was reviewed. The MAR indicated, on 3/28/2025 for the 9 p.m. administration time, there was no licensed staff initials in the box for Resident 1's Symbicort Inhalation Aerosol 160-4.5mcg/act, to demonstrate the medication was administered. The MAR also indicated, on 3/28/2025 for the 5 p.m. and 10 p.m. administration times, there were no licensed staff initials in the box for Resident 1's Albuterol Sulfate Inhalation Nebulization Solution 5mg/ml), to demonstrate the medication was administered. LVN 1 stated there was no documentation on the MAR dated 3/2025 that indicated Resident 1 received the Sympicort Inhalation Aerosol 160-4.5mcg/act on 3/28/2025 at 9 p.m. LVN 1 also stated there was no documentation on the MAR dated 3/2025 that indicated Resident 1 received the Albuterol Sulfate Inhalation Nebulization Solution 5mg/ml 1 unit on 3/28/2025 at 5 p.m. and 10 p.m. LVN 1 stated the failure to administer medications could have potentially caused Resident 1 to experience shortness of breath. During an interview on 4/3/2024 at 4:02 p.m. with the Director of Nursing (DON), the DON stated the facility failed to administer Resident 1's medications and treatments as ordered by the physician. The DON stated failure to follow physicians' medication and treatment orders had the potential to jeopardize Resident 1's safety potentially causing respiratory complications and desaturation (a decrease in the oxygen saturation of the blood). During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 1/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame 23. As required or indicated for the medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered . g. the signature and title of the person administering the drug . 24. Topical medications used in treatments are recorded on the resident's treatment record (TAR). b. During a review of Resident 1's Order Summary Report, the report indicated the following physician's orders: -12/10/2024: Oxygen at 4 to 5 Liters (L-unit of measurement) per minute via nasal cannula (a device that gives additional oxygen through the nose) continuously to keep Oxygen saturation (O2 sat-measurement of how much oxygen blood is carrying as a percentage of the maximum it could carry) > (symbol for greater than) 90% every shift for COPD. - 3/20/2025: Patient to be at cardiology (the medical specialty focused on the diagnoses, treatment, and prevention of diseases and disorders of the heart and blood vessels) office on 4/3/2025 at 2:00 p.m. to remove a heart monitor and needs transportation to be arranged. During a concurrent observation and interview on 4/2/2025 at 10:48 a.m. with Resident 1 in Resident 1's room, Resident 1was observed receiving oxygen via nasal cannula at 4 L per min. Resident 1 stated during several clinic appointments, the facility provided Resident 1 with one oxygen tank which did not contain enough oxygen to last until Resident 1 returned to the facility causing shortness of breath. During an interview on 4/3/2025 at 11:35 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated she worked as a Social Services Assistant until 4/2025. CNA 2 stated the Social Worker (SW) arranged transportation for Resident 1's clinic appointments. CNA 2 stated the licensed nurse would provide Resident 1 with one oxygen tank for Resident 1's clinic appointments. During a concurrent observation and interview on 4/3/2025 at 10:04 a.m. with Licensed Vocational Nurse (LVN) 1 in the Oxygen Storage Room, one oxygen tank was observed to contain 2,000 pounds per square inch (psi-unit of pressure used to measure the amount of oxygen compressed and stored within the tank, indicating how much oxygen remains) of oxygen. LVN1 stated Resident the type of the oxygen tank observed was provided to Resident 1 during clinic appointments. LVN 1 stated the oxygen tank observed contained 2000 psi of oxygen. LVN 1 stated Resident 1 received oxygen via nasal cannula at 4 to 5L per min. During an interview on 4/3/2025 at 12:25 p.m with LVN 1, LVN 1 stated Resident 1 was scheduled for a clinic appointment on 4/3/2025 at 1 p.m. LVN 1 stated Resident 1 would be provided with one oxygen tank. During a concurrent observation and interview on 4/3/2025 at 12:32 p.m. with Resident 1 in Resident 1's room, one oxygen E tank was observed near the entrance to the room. Resident 1 stated she was scheduled for a cardiology office appointment and the oxygen tank was brought to her room to prepare for transfer. During an interview on 4/3/2025 at 12:37 p.m. with the Oxygen Provider (OP), the OP stated facility received two types of oxygen tanks: E tanks that contained 24 cubic feet (unit of measurement) of oxygen and H tanks which contained 2024 cubic of oxygen. The OP stated E tanks which were suitable for transportation contained 680L of oxygen which was equivalent to 2,000 psi and would last for a maximum of two hour for a Resident who uses 4 to 5L of oxygen per minute. During an interview on 4/3/2025 at 1:05 p.m. with the Director of Nursing (DON), the DON stated before transfer to cardiology clinic appointment, LVN 1 was instructed to provide Resident 1 with second oxygen E tank. During a follow up interview on 4/3/2025 at 4:02 p.m. with the DON, the DON stated facility did not have a facility plan or policy addressing providing residents with oxygen during transportation. The DON stated facility's failure to provide Resident 1 with enough oxygen to last during clinic visits could have potentially endangered Resident 1's life. During an interview on 4/3/2025 at 4:15 p.m. with Resident 1, Resident 1 stated on 4/3/2025 at approximately 3:15 p.m. while at the clinic, Resident 1 had to switch to the second oxygen tank since the fist oxygen tank she used ran out of oxygen (one tank of Oxygen is not enough to last while Resident 1 was out of 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

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 and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three sampled residents (Resident 1) by: 1. Failing to maintain clean and sanitary floors in Resident 1's room. 2. Failing to keep Resident 1's bedside commode (portable toilet-a chair with a bucket or receptacle designed to be used by people with limited mobility who cannot easily reach a regular bathroom) clean and disinfected. This deficient practice had the potential to place Resident 1 at risk for acquiring infection and negatively affect Resident 1's quality of life. Cross Reference with F584 Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], and readmitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (a chronic lung disease causing difficulty in breathing), systemic lupus erythematosus (a condition that can affect various parts of the body including the skin, joints, kidneys, and other organs, causing pain and inflammation), legal blindness (severe visual impairment), schizophrenia (a mental illness that is characterized by disturbances in thoughts), epilepsy (a neurological condition characterized by recurrent, sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares and loss of consciousness), contracture of the left hand (a stiffening/shortening at any joint, that reduces the joint's range of motion( full movement potential of a joint)). During a review of Resident 1's History and Physical (H&P), dated 11/5/2024, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Care Plan (CP), dated 11/7/2024, the CP indicated Resident 1 was blind and was dependent on staff. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 2/7/2025, the MDS indicated Resident 1 had moderately impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 1 required moderate assistance with toilet transfers, toilet hygiene, and maximal assistance with lower body dressing. The MDS indicated Resident 1 was always incontinent of urine and bowel movements. During a concurrent observation and interview on 4/2/2025 at 11:05 a.m. with Certified Nurse Assistant (CNA) 1 in Resident 1's room, food remains and utensils were observed on the floor next to the right side of Resident 1's bed. CNA 1 stated a plastic spoon with brown residue, a glass jar with brown residue, an upside-down brown plate, orange peels, and cut orange was observed on the floor next to the right side of Resident 1's bed. CNA 1 stated there were ants inside the glass jar and on the floor next to the right side of Resident 1's bed. CNA 1 stated it is important to keep Resident 1's room clean to prevent infections. During a concurrent observation and interview on 4/2/2025 at 11:25 a.m with CNA 1 in Resident 1's room, brown residue was observed on Resident 1's bedside commode. CNA 1 stated there was a dried fecal residue on the bedside commode. CNA 1 stated the bedside commode should have been cleaned to prevent spread of infection. During an interview on 4/3/2025 at 11:45 a.m. with the MDS Coordinator who was covering for the Infection Preventionist (IP), the MSD Coordinator stated facility failed to keep Resident 1's room clean and sanitary which could potentially jeopardize Resident 1's health by causing infection to Resident 1. During an interview on 4/3/2025 at 4:02p.m. with the Director of Nursing (DON), the DON stated resident rooms should be kept clean and sanitary. The DON stated the facility failed to keep Resident 1's room clean, provide homelike environment, and maintain infection control measures which could potentially become a hazard to Resident 1's health. During a review of the facility-provided P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, last reviewed on 1/2025, the P&P indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CSC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin Such devices should be free from all microorganisms

Apr 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure that two of six emergency exit doors (Exit Door 1 and Exit Door 2) were free from obstructions. This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress (designated emergency exit door) access in the event of an emergency. Findings: During a concurrent observation and interview on 4/2/2025 at 12:15 p.m. with the Director of Nursing (DON), observed Exit Door 2 (the emergency exit door located at Station 2's hallway between resident Room A and resident Room B) was blocked by a wheelchair and a walker (a device that gives support to maintain balance or stability while walking). The DON stated the walker and the wheelchair blocked the emergency exit door. During a concurrent observation and interview on 4/2/2025 at 12:20 p.m. with the Minimum Data Set Nurse (MDSN), observed Exit Door 1 (the emergency exit door located at Station 1's hallway between resident Room C and resident Room D) was blocked by a wheelchair. The MDSN stated the wheelchair should not block the emergency exit door. The DON observed the wheelchair blocking the emergency exit door and had instructed the MDSN to remove the wheelchair. During a follow-up interview on 4/2/2025 at 12:24 p.m. with the DON, the DON stated the blocked emergency exit doors (Exit Door 1 and Exit Door 2) pose a danger to staff and residents. The DON stated emergency exit doors should be clear with an open pathway to the outside of the facility. The DON stated the facility failed to ensure emergency exits were cleared to ensure resident safety in case of an emergency. During a record review of the facility's policy and procedures (PnP) titled, Exits or Means of Egress, last reviewed on 1/2025, the PnP indicated the facility had designated exits for each area of the building to allow for rapid evacuation. The PnP indicated all personnel shall keep exits clear at all times. The PnP indicated exit doors should never be blocked, even briefly.

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to respect resident ' s rights for one of six sampled residents (Resident 1). Resident 1 had an appointment which was cancelled without Resident 1 being informed. This failure denied Resident 1 the right to receive clear and understandable information about their health condition(s), treatment option(s), and the right to an active participation in personal healthcare plan. Findings: A review of Resident 1 ' s admission Record indicated an admission date of 4/21/2022 with the diagnoses of epilepsy (a brain disorder causing loss of consciousness or involuntary rapid muscle movements of the body), generalized anxiety disorder (persistent worrying or feelings of nervousness), and muscle weakness. A review of Resident 1 ' s Minimum Data Set ([MDS] standardized assessment and care planning tool), dated 3/25/2025, indicated Resident 1 was fully alert and able to answer questions without difficulty. A review of Resident 1 ' s Physician ' s Orders, dated 12/31/2024 at 12:26 a.m., indicated Resident 1 had an eye appointment scheduled on 3/19/2025 at 8:40 a.m. During an interview with Resident 1 on 3/20/2025 at 12:07 p.m., Resident 1 indicated having an eye appointment scheduled on 3/19/2025. Resident 1 stated, I am going blind, and I was told it was due to cataracts (having cloudy vision). It took three months to get this appointment. I was dressed up and waiting at the front of the facility yesterday, only to find out that the appointment was cancelled. No one ever told me it was cancelled previously. I was annoyed that no one told me. On 3/20/2025 at 2:54 p.m., during a phone interview with Registered Nurse 1 (RN 1), RN 1 stated that staff need to inform the residents of their appointments. RN 1 indicated Resident 1 ' s appointment was regarding Resident 1 ' s vision. RN 1 stated not informing Resident 1 that the appointment was cancelled, and that it was Resident 1 ' s right to know. On 3/20/2025 at 4:07 p.m., during an interview with the Director of Nursing (DON), the DON stated, The resident was expecting to attend his appointment, he was dressed up and waiting for his transport, so the facility failed to respect the resident ' s right to know. A review of the facility provided Policy & Procedure titled Resident Rights with the last revised date of 2021 stated, Employees shall treat all residents with kindness, respect, and dignity. The policy also indicated Federal and State laws guarantee certain and basic rights to all residents of this facility, including the right to: a. A dignified existence b. Be treated with respect, kindness, and dignity, & p. Be informed of, and participate in, his or her care planning and treatment.

Jan 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from abuse for two of seven sampled residents (Resident 1 and Resident 2). On 12/23/2024, Resident 1 was subjected to verbal abuse, while Resident 2 was subjected to physical abuse, both by another resident, Resident 3. This deficient practice affects the safety and well being of the residents, exposing the residents to unnecessary physical and mental trauma. Findings A review of Resident 1's admission Record indicated an admission date of 9/20/2024 with the diagnoses of generalized osteoarthritis (having pain, stiffness, or tenderness to joints during movement), Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), and lack of coordination (having difficulty in controlling muscles or movement). A review of Resident 1's Minimum Data Set ([MDS] resident assessment tool), dated 12/18/2024, indicated Resident 1 to be with severe impairment in thought process or capacity to understand and answer questions. A review of Resident 1's record titled Change in Condition, dated 12/23/2024 at 8:30 p.m., indicated Resident 1 was subjected to verbal aggression by Resident 3 with the statement, I'm gonna kill you! A review of Resident 2's admission Record indicated an admission date of 5/17/2024 with the diagnoses of encephalopathy (a group of conditions that cause confusion, memory loss, and personality changes), lack of coordination, and major depressive disorder (having persistent feelings of sadness, hopelessness, or loss of interest with day-to-day activities). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 to be with severe impairment in thought process or capacity to understand and answer questions. A review of Resident 2's record titled Change in Condition, dated 12/23/2024 at 9:27 p.m., indicated Resident 2 was subjected to physical abuse by Resident 3, with Resident 1 being kicked then shoved on the shoulders. A review of Resident 3's admission Record indicated an admission date of 11/9/2022 with the diagnoses of alcohol cirrhosis of liver with ascites (damaged liver due to alcohol abuse and unable to regulate fluid levels, causing fluid to accumulate in the belly area), anxiety disorder (to excessively worry and have feelings of fear, dread, or uneasiness), and alcohol dependence (to crave consumption of alcohol and be unable to control drinking amount). A review of Resident 3's MDS, dated [DATE], indicated Resident 3 to be with moderate impairment in thought process or capacity to understand and answer questions. A review of Resident 3's record titled Progress Notes, dated 12/23/2024 at 9:27 p.m., indicated Resident 3 kicked Resident 2 and shoved Resident 2 on the shoulders. On 1/10/2025 at 12:37 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 3 first kicked Resident 2 on Resident 2's lower right leg, then shoved Resident 2 on the shoulder area. For Resident 1's involvement, Resident 1 was walking by, Resident 3 verbally threatened Resident 1 by saying Get out of the way or I'll kill you! LVN 1 stated this incident was intentional abuse as Resident 3 is alert and physically abused Resident 2, then verbally threatened the safety of Resident 1. A review of the facility provided policy and procedure titled Abuse Prevention Program with last revised date of 8/2006 indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. The policy adds, Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, providing services to our residents, family members, legal guardians, surrogates, sponsors friends, visitors, or any other individual.

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical and verbal abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) on 11/11/2024. Resident 2 was witnessed striking Resident 1 three times on the top of the right foot and yelling at Resident 1. This deficient practice resulted in Resident 1 being subjected to physical and verbal abuse by Resident 2 while under the care of the facility and caused emotional distress and pain to Resident 1. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included legal blindness (severe vision impairment that limits some activities, such as driving), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with hypoxia (a condition where there is a decrease in the amount of oxygen in the body's tissues), and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/8/2024, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) with personal hygiene, oral care and required supervision assistance (helper provides verbal cues and or touching assistance as resident completes activity) with eating. During a review of Resident 1's Change in Condition (COC - a significant change in resident's health status) Evaluation, dated 11/11/2024 at 7:53 p.m., the COC indicated Resident 1 reported being physically abused by roommate, Resident 2. The COC Evaluation indicated CNA 1 informed Licensed Vocational Nurse 1 (LVN 1) of a verbal altercation between Resident 1 and Resident 2. Upon CNA 1 entering the room (Resident 1 and Resident 2's room) CNA1 witnessed Resident 2 physically striking Resident 1 on the right top of the foot. Upon LVN 1 entering Resident 1's room, Resident 1 stated that Resident 2 slapped Resident 1 three (3) times on the right top of her foot. Resident 1 stated Resident 1's right foot felt tenderness. Resident 2 re-entered the room and continued to be verbally aggressive to Resident 1. During a review of Resident 1's Care Plan created on 11/11/2024for Risk for emotional distress related to physical abuse indicated interventions that included to encourage theresident to express feelings, notify the doctor if emotional distress interferes with functioning and staff will approach resident in a calm and unhurried manner. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 10 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition), dementia (a progressive state of decline in mental abilities), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood. A review of Resident 2's Progress Notes dated 11/11/2024 at 8:15 p.m. indicated per CNA 1, CNA1 heard both (Resident 1 and Resident 2) arguing and when CNA 1 got to the room (Resident 1 and Resident 2's room) CNA1 saw Resident 2 slapping Resident 1's right foot. Resident 1 is bed bound and unable to move. A review of Resident 2's COC Evaluation, dated 11/11/2024 at 9:34 p.m. for behavioral symptoms (agitation, psychosis indicated Resident 2 continues to be verbally aggressive. A review of Resident 2's Care plan created on 11/11/2024 for Risk for emotional distress related to physical aggression toward other residents indicated interventions that included staff will approach resident in a calm and unhurried manner, staff will encourage resident to express feelings, and will monitor resident for signs and symptoms of emotional distress. During a review of Resident 2's Care plan created on 11/11/2024 for Potential to be physically aggressive related to poor impulse control included interventions to monitor and document observed behavior and attempted intervention in behavior log, and administer medications as ordered. A review of Resident 2's Psychological Progress Note dated 11/15/2024 indicated Resident 2 had paranoid religious delusion about this new patient (Resident 1) being evil and was verbally and physically aggressive with her (Resident 1). During an interview on 11/26/2024 at 9 a.m. with Resident 1, Resident 1 stated because she is blind Resident 1 must speak into her phone and everything must be read out loud by her phone. Resident 1 stated Resident 1 could not recall the date or time but Resident 2 grabbed her (Resident 1's) legs and slapped her bare feet. Resident 1 stated she was verbally, emotionally, and physically harmed by Resident 2. Resident 1 stated Resident 2 stated Resident 1 had evil in her and was the devil, and that she stunk. During an interview on 11/26/2024 at 1:22 p.m. with LVN 1, LVN 1 stated LVN 1 could not recall the date, but it was during the night around 8 p.m. CNA 1 came to the nurses' station and stated CNA 1 heard yelling. CNA1 recognized Resident 2's voice and ran into Resident 1 and Resident 2's room. Resident 1 was in bed and Resident 2 was in a wheelchair by the foot of Resident 1's bed. LVN 1 stated CNA 1 stated CNA1 observed Resident 2 striking Resident 1's right foot but was not sure if it was with an open hand or closed fist. CNA 1 brought Resident 2 out of the room into the nurse's station. LVN 1 went to speak to Resident 1 who stated Resident 1 felt tenderness to the right foot. (LVN 1 stated Resident 1 stated Resident 2 was calling her names and felt when Resident 2 hit her leg. LVN 1 stated this was absolutely abuse, this was physical, verbal, and emotional abuse towards Resident 1. During an interview on 11/26/2024 at 3:39 p.m. with the Assistant Administrator (AA), the AA stated AA was working in facility on 11/11/2024 and was told there was a resident-to-resident altercation. The AA stated the incident between Resident 1 and Resident 2 would be considered abuse and abuse is not allowed in the facility. A review of the Facility's policy and procedure titled, Abuse Prevention Program, last reviewed on 1/2023, indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. A review of the Facility's policy and procedure titled, Abuse Prevention/Prohibition, last reviewed on 1/2023 indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation and or mistreatment, and develops facility policies, procedures, training program, and system to promote anenvironment free from abuse and mistreatment. Abuse is defined as willful infliction of injury, involuntary seclusion, physical, or chemical restraint not required to treat the residents' symptoms, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Types of abuse: 1. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms directed to residents, or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. 3. Physical abuse is defined as hitting, slapping, pinching, and or kicking. It also includes controlling behavior through corporal punishment.

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 F0602 (Tag F0602)

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 protect the resident's right to be free from misappropriation of property (the intentional, illegal use of the property or funds of another person for one's own use or other unauthorized purpose) for one of three residents (Resident 3) when the facility failed to replace Resident 3's missing book. This deficient practice resulted in Resident 3 book not being replaced. Findings During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness (generalized), depression (a mental health condition that involves a persistent low mood and loss of interest in activities that are usually enjoyable), and essential (primary) hypertension (HTN-high blood pressure). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 10/29/2024, the MDS indicated Resident 3 had the ability to understand and be understood. A review of Resident 3's Resident's Clothing and Possessions form dated 2/17/2024, indicated Resident 3 had oneChemistry configuration book. During an interview on 11/26/2024 at 8:31 a.m. with Resident 3, Resident 3 stated Resident 3 could not recall how long ago, but one of her books went missing, was told they would replace it, but they have yet to replace it. Resident 3 stated it is a chemistry book. During an interview on 11/26/2024 at 3:18 p.m. with the Social Services Director, (SSD), the SSD thinks Resident 3's missing book went missing at the end of October. The SSD stated did a walkthrough of the facility and Resident 3's room but was unable to find the book. The SSD stated SSD informed Resident 3's daughter to buy another book and facility would reimburse the daughter for the book. The SSD stated the facility process for missing items indicates they have five working days to come up with a conclusion and if unable to find will conclude and reimburse. The SSD stated theywill create a grievance the initial day so that it is not forgotten. The SSD stated she did not complete a grievance for Resident 3's lost book. The SSD stated the potential outcome for not following the facility's process of writing a grievance is that it can be forgotten and will result in not followingup with resident and or family. The SSD stated it can cause theresident to be unhappy and feel disappointment if the item is not replaced. The SSD stated if an item is listed in the inventory list it must be replaced by facility. A review of the Facility's policy and procedure titled, Investigating Incidents of Theft and or Misappropriation of Resident Property, last reviewed on 1/2023, indicated all reports of the theft or misappropriation of resident property shall be promptly and thoroughly investigated. The result of the investigation will be reported to the Administrator within five (5) working days of the reported incident.

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

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 develop a comprehensive (complete) person-centered care plan (a document that outlines a resident ' s care needs and how they will be addressed) for one of three sampled residents (Resident 1), who was identified as high risk (an identified concern that is likely to cause the resident to experience increased injury or harm) for falls. As a result, on 10/19/2024 at around 1:30 p.m., Resident 1 fell requiring immediate transfer to General Acute Care Hospital 1 (GACH 1) for further evaluation. Resident 1 sustained a facial contusion (an injury to the skin and underlying tissue on the face) and nasal laceration (an injury to the nose). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 6/4/2024 with diagnoses that included encephalopathy (a disturbance of brain function), lack of coordination, dementia (a progressive state of decline in mental abilities), and Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 1 ' s Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/5/2024, the MDS indicated the resident had severely impaired cognition (the mental process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing, lower body dressing, toilet hygiene, and personal hygiene. The MDS indicated Resident 1 needed partial/moderate assistance to come to a standing position from sitting in a wheelchair. During a record review of Resident 1 ' s Fall Risk Evaluation, dated 9/27/2024 at 5:26 p.m., the Fall Risk Evaluation indicated Resident 1 was a high risk for falls. During a record review of Resident 1 ' s Change of Condition (COC – a significant change in resident ' s health status), dated 10/19/2024, timed at 2:11 p.m., the COC indicated Certified Nursing Assistant 2 (CNA 2) noted Resident 1 on the floor next to his (Resident 1) bed. Resident 1 was lying on the floor face down. Resident 1 was noted with blood in the nose and bruising (discolored mark on your skin that forms when blood vessels [a tube through which blood circulates in the body] under your skin break and leak) in the face. Resident 1 was transferred back to his bed with a three-person (not specified) assist. The facility called 911 (the telephone number to call for emergency services) to transfer Resident 1 to GACH 1. During an interview with Registered Nurse 1 (RN 1) on 10/22/2024 at 9 a.m., RN 1 stated that on 10/19/2024, at around 1:30 p.m., CNA 2 came to the nurse ' s station and reported that she (CNA 2) found Resident 1 faced down on the floor next to his(Resident 1 ' s) bed. RN 1 stated she then went to assess Resident 1 with Licensed Vocational Nurse 1 (LVN 1), and observed Resident 1 was on the floor, face down next to his bed in front of his (Resident 1 ' s) wheelchair. RN 1 stated she (RN 1) turned Resident 1 on his back and noted Resident 1 with blood and purple discoloration (any change in the natural skin color or tone) on his nose and purple discoloration to Resident 1 ' s right eyebrow. RN 1 stated she (RN 1) instructed LVN 1 to call 911 to transfer Resident 1 to GACH 1. RN 1 stated Resident 1 was a high risk for falls. RN 1 stated not remembering if Resident 1 had a wrist band indicating he (Resident 1) was a high risk for falls. RN 1 stated, prior to the fall, Resident 1 was observed sitting in his wheelchair and his call light (a button that residents in nursing homes use to communicate with nursing staff and request assistance) was not within reach. During an interview with LVN 1 on 10/22/2024 at 4 p.m., LVN 1 stated that on 10/19/2024, at 1:20 p.m. CNA 2 reported that she (CNA 2) found Resident 1 on the floor faced down. LVN 1 stated Resident 1 was awake, alert, and verbally responsive. LVN 1 stated he (LVN 1) called 911 to transfer Resident 1 to GACH 1 for further evaluation. LVN 1 stated Resident 1 was identified as high risk for falls. LVN 1 stated there was no care plan in place indicating Resident 1 was high risk for falls. LVN 1 stated Resident 1 did not have a fall risk wrist band (a piece of material that goes around the wrist used to identify resident is a high fall risk) and no yellow star sticker (an indicator that a resident is a high risk for falls) next to Resident 1 ' s name by the door. LVN 1 stated Resident 1 ' s call light needed to be within reach. During an interview with CNA 2 on 10/23/2024 at 1 p.m., CNA 2 stated Resident 1 was eating lunch in the dining area, and she (CNA 2) was passing lunch trays to other residents at that time. CNA 2 stated after lunch time she (CNA 2) took Resident 1 to his room in his wheelchair. CNA 2 stated Resident 1 was sitting in his wheelchair by the foot of the bed close to the door. CNA 2 asked Resident 1 if he (Resident 1) wanted to go back to bed, and he (Resident 1) said no. CNA 2 stated she then left Resident 1 ' s room to do her charting and provided personal care to another resident (name not indicated) when she heard another nurse (name not indicated saying that Resident 1 fell. CNA 2 stated she went to Resident 1 ' s room and found Resident 1 face down on the floor. CNA 2 stated Resident 1 ' s call light was too far (exact distance not specified) from Resident 1 at the time of the fall. CNA 2 stated, LVN 1 and RN 1 came into the room to help. CNA 2 stated Resident 1 had a bloody nose. CNA 2 stated there was no yellow star sticker next to Resident 1 ' s name by the door. During an interview with CNA 1 on 10/23/2024 at 2 p.m., CNA 1 stated she saw Resident 1 sitting in his wheelchair by the foot of his bed next to the door. CNA 1 stated Resident 1 got up by himself and she saw Resident 1 fell on the floor with face down. CNA 1 stated she went to call for help immediately. CNA 1 stated residents who are high risk for falls will have a wrist band indicating they are a high risk for falls. CNA 1 stated she did not remember if Resident 1 had a fall risk wrist band. CNA 1 stated Resident 1 had a bloody nose. During a concurrent interview and record review of Resident 1 ' s Fall Risk Assessment, dated 9/27/2024, with the Director of Nurses (DON) on 10/23/2024 at 4 p.m., the DON stated Resident 1 was a high risk for falls. The DON stated she could not locate any care plan addressing Resident 1 ' s fall risk assessment. The DON stated this is a problem because the staff will not know which interventions to implement. The DON stated a care plan regarding a high risk for falls includes having a call light within reach, a low bed, belongings within reach, and floor mats. The DON stated Resident 1 did not have these interventions in place. The DON stated the facility did not have an IDT meeting regarding Resident 1 ' s risk for falls. The DON stated the purpose of having a care plan is to inform the staff of Resident 1 ' s needs and to address specific interventions. The DON stated that had a care plan been in place indicating Resident 1 was a high risk for falls, the injury could have been prevented. During a record review of Resident 1 ' s Fire Department Patient Care Report, dated 10/19/2024 at 1:36 p.m., the report indicated the paramedics (health professionals certified to perform advanced life support procedures) arriving on scene to find Resident 1 sitting upright in bed. Resident 1 was alert and oriented. Resident 1 had a mechanical trip and fall while walking to the bathroom landing on his face. Resident 1 had a laceration on the bridge of the nose and contusions on the bridge of the nose. Resident 1 was transported to the GACH. During a review of Resident 1 ' s GACH records, dated 10/19/2024 at 2:22 p.m., the GACH Emergency Department record indicated Resident 1 was presented to the Emergency Department for evaluation of a ground-level fall facial (referring to the face) trauma (physical injury). Resident 1 arrived from the nursing facility after an apparent ground-level trip and fell to the front of his (Resident 1) face. Resident 1 was diagnosed with severe sepsis (occurs when one or more of the body ' s organs is damaged from an inflammatory response), facial contusion, and laceration of the nose. During a review of the current facility-provided policy and procedure (P&P) titled, Care-Planning-Interdisciplinary Team, dated 3/2022 and reviewed on 1/25/2024, the P&P indicated the interdisciplinary team is responsible for the development of resident care plans. Resident care plans are developed according to the timeframes and criteria established. Comprehensive, person-centered care plans are based on resident assessments and developed by an IDT. During a review of the current facility-provided P&P titled, Falls and Falls Risk, Managing, dated 3/2018 and reviewed on 1/25/2024, the P&P indicated that based on previous evaluations 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 from falling. Resident-Centered approaches to managing falls and fall risk included the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. During a review of the current facility-provided P&P titled, Fall Program: Falling (Yellow) Star Program, reviewed on 1/25/2024, the P&P indicated that upon resident ' s admission, a licensed nurse will identity residents who are risk for falls by utilizing Resident Fall Risk Assessment Form. Once identified as a high risk for fall, the resident will be added to the yellow star program resident list and will be provided with a yellow star, and this will be placed next to the resident ' s name by the door. Residents identified to be fall high risk will have a yellow-colored name band (wrist band).

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) on 10/11/2024 when Resident 2 punched Resident 1 on the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included depression, chronic obstructive pulmonary disease, epilepsy, cachexia, anxiety disorder, and malignant neoplasm of left lung. During a review of Resident 1 ' s Minimum Data Set (MDS- a a federally mandated resident assessment tool), dated 7/19/2024, the MDS indicated Resident 1 had severely impaired cognition and required staff supervision with, toilet hygiene, bathing, dressing, and personal hygiene. During a review of Resident 1 ' s Change of Condition (COC - a significant change in a resident ' s health status), dated 10/11/2024, timed at 3:03 a.m., the COC indicated that on 10/11/2024 at 2:15 a.m., the Charge Nurse heard yelling from Resident 1 ' s room, and went to investigate the situation. Upon arriving to Resident 1 ' s room, the Charge Nurse saw Certified Nurse Assistant (CNA 1) wheeling Resident 1 out from the room. CNA 1 reported that Resident 2 allegedly hit Resident 1 in the face. Both residents were immediately separated. The Charge Nurse Assessed Resident 1, no injuries were noted. Resident 1 verbalized pain and pain medication was administered. The Charge Nurse asked Resident 1 why he felt that Resident 2 hit him. Resident 1 was confused, and unable to answer. Resident 1 complained of pain level of 6 out of 10 to face. During a review of Resident 1 ' s Care Plan, dated 10/11/2024, the care plan indicated that staff reported that Resident 1 was allegedly hit by another male resident (Resident 2). The care plan Interventions included, both residents were separated immediately, pain assessment was done, Medical Doctor, and representative notified. During a review Resident 1 ' s Medication Administration Record (MAR), dated 10/11/2024, the MAR indicated that Resident 1 received ibuprofen (medication that can treat fever and mild to moderate pain) tab 600 mg (milligram- unit of measurement) by mouth for moderate pain (pain rated at one to four on a pain scale from zero [0] to 10, where 10 is the worst possible pain) of 6 out of 10 pain level related to Resident 1 ' s complaint of pain to his face. During a review of Resident 2 ' s admission Record, the admission Record indicated the facility originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, schizoaffective disorder, anxiety disorder, and chronic obstructive pulmonary disease. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 had moderately impaired cognition and required moderate assistance on staff with, toilet hygiene, bathing, dressing, and personal hygiene. During a review of Resident 2 ' s Change of Condition (COC - a significant change in a resident ' s health status), dated 10/11/2024, timed at 6:19 a.m., the COC indicated that on 10/11/2024 at 2:15 a.m., CNA 1 allegedly reported that Resident 2 hit Resident 1 in the face. Resident 2 was asked why he hit Resident 1, Resident 2 was unable to answer the question. Resident 2 was aggressive and agitated. During an interview with Registered Nurse (RN 1) on 10/15/2024 at 1:00 p.m., RN 1 stated, she was in the bathroom at the time of the incident, and she did not witness the altercation, however she was notified by the Licensed Vocational Nurse that Resident 2 punched Resident 1 in the face. RN 1 stated, she interviewed CNA 1 and she stated (CNA 1) Resident 1 wandered into Resident 2 ' s room accidentaly, and this must have led Resident 2 to react and hit Resident 1 in the face. RN 1 stated Resident 2 hitting Resident 1 is considered physical abuse. RN 1 stated, Resident 1 needed closer supervision, and frequent visual checks. During an interview with Certified Nurse Assistant (CNA 1) on 10/15/2024 at 1:30 p.m., CNA 1 stated, she heard screaming inside Resident 2 ' s room, and she ran to the room to see what was happening. CNA 1 stated, she observed Resident 1 in his wheelchair inside Resident 2 ' s room. CNA 1 stated she observed Resident 2 punching Resident 1 in the face. CNA 1 stated, she saw Resident 2 with a closed fist punching Resident 1 one time on the right side of his face. CNA 1 stated, she yelled out for help. CNA 1 stated, Resident 1 had wandered into Resident 2 ' s room. CNA 1 stated, Resident 1 needed closer monitoring and constant redirection. CNA 1 stated, she is unsure what happened on this night. During an interview with the Administrator (ADMIN) on 10/15/2024 at 4:00 p.m., the ADMIN stated, this incident was considered physical abuse against Resident 1. ADMIN stated Resident 1 and Resident 2 used to be roommates, but they were not getting along, and they would argue. ADMIN stated they moved Resident 1 to another room, and she believes Resident 1 forgot where his new room was and wandered into Resident 2 ' s room. ADMIN stated, the staff need more training on monitoring of residents, and training the night staff on providing closer monitoring of residents. A review of the facility ' s policy and procedure titled Abuse Prevention/Prohibition undated, indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property and/or mistreatment, and develops facility policies, procedures, training program systems in order to promote an environment free from abuse and mistreatment.

Sept 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of four sampled residents (Resident 1) when on 9/20/2024 at 7:15 a.m. Resident 2 was trying to touch Resident 1 on her right upper arm. Resident 1 told Resident 2 to get off me. Resident 2 grabbed Resident 1 by the shoulder and hit Residents 1's right upper arm. This deficient practice resulted in Resident 1 being subjected to abuse while under the care of the facility. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 5/10/5024 and readmitted the resident on 8/12/2024 with diagnoses that included chronic kidney disease (a long-term condition that occurs when the kidneys gradually lose their ability to filter blood properly), respiratory disorder (a condition that affects the lungs or other parts of the respiratory system), and hypertensive heart disease (a group of heart conditions that can develop when chronic high blood pressure is left unmanaged) with heart failure (a long-term condition that occurs when the heart can't pump enough blood to meet the body's needs). A review of Resident 1's History and Physical Exam, dated 8/12/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/16/2024 indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) with toileting, showering, upper and lower body dressing, putting on and off footwear and personal hygiene. A review of Resident 1's Change in Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains documentation) Evaluation, dated 9/20/2024 at 7:15 a.m. indicated Resident 1 stated that Resident 2 was trying to touch her right upper arm when Resident 1 told Resident 2 to get off me. Resident 2 grabbed Resident 1 at the back of her shoulder and hit Resident 1's right upper arm. A review of Resident 1's Care plan, developed on 9/20/2024, indicated interventions that included to separate residents immediately, one to one staff to monitor male resident and skin assessment. A review of Resident 1's Dadoyan Behavioral Medical Group Simple Note, dated 9/20/2024, indicated Resident 1 reported being grabbed multiple times by another patient (Resident 2) this morning, causing Resident 1 emotional distress. A review of Resident 1's Interdisciplinary Team Conference Record (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of their clients), dated 9/20/2024, indicated Resident 1 was sitting in the front lobby patio and Resident 2 went out to the front lobby patio to where Resident 1 was sitting. Facility Receptionist 1 (FR 1) heard Resident 1 yelling and when staff looked and saw Resident 2 pulling Resident 1 by her sweater. Resident 1 stated that Resident 2 was trying to touch her right upper arm and when Resident 1 told Resident 2 get off me, Resident 2 grabbed Resident 1 at the back of her shoulder and hit Resident 1's right upper arm. b. A review of Resident 2's admission Record indicated the facility admitted the resident on 9/16/2024 with diagnoses that included schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions] symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression), anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress), and bipolar disorder (a mental illness that causes extreme mood swings, or shifts in mood, energy, and activity levels). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the ability to usually be understood and had the ability to understand. The MDS indicated Resident 2 required maximal assistance (the helper does more than half the effort) with showering, lower body dressing, and putting on and taking off footwear and partial assistance (helper does less than half the effort) with oral hygiene, toileting, and upper body dressing. A review of Resident 2's History and Physical Exam, dated 9/22/2024, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's Care plan, developed on 9/19/2024, regarding the resident's potential to be physically aggressive related to poor impulse control, grabbing the hand or shoulder of the staff during care. The interventions included staff to intervene before agitation escalates, administer medication as ordered, and psychiatric and or psychogeriatric consult as needed. A review of Resident 2's Care plan, developed on 9/19/2024, regarding the resident's potential to be verbally aggressive related to mental, emotional illness, poor impulse control, yelling, screaming cursing, verbally inappropriate to staff, saying foul language to staff. The interventions included to administer medications as ordered, psychiatric and psychogeriatric consult and provide positive feedback for good behavior. A review of Resident 2's Care plan, developed on 9/19/2024, regarding the resident's episodes of inappropriately grabbing or touching the shoulder, hands, and arms of female staff, attempting to touch chest of female staff or nurses. The interventions included to refer to a psychiatrist as needed, when possible, assign male nurse to resident during care, if no male nurse available, staff to have two female nurses to attend to the resident's care. A review of Resident 2's COC Evaluation, dated 9/20/2024 at 7:20 a.m., indicated Resident 2 hit Resident 1. A review of Resident 2's Care plan, developed on 9/20/2024, regarding the resident hiting Resident 1 with interventions that included the residents were separated immediately, refer for psychosocial support, and one on one monitoring. A review of Resident 2's IDT, dated 9/20/2024, indicated Resident 1 was sitting in the front lobby patioand Resident 2 went out to the front lobby patio to where Resident 1 was sitting. Facility Receptionist 1 (FR 1) heard Resident 1 yelling and when staff looked Resident 2 was pulling Resident 1 by her sweater. Resident 1 stated that Resident 2 was trying to touch her right upper arm and when Resident 1 told Resident 2 get off me, Resident 2 grabbed Resident 1 at the back of her shoulder and hit Resident 1's right upper arm. A review of Resident 2's Psychological Evaluation dated 9/20/2024 indicated report from staff that patient (Resident 2) has been physically aggressive with another patient (Resident 1) and touches staff and patients without consent. Resident 2 denies any knowledge of aggressively touching another patient (Resident 1) but admits that he enjoys touching people because I love everyone. During an interview on 9/30/2024 at 10:18 a.m., Resident 1 stated on the morning of 9/20/2024 Resident 1 was in the patio when Resident 2 wheeled himself to the patio and grabbed Resident 1's right arm. Resident 1 stated she tried to pull her arm away when Resident 2 pulled on her sleeve and she hit Resident 1 with a closed fist Resident 1's right forearm. Resident 1 stated FR 1 then came outside and told Resident 2 you can't hit a lady, and took Resident 2 back into the facility. Resident 1 stated she was scared after the incident. Resident 1 stated she enjoys going out to the patio but is now afraid to go to the patio. Resident 1 stated she is now aware who is coming and going in and out of the patio because she is now on constant alert. During an interview on 9/30/2024 at 1:35 p.m. with the Social Services Director (SSD) stated on 9/20/2024 was coming into the facility when SSD saw the commotion, Resident 1 was sitting in front patio speaking to staff, Resident 1 alleged Resident 2 hit her. The SSD stated Resident 1 stated Resident 2 came out and grabbed Resident 1 and shook her around then punched Resident 1' arm. The SSD stated she then spoke to FR 1 who stated heard yelling and looked up and saw Resident 2 pulling Resident 1 by the back of Resident 1's sweater. During an interview on 9/30/2024 at 3:10 p.m., the Director of Nursing (DON) statedshe was not in the building on 9/20/2024 but heard from the SSD that one staff reported Resident 2 hit the right upper arm of Resident 1. The DON stated when she came in saw Resident 1 in the patio and Resident 1 stated Resident 2 tried to pat Resident 1, and Resident 1 stated to Resident 2 to get off me, and that was when Resident 2 hit Resident 1's upper arm. During an interview on 9/30/2024 at 3:31 p.m., the DON stated the way Resident 1 described the situation would be considered as abuse because Resident 1 alleged that Resident 2 punched her. A review of the facility's policy titled, Reporting Abuse to Facility Management, revised on 12/2013, indicated our facility does not condone resident abuse by anyone. Abuse is defined as the willful infliction of injury. A review of the facility's policy titled, Abuse Prevention Program, revised on 8/2006 indicated residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion.

Sept 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

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 residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for one of two sampled resident (Resident 3), by failing to schedule Resident 3's neurologist (a medical specialty that deals with the disorders of the nervous system) appointment due to episodes of seizure (a sudden, uncontrolled burst of electrical activity in the brain) as ordered by the physician. This deficient practice had the potential to result in a delay of necessary care and treatment the resident needs. Findings: During a review of Resident 3's Face Sheet (admission record), the Face Sheet indicated the facility originally admitted the resident on 7/17/2019 and readmitted the resident on 6/30/2024 with diagnoses including generalized epilepsy (occurs when the abnormal electrical activity causing a seizure begins in both halves of the brain at the same time), squamous cell carcinoma (a type of cancer [abnormal cells divide in an uncontrolled way] that begins in cells that form the epidermis (outer layer of the skin) of anal skin. During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/13/2024, the MDS indicated the resident sometimes made self-understood and sometimes understood others. The MDS indicated the resident required supervision with sit to lying, lying to sitting, chair/bed-to-chair transfer, and requires substantial/maximal assistance (helper does more than half the effort) with oral hygiene, toileting hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. During a review of Resident 3's General Acute Care Hospital History (GACH) and Physical, dated 6/26/2024, it indicated the resident has a history of seizure disorder and a planned neurology consult for medication dosage adjustment. During a review of Resident 3's Physician's Telephone Order, dated 7/2/2024, the order indicated Resident 3 to be referred to neurologist due to episodes of seizure. During a review of Resident 3's Change in Condition, dated 9/8/2024, it indicated the resident had a seizure and was transferred via 911 (an emergency transportation ambulance) and sent to GACH 1. During a concurrent interview and record review of Resident 3's nursing progress notes and care plans on 9/9/2024 at 10:55 a.m., with Registered Nurse 1 (RN 1), RN 1 stated there was no physician's order for a neurologist referral consultation and there was no care plan indicating an intervention for a neurologist appointment. RN 1 stated the neurologist consultation should have been scheduled to prevent the resident from having another seizure and to know the cause of the seizures. RN 1 stated the purpose of having a care care plan is for all staff to be aware of the interventions in place to address the resident's seizure disorder. During an interview on 9/9/2024 at 2:31 p.m., with the Director of Nursing (DON), the DON stated the licensed nurse who received the order should have scheduled the neurologist consult. The DON stated it is important that outside referrals are followed through for the resident's health and well-being. A review of the facility's policy and procedure titled, Seizures and Epilepsy - Clinical Protocol, dated 1/25/2024, indicated if seizures are complex, not readily responsive to medication dosage adjustments, or persist despite treatment with up to three antiepileptic medications, the physician should consider a referral to a neurologist.

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 F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the peripheral intravenous catheter (peripheral IV, a flexible plastic tube that is inserted into a vein to deliver fluids and medications) was labeled with the insertion date for one of one sampled resident (Resident 1). This deficient practice placed the resident at risk for infection due to missed dressing changes and lack of assessment and monitoring of the site. Findings: During a review of Resident 1's History and Physical (H&P), dated 2/4/24, the H&P indicated, Resident 1 had the following diagnoses, but not limited to, metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance that can cause confusion), diabetes mellitus (a long-term condition that affects how the body uses sugar for energy), hypertension (high pressure in vessels that carry blood away from the heart), atrial fibrillation (an irregular and often rapid heart rate), anxiety disorder (feeling of anxiousness that affects daily life), and muscle weakness. During a review of Resident 1's nursing progress notes, dated 9/5/24, the nursing progress notes indicated, Resident 1 was readmitted from the hospital on 9/5/24 with diagnoses of pneumonia (a lung infection which can cause difficulty breathing) and was receiving intravenous antibiotics (a medication to treat bacterial infection). During a review of Resident 1's Order Summary Report, dated 9/5/24, the Order Summary Report indicated, Resident 1 was prescribed ceftriaxone sodium (an antibiotic medication to treat certain bacterial infections) one gram (gm), to be administered via intravenous catheter every day until 9/11/24 for pneumonia (infection of the lungs). During a concurrent observation and interview on 9/9/24 8:13 a.m., with Resident 1, in the Social Services Director's Office, Resident 1 had a peripheral IV on the left wrist secured with gauze and tape. The peripheral IV was not labeled or dated. Resident 1 stated the peripheral IV was placed when he was in the hospital. During an interview on 9/9/24, at 8:25 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's peripheral IV was not labeled with the insertion date. During a concurrent interview and record review on 9/9/24, at 10:52 a.m., with Registered Nurse 1 (RN 1), Resident 1's nursing progress notes, dated 9/5/24 were reviewed. RN 1 stated the nursing progress notes indicated, Resident 1 had a peripheral IV and was receiving intravenous antibiotics. RN 1 stated the nursing progress notes did not indicate when Resident 1's peripheral IV was inserted. RN 1 also stated it is important to label and date peripheral IV sites to make sure residents are safe. During an interview on 9/9/24, at 2:29 p.m., with DON, the DON stated peripheral IV sites should be labeled, dated, documented, and changed every 72 hours. The DON also stated if a resident is admitted from a hospital with a peripheral IV that is not dated, the admitting nurse should contact the hospital to clarify and document the insertion date. The DON stated the purpose of correct documentation is to know when the peripheral IV needs to be changed. A review of the facility's policy and procedure titled, Peripheral IV Catheter Insertion, dated February 2022, indicated the date and time of the peripheral IV insertion should be documented in the resident's medical record.

Aug 2024 10 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · 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 23 sample residents (Resident 216) who had a behavior of ingesting foreign objects (when a person swallows objects that may be inserted/ingested into the body accidentally or intentionally that is not meant to be eaten such as batteries, paper clips, nails, pins, screws, coins, plastic, pens) was supervised to prevent ingesting a paper clip and batteries by failing to: 1. Monitor and supervise Resident 216 to ensure the resident did not have episodes of self-harm behavior (the resident ingested a paper clip on 8/19/2024 and ingested batteries on 8/25/2024) in accordance with the care plan focusing on risk for injury. 2. Notify the Primary Medical Doctor (PMD) on 8/19/2024 that the ordered STAT (to do something immediately or without any delay) abdominal x-ray (AXR - imaging test that looks at organs and structures in the abdomen) was not done immediately (after the resident had ingested a paperclip) as ordered by the physician for Resident 216 due to insurance eligibility issues. 3. Revise the care plan focusing on risk for injury after Resident 216 ingested a paper clip on 8/19/2024, and after the resident ingested batteries on 8/25/2024, to ensure interventions are in place to prevent the resident from self-harm behaviors like ingesting foreign objects. These deficient practices placed Resident 216 at increased risk for serious injury, serious harm, intestinal hemorrhage (bleeding), bowel obstruction (a serious condition that occurs when the small intestine or large intestine becomes blocked that keeps food or liquid from passing through), gastrointestinal (GI) erosion (a sore or raw area in the stomach lining), serious impairment, or death. Resident 216 was transferred to the General Acute Care Hospital (GACH) for further evaluation and management on 8/20/2024 after ingesting the paper clip. On 8/26/2024, Resident 216 ingested batteries and was transferred to the GACH on the same date at 3:14 p.m. for further evaluation and management. Resident 216 has not returned to the facility as of 8/31/2024. On 8/29/2024 at 6:56 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM), Interim Director of Nursing (IDON), and Quality Assurance Nurse (QA - A staff member that looks at activities or products on a regular basis to make sure they are being done at the required level of excellence) due to the facility's failure to ensure Resident 216 was free from accidents under 42 Code of Federal Regulations (CFR) §483.25(d) Accidents. The facility was requested to provide an acceptable IJ removal plan (interventions to correct the deficient practices). On 8/31/2024 at 4:46 p.m., the IJ was removed after the ADM and the IDON submitted an acceptable IJ removal which was verified and confirmed through observation, interview, and record review. The acceptable IJ removal plan included the following: 1. On 8/29/2024, the Maintenance Supervisor (MS) conducted environmental rounds of all resident rooms, resident toilets, dining room, activity room, shower areas, drawers, closets, floors, and smoking patios to remove foreign and hazardous objects (batteries, paper clips, nails, pins, screws, coins, plastic utensils, pad locks, push pins, straw, keys, toothbrushes, pens, cleaning chemicals). The environmental rounds will continue daily to search and remove any hazardous objects. 2. On 8/29/2024, two registered nurses (RNs) reassessed 70 residents for any behavior related to ingesting or swallowing foreign objects. No other resident was identified to have ingested foreign objects at that time. Residents with behavior of ingesting foreign objects will have an individualized care plan initiated such as daily room rounds and the MS and the Assistant Maintenance Supervisor (AMS) will continue to conduct resident room rounding during weekdays and weekends. The charge nurse will maintain a log of all residents on every shift to ensure no hazardous objects were within residents' reach. 3. On 8/29/2024, the IDON and the Director of Staff Development (DSD) initiated and completed an in-service (staff training) to one registered nurse (RN) and five licensed vocational nurses (LVNs) regarding supervising and monitoring residents who have ingested foreign objects. Licensed nurses on vacation/sick leave will not be scheduled to work until they have completed in-services on their first day back to work regarding supervising and monitoring residents for ingesting foreign objects Ten Department Heads and six certified nursing assistants (CNAs) completed the in-services. 4. On 8/30/2024, the facility's Medical Director (MD), was informed by the ADM that an IJ was called at the facility on 8/29/2024 about Resident 216 ingesting two AA batteries. 5. On 8/30/2024, the IDON provided one on one (1:1) counseling and training to Registered Nurse Supervisor 1 (RNS 1) on assessment and change of condition (COC - a decline in a resident's mental, psychosocial, or physical functioning) of resident behavior of ingesting foreign/toxic objects including batteries, paper clips, and supervising and monitoring residents. The IDON will continue to provide in-service training to licensed nurses regarding change of condition and emergency transfers and discharges of residents to GACH, including documentation and notification to physician and the resident's family member. 6. Effective 8/30/2024, the ADM (or designee) and Department Heads will conduct ambassador rounds (environmental rounds) on Mondays to Fridays, while the RN Supervisor conducts those rounds on weekends to search for foreign objects that residents can ingest. Residents identified with such behavior of ingesting foreign objects will be placed on 1:1 (staff must maintain full continuous view of the patient) supervision by assigned staff. 7. Effective 8/30/2024, during stand-up meetings (short, daily meetings conducted while attendees participate while standing to discuss progress and identify blockers) on Mondays to Fridays, the ADM (or designee) and Department Heads will discuss any environmental room round findings and implement preventive measures. The RN supervisor will conduct the stand-up meetings on weekends. The charge nurse, during every shift huddle (brief, stand-up meeting designed for quick information sharing and decision-making) will discuss any resident identified with the behavior of ingesting foreign objects to ensure the resident is adequately supervised and monitored. 8. Effective 8/30/2024, any residents identified with ingestion of foreign objects will have a revised individualized plan of care. 9. On 8/30/2024, the facility conducted a root cause analysis on residents that demonstrated the behavior of ingesting foreign objects. Hazardous materials i.e. batteries, paper clips will be removed immediately from the resident's room. 10. Effective 8/30/2024, the primary care physician will be notified of residents noted with the behavior of ingesting foreign objects and the residents will immediately be transferred to GACH for further evaluation. The resident/legal representative will be notified immediately as well. The accurate documentation must be recorded in the resident's medical record. 11. Effective 8/30/2024, the facility will conduct Interdisciplinary Committee Team (IDT - a group of experts implementing separate treatments on a resident) meeting with the resident/responsible party regarding the resident ingesting foreign objects. The IDT will review the incident of the ingestion of foreign objects, will investigate, and will make recommendations as necessary for the care of the resident. On Mondays to Fridays, the Medical Records staff will monitor the Change of Condition audit daily and the results will be forwarded daily to the IDON or designee for review and follow-up. During weekends, the RN Supervisor will review and follow-up on any resident change of condition i.e. ingestion of foreign objects. Findings will be given to the ADM (or designee) and IDON (or designee) on the following business day for review and recommendation. 12. The IDON (or designee) will monitor compliance and effectiveness of the plan of action and any deficient findings will be integrated in the monthly and quarterly Quality Assurance and Performance Improvement (QAPI - a data-driven approach to improve care quality and patient outcomes) committee minutes for review, further evaluation, and recommendation if necessary. Findings: During a review of Residents 216's admission Record, the admission Record indicated the facility admitted Resident 216 on 8/16/2024 with diagnoses including schizophrenia (mental disorder which leads to hallucinations [experiences of hearing, seeing or smelling things that are not there], irrational thought patterns or behaviors [patterns of thinking or behaviors that are illogical or not based on reality]), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). During a review of Resident 216's Minimum Data Set (MDS - a standard assessment and care screening tool), dated 8/22/2024 indicated Resident 216 was cognitively intact (has the capacity to think, learn, remember, use judgment, and make decisions). The MDS indicated Resident 216 required supervision/touch assistance from staff for toileting, shower, and personal hygiene. During a review of Resident 216's Situation Background Assessment and Recommendation communication form (SBAR - a form that is a documentation of a complete assessment in response to a change in condition), dated 8/19/2024, the SBAR indicated Registered Nurse Supervisor 1 (RNS 1) documented that Resident 216 claimed to have swallowed a paper clip (time of incident not specified). During a review of Resident 216's Physicians Orders dated 8/19/2024 and timed at 9:40 p.m., the Physicians Orders indicated STAT abdominal x-ray. During a review of Resident 216's AXR results, dated 8/20/2024, the AXR indicated Impression: metallic (metal) radiodensity (portions that appear light whereas other parts are dark) in the [NAME] (antral region, lowermost part of the stomach) of the stomach measuring 97 millimeters (mm -units of measure) by 2 mm. This may represent a swallowed paperclip. During a review of Resident 216's RNS 1's nursing note, dated 8/20/2024 and timed at 5:15 p.m., the RNS 1 nursing note indicated the resident was made aware of the AXR results. The resident insisted to go to the hospital. The doctor ordered to transfer the resident to the hospital per resident's request. During a review of Resident 216's RNS 1's nursing note, dated 8/20/2024 and timed at 10:08 p.m., the RNS 1's nursing note indicated the ambulance arrived to transfer the resident. During a review of Resident 216's care plan, with initiation date of 8/19/2024, the care plan indicated Resident 216 was at risk for injury and claimed to have swallowed a paperclip. The goal indicated resident will have no episodes of self-harm behavior. The care plan interventions/tasks included abdominal x-ray as ordered and to notify the doctor for any significant change. The care plan did not include interventions related to supervision. During a review of Resident 216's SBAR, dated 8/25/2024, the SBAR indicated RNS 1 documented that Resident 216 stated she swallowed a toothbrush. During a review of Resident 216's RNS 1's nursing note, dated 8/25/2024 and timed at 5:17 p.m., the RNS 1's nursing note indicated the resident stated to have swallowed a toothbrush because she was anxious. RNS 1's nursing note indicated the doctor was notified with no new orders. Psychiatry (the branch of medicine focused on the diagnoses, treatment, and prevention of mental, emotional and behavioral disorder) was notified with no response. The Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) was made aware . During a review of Resident 216's Physicians Orders, dated 8/26/2024 and timed at 10:00 a.m., the Physicians Orders indicated STAT x-ray of the stomach; resident claiming I swallowed 2 double A batteries 8/25/24 at 5 p.m. last night. During a review of Resident 216's AXR results, dated 8/26/2024, the AXR Results indicated Findings: consistent with two small batteries probably within the antral region of the stomach are noted .other than findings consistent with 2 small triple or AA sized batteries appear to be located in the region of the [NAME] of the stomach. The AXR Results did not indicate the presence of a toothbrush. During a review of Resident 216's Physicians Orders, dated 8/26/2024 and timed at 1:48 a.m., the Physicians Orders indicated to transfer Resident 216 to GACH for further evaluation. During a review of Resident 216's Transfer Form, dated 8/26/2024 at 3:15 p.m., the Transfer Form indicated that Resident 216 was sent to GACH due to swallowing two batteries. During an interview on 8/29/2024 at 1:43 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 216 needed to be monitored closely at least every 30 minutes because she had swallowed a paper clip before and the Resident 216 eats strange stuff that is not food. CNA 1 stated he was assigned to Resident 216 on the day of the incident (8/25/2024); however, he (CNA 1) was unable to watch her every 30 minutes because I had nine other residents. During an interview on 8/29/2024 at 4:13 p.m. with RNS 1, RNS 1 stated, on 8/19/2024 around 9:30 p.m., Resident 216 came to the nursing station and told her (RNS 1) that earlier in the day around 3 p.m., her (Resident 216) roommate kept going through her (Resident 216) stuff, she (Resident 216) got upset, went to the patio, found a paperclip and she (Resident 216) swallowed it. RNS 1 stated Resident 216 wanted to go to the hospital so I called the doctor for an x-ray, and it was ordered STAT. RNS 1 stated at 11 p.m., when she was leaving the facility, the x-ray had not been done because the x-ray technician said they needed to check for eligibility first. RNS 1 stated she did not notify the doctor about this. RNS 1 stated, I only told the night shift that they (diagnostic lab [DL]) needed to check eligibility for the STAT x-ray before they can do it. RNS 1 stated, I should have called the doctor and let him know that the STAT x-ray was not done and that they (DL) were waiting for a referral before they could do it (x-ray). RNS 1 stated potential adverse outcomes of swallowing a paperclip were bleeding from the puncture because it is a metal. RNS 1 stated she worked the next day (8/20/2024), her shift started at 3 p.m. Resident 216 was still in the facility and her (Resident 216) x-ray results came back that afternoon. RNS 1 stated she notified the doctor of the x-ray results which showed a paperclip in the stomach. RNS 1 stated the doctor stated she (Resident 216) was not in danger, it (paperclip) will pass. RNS 1 stated Resident 216 left for GACH around 10:30 p.m., because she is 300 pounds (lbs - unit of measure), I could not find an ambulance that could take her. RNS 1 stated Resident 216 returned to the facility on 8/21/2024 and there were no changes made to the resident's orders. RNS 1 stated Resident 216, upon returning from GACH to the facility, did not have a one on one (involves providing support specifically to one resident) staff watching her (Resident 216). RNS 1 stated on 8/25/2024 around 5:30 p.m., Resident 216 went to the nursing station and told RNS 1 that she (Resident 216) had swallowed a toothbrush because her roommate was going through her stuff and the resident was upset. RNS 1 stated potential adverse outcomes of ingesting a foreign object such as a toothbrush were pain, puncture of the abdominal wall, bleeding, choking. RNS 1 stated she did not call 911 (telephone number used to reach emergency medical, fire, and police services) because she did not think it was an emergency. RNS 1 stated Resident 216 was transferred to GACH the next day (8/26/2024) after the x-ray results showed that Resident 216 had batteries in the stomach. RNS 1 was asked what the potential adverse outcomes of ingesting a foreign object such as batteries were, RNS 1declined to respond to the question. During a concurrent interview and record review, on 8/29/2024 at 5:38 p.m., with the IDON, Resident 216's care plan focusing on resident's risk for injury, initiated on 8/19/2024 and revised on 8/26/2024 was reviewed. The care plan goal included to closely monitor patient. The IDON stated, closely monitor patient meant one-on-one sitter for the resident. The care plan interventions/tasks included to provide one-to-one bedside monitoring if recommended by the IDT or attending physician/ psychiatrist (medical doctor specializing in mental health disorders). The IDON stated potential adverse outcomes of ingesting foreign objects such as paper clip and batteries were difficulty breathing, nausea, vomiting, obstruction, internal bleeding, hypotension (low blood pressure), altered consciousness, respiratory distress, possibly infection, poisoning, and death. The IDON stated ingestion of a paperclip and batteries is an emergency and we have to call 911 right away. During an interview on 8/30/2024 at 1:21 p.m., with the Medical Director (MD), MD stated, he spoke with the ADM and was aware that Resident 216 had swallowed a paper clip and batteries. The MD stated a resident who ingests a foreign object needs to go and get evaluated at the hospital right away. It is an emergency. MD stated potential adverse outcomes of ingesting batteries can leak toxic chemicals which cause affect the kidneys, stomach, brain or even cause perforation of the stomach. A review of the facility's policy and procedures (P&P) titled, Safety and Supervision of Residents, revised in 12/2007, indicated Policy Statement: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities . Facility oriented approach to safety . 2. 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 Analysis (QA &A) review of safety and incident/accident reports; and a facility-wide commitment to safety all levels of the organization . Resident oriented approach to safety: 1. Our resident-oriented approach to safety addresses safety and accident hazards for individual residents . 3.The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazard or risk for that resident. The care team shall target interventions to reduce the potential for accidents. A review of the facility's (P&P) titled, Hazardous Areas, Devices and Equipment, revised in 7/2017, indicated Policy statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Identification of Hazards . 1.A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of sentimental hazards include, but are not limited to the following: c. sharp objects that are accessible to vulnerable residents; . g. access to toxic chemicals; A review of the facility's P&P, titled, Transfer or Discharge, Emergency, revised in 8/2018, indicated Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s). A review of the undated Duracell (brand name of batteries) Safety Data Sheet, indicated Section 4: First Aid and Measures . Swallowed: If battery contents are swallowed, do not induce vomiting .Seek immediate medical attention.

CONCERN (D)

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

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 32), had a Resident Representative (RR- An individual chosen by the resident or authorized by State or Federal law to act on behalf of the resident) with legal authority to make medical decisions for the resident. This failure had the potential to result in violation of Resident 32's rights to receive treatment. Findings: During a review of Resident 32's admission Record dated 8/28/2024, the admission Record indicated the facility admitted Resident 32 on 5/17/2024 with diagnoses including, but not limited to, schizoaffective disorder depressive type (a mental health condition effecting mood, thoughts, and behavior, involving combination of feeling of sadness, with hallucinations and believes that might not be true), anxiety disorder (feeling of anxiousness that affects daily life). The admission Record indicated Resident 32's responsible party is a friend (RR 1). During a review of Resident 32's History and Physical (H&P), dated May 2024, the H&P indicated Resident 32 has fluctuating capacity to understand and make decisions. During a review of Resident 32's Physician Orders for Life-Sustaining Treatment (POLST-Physician order that allows residents and their representatives to decide what kind of treatment they want to receive), dated 6/11/24, the POLST indicated RR 1 signed the form to consent on behalf of Resident 32 to receive all medically appropriate and possible treatments to save Resident 32's life. During a review of Resident 32's Informed Consent to Psychotropic Drug, Physical Restraint or Medical Device (IC-written form stating resident or RR gives permission to a Physician for a treatment with full knowledge of possible risks and benefits), dated 6/11/24, the IC indicated RR 1 signed it to consent on behalf of Resident 32 to receive two antipsychotic medications ( a substance that can change how a person's brain works and can affect awareness, thoughts, mood, and behavior). During a review of Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 6/14/24, the MDS indicated Resident 32 is rarely or never understood and has poor ability to make decisions. During a review of Resident 32's Psychological Progress Note, dated August 2024, the Psychological Progress Note indicated Resident 32 had severe impairment in cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). During an interview on 8/29/24, at 12:10 p.m., with RR 1, RR 1 stated she has been friends with Resident 32 for four to five years but has not signed a document to become a decision maker for Resident 32. She also stated sometimes she receives calls from nurses asking if they can give Resident 32 certain medications. During an observation on 8/30/24, at 10:25 a.m., in the facility hallway, Resident 32 was walking and talking to himself. It was difficult to understand his speech. During an interview on 8/30/24, at 1:19 p.m., with Medical Director (MD), the MD stated residents who do not have the ability to understand and make decisions, a family member should be assigned as the resident representative. For residents who do not have a family member, the Social Worker needs to clarify who has the right to make decisions for a resident. The MD further stated a friend cannot make medical decisions for a resident. During an interview on 8/30/24, at 1:31 p.m., with Social Services Director (SSD), the SSD stated based on new regulations, friends are allowed to make decisions for residents who do not have the capacity to make decisions for themselves. The SSD stated all communications with RR 1 has been via telephone. During a follow up interview on 8/30/24, at 2:25 p.m., with SSD, the SSD stated she does not have a document to show that a friend of a resident can make medical decisions on behave of the resident. During an interview on 8/30/24, at 5:13 p.m., with the Director of Nursing (DON), the DON stated a friend cannot be considered a decision maker for a resident. The DON also stated a consent signed by a friend is not a legal document and cannot be carried out since it has the potential to deprive the residents of their rights. During a review of facility's policy and Procedure (P&P) titled, Advance Directives, dated 09/2022, the P&P indicated, Legal Representative (i.e., substitute decision-maker, proxy, agent) - a person designated and authorized by an advance directive or state law to make treatment decision for another person in the event the other person becomes unable to make necessary healthcare decisions. The policy further indicated, prior to or upon admission of a resident, the social services director or designee inquires of the Resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, dated June 2019, the P&P indicated, When initiating a new order or an increase in psychotropic drugs, the attending physician will: a) Obtain informed consent from Resident or Responsible Party, b) Seek the consent of the Resident's legal representative uintelligible c) The IDT team may give informed consent on behalf of the Resident, if and only if the resident is not capable of making decisions and there is no surrogate decision maker. During a review of facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2016 indicated, unauthorized release, access, or disclosure of Resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a facility tour on 8/29/2024 at 11:52 a.m., observed resident shower rooms [ROOM NUMBERS] to have shower curtains with black stains in the middle and the bottom of the shower curtains. During an interview on 8/29/2024 at 2:29 p.m., with the Maintenance Supervisor (MS), the MS stated the shower curtains are washed daily. After showing MS the blacks stains on the shower curtains, the MS stated the shower curtains looked clean because the shower curtains were washed yesterday (8/28/2024). During an interview on 8/29/2024 at 2:47 p.m., with the Housekeeping Supervisor, (HS), the HS stated the shower curtains in patient shower rooms [ROOM NUMBERS] are washed every two weeks. The HS stated she (HS) changed the shower curtains in resident shower rooms [ROOM NUMBERS] on 8/28/2024. The HS stated there were black stains on the shower curtains but stated not knowing where the black stains came from. The HS stated the shower curtains in resident shower rooms [ROOM NUMBERS] are clean, I changed them yesterday (8/28/2024). The HS stated even when the shower curtains were dirty, she (HS) will still wait for two weeks before the shower curtains are changed. The HS stated there were no logs to write when shower curtains were last changed. The HS was asked how HS would know when to change the shower curtains if there were no logs showing when the shower curtains were last changed, HS just shrugged shoulders but did not provide an answer. During an interview on 8/30/2024 at 12:18 p.m., with LVN 1, LVN 1 stated shower curtains in resident shower rooms [ROOM NUMBERS] should be replaced weekly and whenever the curtains are visibly dirty with stains or dirt. LVN 1 was asked how dirty shower curtains with black stains would affect the residents using the shower rooms, LVN 1 stated dirty shower curtains may cause skin infections if residents have open wounds or if shower curtains have odors, may cause breathing problems with the residents. During an interview on 8/30/2024 at 5:50 PM, with the Quality Assurance Nurse (QAN), the QAN stated shower curtains should be replaced weekly and whenever the shower curtains have visible dirt or body fluids. The QAN stated the MS, or the HS were responsible in replacing shower curtains. The QAN was asked how dirty shower curtains would affect the residents' health, the QAN stated some residents may refuse to shower with dirty shower curtains, residents may feel dirty, may cause breathing issues when residents inhale the dirt or foul odor. During a review of the facility's policy and procedure (P&P) titled Shower/Tub Bath with a revision date 10/2010, the P&P indicated, the purpose of the shower bath was to promote cleanliness. The P&P indicated for staff to ensure shower is clean. During a review of the facility's P&P titled Quality of Life - Homelike Environment with a revision date 04/2014, the P&P indicated, the facility shall maximize the characteristics of the facility that reflect a personalized homelike setting that includes cleanliness and order. Based on observation and interview facility failed to provide a safe, clean, and sanitary environment for residents by: 1. Failing to clean and disinfect a [NAME] and [NAME] bathroom (a bathroom that has 2 doors and is accessible to two bedrooms) shared by five residents in room [ROOM NUMBER] and 23. This deficient practice had the potential to expose the residents to disease causing microorganisms and could cause vomiting and diarrhea, severe dehydration, resulting in unnecessary hospitalization, and even death. 2. Failing to ensure shower curtains in resident shower rooms [ROOM NUMBERS] were not visibly dirty. This deficient practice has the potential to cause infection to residents when dirty shower curtains in both resident shower rooms [ROOM NUMBERS] were kept in use. Findings: 1. During an initial facility tour on 8/27/2024 at 7:38 a.m., the [NAME] and [NAME] toilet accessible to residents in room [ROOM NUMBER] and 23 was observed to have fecal matter smeared on the toilet seat, toilet cover and the outside walls of the toilet bowl. During an observation and interview on 8/27/2024 at 7:47a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated resident bathrooms are supposed to be kept clean. CNA 3 further stated unsanitary bathrooms places residents at risk for infection. During an interview on 8/31/2024 at 3:23 p.m., with the Director of Nursing (DON), the DON stated the housekeeping staff is responsible for ensuring resident rooms and bathrooms are clean. The DON was unable to state the working days and hours of facility housekeeping staff. The DON stated residents could contract disease causing microorganisms and other communicable diseases, such as C-Difficile (a bacteria that cause diarrhea and inflammation of the colon), and other gastrointestinal (GI) diseases when using an unclean bathroom, which could lead to unnecessary hospitalization. A review of facility policy and procedure (P&P) titled Quality of life-Homelike Environment dated 04/2014 stated, Residents are provided with a safe, clean .homelike environment. The policy further states, the facility staff and management shall maximize to the extent possible the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include Cleanliness and order.

CONCERN (D)

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 investigate and report allegations of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of 23 sampled residents (Resident 215) to the State Agency (SA), to the Long Term Care Ombudsman (LTC Ombudsman -an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse Reporting and Investigation updated on 11/2018, by failing to report an allegation of employee-to-resident altercation within two hours after the allegation occurred on 8/20/2024. This deficient practice had the potential to place Resident 215 at risk for abuse and delay of onsite investigation by the State Agency to ensure the residents' allegation of abuse was investigated. Findings: During a review of Resident 215's admission Record, the admission Record indicated the facility admitted the resident to the facility on 8/10/2024 with medical diagnoses that included anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), muscle weakness (a decrease in muscle strength), and hypertension (HTN -blood pumping with more force than normal through your arteries). During a review of Resident 1's History and Physical (H&P) dated 8/10/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 215's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 8/13/2024, the MDS indicated Resident 215 had intact cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), required partial/moderate to supervisory/touch assistance from staff for activities of daily living. During an interview on 8/27/2024, at 8:18 A.M., with Resident 215, Resident 215 stated on 8/20/2024 near lunch time about 12:30 P.M., the resident had activated the call light for staff assistance to ask for his medication and the Infection Preventionist Nurse (IPN) came into his room to answer the call light. Resident 215 stated he pushed me out of the way to turn the call light off. I told the Administrator (ADM) about it. He (ADM) did nothing, he ignored me, and it did not make me feel good like I was not paying for this place (facility). During an interview on 8/28/2024, at 10:43 A.M., with the IPN, the IPN stated sometime last week, I don't remember exactly when but maybe Wednesday (8/20/2024), a Certified Nurse Assistant (CNA) reported to the IPN that Resident 215 had extra trays in his room. The IPN stated he went to Resident 215's room and found that the resident had three trays in his room. The IPN stated he asked Resident 215 if he could return the trays to the kitchen so that the kitchen is not short of the trays. The IPN stated Resident 215 wanted to keep the cups and the IPN told the resident the resident can keep the cups, but he (IPN) will take the trays back to the kitchen. The IPN stated the call light was on when he was in the resident's room and as he (IPN) was approaching the call light switch which was behind Resident 215, the resident stated oh, now you want to hit me? The IPN stated the resident switched off the call light himself and told the IPN to get out of the room. The IPN stated he reported the incident to the Administrator (ADM). During an interview on 8/28/2024, at 11:21 A.M., with the ADM, the ADM stated he was not aware of the incident that happened between Resident 215 and the IPN. During an observation on 8/29/24, at 07:15 A.M., the IPN was in the hallway by the nursing station walking towards the back of the facility. During an observation on 8/29/24, at 02:02 P.M., the IPN was in the first south hallway, walking out of his office to the main hallway. During an observation on 8/29/24, at 12:58 P.M., the IPN was in the main hallway walking from the front of the facility to the back. During an observation on 8/29/24, at 1:58 P.M., IPN was in the nursing station. During an interview on 8/30/2024, at 8:07 A.M., with ADM, the ADM stated when there is a report of abuse allegation between an employee and a resident, the abuse allegation should be reported to the ombudsman, the police and to the State Agency. The ADM stated employee is sent home immediately and will not report to work until the investigation is done. The ADM stated the potential adverse outcome of the employee not being sent home is the resident may not feel safe. During a review of the facility's P&P titled Abuse Reporting and Investigation updated 11/2018, the P&P indicated the facility will report ALL allegations of abuse as required by law and regulations to the appropriate agencies within 2 hours . ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies . b. Abuse Prevention Coordinator (APC) will notify the LTC Ombudsman and the Law enforcement . in writing (SOC 341) within two (2) hours of initial report.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

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: 1. Residents 37 and 49 received their PASARR Level II (Level II) evaluations and determinations (determines the appropriate settings for the resident and recommends what specialized services and/or rehabilitative services the resident needs) when admitted to the facility. 2. Residents 37 and 49 Level II care plans were based on the recommendations of Level II evaluations and determinations. These deficiencies have the potential for Residents 37 and 49 to miss specialized services and or rehabilitative services as indicated by Level II evaluations and determinations. Findings: a. During a review of Resident 37's admission Record (background information; a document containing demographic and diagnostic information), the admission Record indicated, the facility admitted Resident 37 to the facility on [DATE] and readmitted the resident on 2/08/2024 with diagnoses including schizophrenia (a mental illness that cause disturbed or unusual interest in life, and strong or inappropriate emotions; usually involves delusions[(false beliefs], hallucinations [seeing or hearing things that do not exist], unusual physical behavior, & disorganized thinking & speech), anxiety disorder (a condition of excessive worry about daily issues and situations), major depressive disorder (causes a persistently low or depressed mood and a loss of interest in activities), and psychoactive substance (drugs that change a person's experiences or consciousness) abuse with unspecified psychoactive substance-induced disorder (caused by the misuse of psychoactive substance drugs). During a review of Resident 37's Minimum Data Set (MDS - a core set of screening, clinical and functional status elements forming the foundation of a comprehensive assessment), dated 7/12/2024, the MDS indicated, Resident 37 had a severely impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). MDS indicated, Resident 37 had active diagnoses of anxiety disorder, depression, and schizophrenia. During a review of Resident 37's History and Physical (H&P- a physician's complete patient examination) examination dated 10/31/2023, the H&P indicated Resident 37 did not have the capacity to understand and make decisions. During a review of Resident 37's Psychiatric Progress Note (a standardized tool used by psychiatrist to record resident's mental health evaluation, diagnosis, treatment plans, and progress updates) dated 8/09/2024, the note indicated, Resident 37 continue to be on psychoactive medications but have no side effects from the medications. During a review of Resident 37's Care Plan (CP, a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) on schizophrenia dated 10/30/2023 with revision dates of 1/2024, 4/2024, and 7/2024, the CP indicated, Resident 37 was at risk for increasing confusion and disordered thought secondary to schizophrenia with a goal of Resident 37 will have less episode of confusion or disordered thoughts daily for 90 days. The care plan on depression dated 10/30/2023 with revision dates of 1/2024, 4/2024, and 7/2024, indicated, Resident 37 was depressed as shown by poor appetite with a goal of Resident 37 having less episode of depression for 90 days. Both care plans have a re-evaluation date of 10/2024. During a review of Resident 37's Care Plan, the CP did not indicate completion of PASARR Level II care plan. b. During a review of Resident 49's face sheet, the face sheet indicated Resident 49 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including schizophrenia and metabolic encephalopathy (a general term that describes a brain disease, damage, or malfunction; brain function is disturbed). During a review of Resident 49's H&P dated 7/12/2024, indicated, Resident 49 had the capacity to understand and make decisions. During a review of Resident 49's Physician Progress Notes (captures the details of a patient's health status, treatment progress, and any changes in their condition over time), dated 8/15/2024, indicated, Resident 49 was being monitored and under the care of a psychiatrist for psychosis (a person loses contact with reality). During a review of Resident 49's Psychological Progress Note dated 8/15/2024, the note indicated, Resident 49 reported feeling down having ongoing depression due to encephalopathy (brain dysfunction that can appear as confusion, memory loss, personality changes) that affected Resident 49's memory which created anxiety. During a review of Resident 49's MDS dated [DATE], the MDS indicated, Resident 49 had a severely impaired cognition. The MDS indicated Resident 49 has an active diagnosis of schizophrenia. During review of Resident 49's Care Plan on schizophrenia dated 7/12/2024 with a re-evaluation date of 10/2024, the CP indicated, Resident 49 was at risk for increasing confusion and disordered thought secondary to schizophrenia with a goal of Resident 49 will have less episode of confusion or disordered thoughts daily for 90 days. During a review of Resident 49's Care Plan, the CP did not indicate completion of PASARR Level II care plan. During a concurrent interview and record review on 8/28/2024 at 9:29 AM with the Minimum Data Set Nurse (MDSN), the MDSN stated, Resident 37 had a positive Level I (an individual with an identified mental health disorder [a significant disturbance in an individual's cognition, emotional regulation, or behavior] or intellectual disability disorder [a condition that involves limitations on intelligence, learning, and everyday abilities]). The MDSN stated Resident 37's Level II cannot be found anywhere in the medical chart (paper charting) nor in the electronic health record. The MDSN stated Level I or Level II documents cannot be found anywhere else in the facility. The MDSN stated failure to coordinate Resident 37's Level II evaluation. The MDSN was asked what may happen to the resident when Level II was not coordinated with the State-designated authority, the MDSN stated Resident 37's mental health needs may not be appropriately addressed. The MDSN stated Resident 37 may get worse such as hearing voices, striking staff physically, and become verbally aggressive. During a concurrent interview and record review on 8/28/2024 at 8:27 AM with MDSN, the MDSN stated, Resident 49 had a positive Level I. MDS acknowledged Resident 49's Level II cannot be found anywhere in the medical chart (paper charting) nor in the electronic health record. The MDSN stated Level I or Level II document cannot be found anywhere else in the facility. MDSN acknowledged failure to coordinate Resident 49's Level II evaluation. The MDSN was asked what may happen to the resident when Level II was not coordinated with the State-designated authority, the MDSN stated Resident 49's mental health needs may not be appropriately addressed. The MDSN stated Resident 49 may get worse such as hearing voices, striking staff physically, and become verbally aggressive. During a review of the facility's policy and procedure (P&P) titled Pre-admission Screening and Resident Review (PASARR) with a release date of 12/2017, the P&P indicated, a positive Level I requires an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to the nursing facility.

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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Based on observation, interview and record review, the facility failed to ensure pharmaceutical services meet the needs of residents by failing to safeguard the access and disposition (the process of returning and/or destroying) of unused medications. This deficient practice had the potential for loss of accountability, that could affect the controls against drug loss and diversion (illegal transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use), and theft. During a medication storage inspection on 08/27/24 at 9:55 am, inside the medication room, observed a bucket with a red plastic biohazard bag liner and a wide lid cover which had a paper taped to it with the statement Please do not throw away med cups, syringes, ETC, here. The plastic biohazard bag was observed to have an assortment of medications pills, insulin bottles, inhalers, eyedrop containers and insulin pens inside it. During an interview on 8/27/2024 at 10:05 am, with Licensed Vocational Nurse (LVN2), LVN 2 stated the medication room is accessible to licensed nursing staff only, and the bucket is a pharmaceutical medication waste bucket used to discard medications of discharged residents. LVN 2 stated the Director of Nursing (DON) discards narcotic medication inside the waste bucket monthly. During an interview on 8/27/2024 at 10:20 am, with the DON, the DON stated she and the facility contracted pharmacist reconcile and document administered and non-administered narcotic medications in the narcotic sheet to ensure accountability. The DON stated she (DON), in the presence of the pharmacist, disposes of each narcotic medication pill into the same pharmaceutical waste bucket where the non-narcotic medications are wasted. The DON stated the pharmaceutical waste bucket is not locked; a facility contracted vendor picks up the wasted medications as is. During a follow-up interview on 8/30/2024 at 9:40 am, with the DON, the DON stated she has never witnessed the medications getting picked up by the facility contracted vendor. The DON stated the pharmaceutical waste bucket has no lock, opens easily and the wasted narcotic and non-medications are easily retrievable. The DON stated facility has no control of what happens once the narcotic and non-narcotic medications are picked up by the contracted waste management vendor. The DON stated the narcotic and non-narcotic medications can be easily diverted and adulterated (a drug or device that is unsafe, defective, or not produced under sanitary conditions). The DON further stated licensed staff with access to the medication storage room can also divert the medications for personal consumptions and/or diversion. During a telephone interview on 8/30/2024 at 10:12 am, with the facility contracted pharmacist (PHM), the PHM stated, narcotic medications should be wasted in a sealed medical waste container with liquid substance such as bleach inside and the the sealed container should have a hole that is smaller than one's fist to prevent adulteration and/or diversion. During a review of facility policy and procedure (P&P) titled Discarding and Destroying medications, the P&P indicated, for unused, non-hazardous controlled substances that are not disposed by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps: Take the medications out of the original containers, mix medication with either liquid or solid with an undesirable substance. Undesirable substance include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. The policy indicated, destruction of a controlled substance must render it non-retrievable, meaning the process permanently alters the physical or chemical properties of the substance so that it is no longer available or usable, and cannot be illegally diverted.

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 maintain the kitchen in a clean, safe, and sanitary condition in which food was stored, prepared, and served in accordance with professional standards of food service safety by: 1. Failing to ensure the Dietary [NAME] (DC) follow facility policy for proper cooling process for foods prepared in advance of service. 2. Failing ensure the resident refrigerator (refrigerator for food brougfhgt in by family members) was in working order and ensure the food items stored in the refrigerator and freezer were dated and labeled. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness for residents who received food from the facility including residents who had food stored in the resident refrigerator. Findings These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 70 of 70 medically compromised residents who received food and have food prepared from the kitchen staff. Findings: a. During the initial tour observation of the kitchen and interview on 08/27/24 at 07:52 a.m, with the Dietary Supervisor (DS), observed inside the walk-in refrigerator a pan of cooked roast beef. The DS stated she did not cook the roast beef. During an observation of the temperature of the cooked roast beef with DS current temperature is 62 degrees. The DS checked the temperature of the roast beef with two different thermometers. The DS stated the current temperature of the roast beef is 62 degrees Fahrenheit (a scale of temperature). The DS was able to explain the preparation, cooking, and the cooling down system for roast beef. The DS stated if the residents consume foods that are not cooked and prepared properly, the residents can get very sick, and may experience vomiting and stomach aches. The DS stated it is important to complete annual skills competencies so that the cooks and the other kitchen staff remember how to do their jobs correctly. During an interview on 08/27/24 at 08:26 am, with the Dietary [NAME] (DC), the DC stated she has been employed with the facility for five years. The DC Stated she cooked the roast beef and started the preparation of the cool down process for the roast beef in question. The DC stated she cooked the roast beef for 3-4 hours. and took the roast beef out of the oven on 8/26/24 at 12:00 p.m. The DC stated she placed the roast beef in the refrigerator with the temperature at 165 degrees. The DC stated as of today the temperature should be at 38 to 39 degrees Fahrenheit. The DC stated the temperature of the roast beef should be between 35-41 degrees Fahrenheit within six 6 hours after cooking. The DC stated she does not know the complete cooling process when cooking roast beef. The DC stated if roast beef is not prepared and cooked properly the residents can get very sick. During an interview on 08/27/24 at 10:56 a.m., with the DS. The DS stated she spoke with the Registered Dietician (RD) and they (DS and RD) decided to discard the roast beef and replace the meat with Salisbury steak for lunch. The DS stated the kitchen staff were not in-serviced for cooling down process for food. During an observation on 08/27/24 at 12:13 pm, of food tray line for lunch. The DS and the DC replaced the roast beef with Salisbury steak. The dietary staff followed the recipe for Salisbury steak for lunch correctly. During an interview on 08/30/24 at 03:15 pm, with the RD, the RD stated the dietary staff is supposed to complete their annual skills competencies with the DS annually. The RD stated most of the dietary in-services are given by the DS. The RD stated all dietary cooks should know the cooling down method for roast beef. The RD stated if the food is not prepared and cooked properly the residents can get very sick. During a review of the facility policy and procedure (P&P) titled Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, the P&P indicated when cooked PHF or TCS food will not be served right away it must be cooled as quickly as possible. The method is the two stage method: . Cool cooked food from 140 degrees Fahrenheit to 70 degrees Fahrenheit within two hours. . Then cool from 70 degrees F to 41 degrees Fahrenheit or less in an additional four hours for a total cooling time of six hours. During a review of the facilities policy titled Food and Nutrition Service Staff with a revised date of 10/2017, indicated the food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department. b. During an observation on 08/29/24 at 08:05 am, of residents outside food storage refrigerator with the Housekeeping Supervisor (HKS) and Registered Nurse Supervisor (RNS), observed the refrigerator to be unplugged with a foul odor. The food items observed inside the refrigerator were whipping cream, fresh strawberries, grapes, berries, 3 cups of milk, green salsa, ham lunch meat, a dozen of fresh uncooked eggs, a container of unknown food, two plastic bags with unknown food items, mayonnaise, salad dressing, potato salad. Observed the freezer with 1 ice cream bar, 1 container of ice cream, and three other unknown and unlabeled food items thawed and sitting in a puddle of water. The thermometer for the refrigerator read 10 degrees and the thermometer for the freezer at 70 degrees. During an interview on 08/29/24 at 08:25 am, with the HKS, the HKS stated she is responsible for cleaning the residents outside food storage refrigerator. The HKS stated she checked the refrigerator on 8/28/2024 but did not discard any of the food or liquids that were improperly stored and labeled in the refrigerator. The HKS stated if she does not clean the residents outside food storage refrigerator, the residents could consume food not properly stored and labeled and the residents could get very sick. The HKS stated the facility do not keep a log for cleaning the resident refrigerator. The HKS stated if the thermometer for the resident refrigerator is not working properly, she will report it to Maintenance Supervisor. During an interview on 08/29/24 at 08:39 am, with RNS 2, RNS 2 stated when outside food is brought into the facility it is the nurse's responsibility to label and store the resident's food properly in the outside food storage refrigerator. RNS 2 stated it is housekeeping's responsibility to clean out the refrigerator once a week on Fridays and discard all the food and drink items that are not labeled properly and all expired food. RNS 2 stated if the residents consume spoiled food the residents can get really sick and may experience vomiting and diarrhea. During an interview on 08/30/24 at 02:15 p.m., with the DON, the DON stated it is the HKS's responsibility to clean out the food storage refrigerator for the residents. The DON stated if the residents consume foods that are not cooked, labeled, and stored, and prepared properly by the facility kitchen and staff, the residents can become ill. During a review of the facilities policy and procedure (P&P) titled Food brought in by family members with a revised date of 10/2017, the P&P indicated: 8. The nursing staff will discard perishable foods on or before the used by date. 9. The nursing and /or food service staff will discard any foods prepared for the residents that show obvious signs of potential foodborne danger. During a review of the facilities policy and procedure (P&P) titled Refrigerators and Freezers with a revised date of 11/2022, the P&P indicated; 1. Refrigerators and or freezers are maintained in good working condition. Refrigerators keep foods at or below 41 degrees and freezers keep frozen foods frozen solid.

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, facility failed to: 1. Clean and disinfect a frequently used and visibly soiled toilet surface shared by residents in room [ROOM NUMBER] and 23. 2. Clean and disinfect the surface of dispensers filled with alcohol-based hand rub placed in hallways next to rooms next to resident rooms 22, 24, 25, 26, 27. 3. Disinfect and clean dried dark colored smears observed on door frame of room [ROOM NUMBER]. These deficient practices had the potential to result in pathogen (germ) exposure by disease causing microorganisms and placed the facility residents and staff at risk for developing symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever that could lead to other serious medical complications and unnecessary hospitalization of residents and staff. Findings: 1. During an initial facility tour on 8/27/2024 at 7:38 a.m., the [NAME] and [NAME] toilet accessible to residents in room [ROOM NUMBER] and 23 was observed with fecal matter smeared on the toilet seat, toilet cover and the outside walls of the toilet bowl. During a concurrent observation and interview on 8/27/2024 at 7:47 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated resident bathrooms are supposed to be kept clean. CNA 3 further stated unsanitary bathrooms places residents at risk for infection. During a concurrent observation and interview with 08/27/24 at 08:11 a.m., with the Infection Preventionist (IP), observed the bottom portion of hand sanitizer dispensers next to rooms 22, 24, 25, 26, 27 to have grey black residue. The IP stated he (IP) and the maintenance supervisor will replace the hand sanitizers and clean the dispensers. During an observation on 8/28/2024 at 11:28 a.m., the door frame of room [ROOM NUMBER] was observed to have dried dark colored smears. During an interview on 8/28/2024 at 11:32 a.m., with the Quality Assurance Nurse (QA Nurse), the QA Nurse stated the dried smears observed on the door frame of room [ROOM NUMBER] is fecal matter. The QA nurse further stated the door frame should be free of fecal matter for infection control. During an interview on 8/31/2024 at 9:19 a.m., with the House Keeping Supervisor (HKS), stated she cleans the side-rails and ABHR dispensers 3x a day, cleans the entry ways at least once a week and as needed. The HKS stated the whole dispenser including areas not visible should be cleaned. The HSK stated she works from Monday through Friday from 5:00 a.m. to 1:30 p.m. During an interview on 8/31/2024 at 3:23 p.m., with the Director of Nursing (DON), the DON stated the housekeeping staff is responsible for ensuring resident rooms and bathrooms are clean. The DON stated residents could contract disease causing microorganisms and other communicable diseases, such as C-difficile (a bacteria that cause diarrhea and inflammation of the colon), and other gastrointestinal (GI) diseases when using an unclean bathroom, which could lead to unnecessary hospitalization. During a review of facility policy and procedure (P&P) titled Monitoring Compliance with Infection Control, dated, 08/2019, the P&P indicated, the infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and practices. During a review of facility policy and procedure titled Cleaning and Disinfecting environmental Surfaces dated 08/2019, the P&P indicated environmental surfaces will be cleaned and disinfected according to the current Center for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the OSHA .pathogen standard. Policy states housekeeping surfaces will be cleaned on a regular basis when spills occur and when these surfaces are visibly soiled. Policy further states Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.

CONCERN (F)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

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Based on interview and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills to ensure the Dietary [NAME] was able to verbalize proper cooling procedures of food. This failure had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 70 of 70 medically compromised residents who received food and have food prepared from the kitchen staff. Findings: During the initial tour observation of the kitchen and interview on 08/27/24 at 07:52 am, with the Dietary Supervisor (DS), observed inside the walk-in refrigerator a pan of cooked roast beef. The DS stated she did not cook the roast beef. During an observation of the temperature of the cooked roast beef with DS current temperature is 62 degrees. The DS checked the temperature of the roast beef with two different thermometers. The DS stated the current temperature of the roast beef is 62 degrees Fahrenheit (a scale of temperature). The DS was able to explain the preparation, cooking, and the cooling down system for roast beef. The DS stated if the residents consume foods that are not cooked and prepared properly, the residents can get very sick, and may experience vomiting and stomach aches. The DS stated it is important to complete annual skills competencies so that the cooks and the other kitchen staff remember how to do their jobs correctly. During an interview on 08/27/24 at 08:26 am, with the Dietary [NAME] (DC), the DC stated she has been employed with the facility for five years. The DC Stated she cooked the roast beef and started the preparation of the cool down process for the roast beef in question. The DC stated she cooked the roast beef for 3-4 hours. and took the roast beef out of the oven on 8/26/24 at 12:00 p.m. The DC stated she placed the roast beef in the refrigerator with the temperature at 165 degrees. The DC stated as of today the temperature should be at 38 to 39 degrees Fahrenheit. The DC stated the temperature of the roast beef should be between 35-41 degrees Fahrenheit within six hours after cooking. The DC stated she does not know the complete cooling process when cooking roast beef. The DC stated if roast beef is not prepared and cooked properly the residents can get very sick. During a review of the facility policy and procedure (P&P) titled Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023, the P&P indicated when cooked PHF or TCS food will not be served right away it must be cooled as quickly as possible. The method is the two stage method: . Cool cooked food from 140 degrees Fahrenheit to 70 degrees Fahrenheit within two hours. . Then cool from 70 degrees F to 41 degrees Fahrenheit or less in an additional four hours for a total cooling time of six hours. During a review of the facilities policy titled Food and Nutrition Service Staff with a revised date of 10/2017, indicated the food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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Based on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 24 of 24 resident rooms, (rooms 1,2, 3,4,5,6,7,8,10,11,12,14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the safety and quality of life for the residents. Findings: During a review of the Request for Room Size Waiver letter submitted by the Administrator, dated 8/29/2024, the letter indicated 24 resident rooms in the facility that do not meet the requirement of at least 80 square feet per resident per federal regulation. The letter indicated the resident beds are in accordance with the special needs of the residents and will not adversely affect the residents' health and safety and do not impede the ability of the residents in the room to obtain their highest practicable well- being. The following rooms provided are less than 80 sq. ft. pr resident: Room Room Size Floor Area #of beds 1 15.75x11.25 177.19 3 2 15.83x11.25 178.0 3 3 15.83x11.25 178.0 3 4 15.83x11.25 178.0 3 5 15.83x11.25 178.0 3 6 15.83x11.25 178.0 3 7 15.83x11.25 178.0 3 8 15.83x11.25 178.0 3 10 15.83x11.25 178.0 3 11 15.83x11.25 178.0 3 12 15.83x11.25 178.0 3 14 15.83x11.25 178.0 3 15 15.83x11.25 178.0 3 16 15.83x11.25 178.0 3 17 15.83x11.25 178.0 3 19 15.83x11.25 178.0 3 20 15.83x11.25 178.0 3 21 15.83x11.25 178.9 3 22 15.83x11.25 178.0 3 23 15.83x11.25 178.0 3 24 15.83x11.25 178.0 3 25 15.83x11.25 178.0 3 26 15.83x11.25 178.0 3 27 15.83x11.25 178.0 3 According to the federal regulation, the minimum square footage for a 3 bedroom should be at least 240 sq. ft. During the recertification survey on 8/30/2024, staff interviews indicated there were no concerns regarding the size of the rooms. During multiple observations of the resident's rooms from 8/27/2024-8/31/2024, the residents had ample space to move freely inside the rooms. There were sufficient spaces to provide freedom of movement for the residents and for nursing staff to provide care to the residents. There were sufficient spaces for bedside tables, side tables and resident care equipment. During a concurrent observation and interview on 8/28/2024, at 9:44 A.M., with the Maintenance Supervisor (MS) using tape measurer to measure the size of the room from the window to the door for the length, then measuring from wall to the start of the closet horizontally for the width. The MS stated, this is how I measure to verify the size of the rooms. During an interview on 8/30/2024 at 2:47 P.M., with the Administrator (ADM), the ADM stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care.

Aug 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

Safe Environment (Tag F0921)

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 a safe, functional, and comfortable environment for all residents when one of two showers (Shower room [ROOM NUMBER]) was observed on 8/19/2024 without a shower valve. This deficient practice had the potential to affect the resident's quality of life. Findings: a. A review of Resident 1's Facesheet (admission Record) indicated the facility admitted the resident on 8/10/2024 with diagnosis hypertension (when the pressure in your blood vessels is too high [140/90 mmHg or higher]), lack of coordination (difficulties in controlling and organizing movements) and neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 8/13/2024 indicated the resident had the ability to understand and be understood. The MDS indicated Resident 1 required substantial to maximal assistance (helper does more than half the effort) with toileting, showering, and putting on and taking off footwear. During an interview on 8/19/2024 at 10:38a.m. with Resident 1 stated there is no shower valve for the cold water in Shower room [ROOM NUMBER]. Resident 1 stated he is unable to turn on or off the cold water making it difficult to shower. Resident 1 stated not being able to use the cold-water valve to Shower room [ROOM NUMBER] which makes him feel frustrated. b. A review of Resident 2's Facesheet indicated the facility admitted the resident on 4/17/2024 and readmitted the resident on 7/12/2024 with diagnosis that included lack of coordination, primary generalized osteoarthritis (a chronic joint disease that causes the breakdown of joint tissues over time), and rhabdomyolysis (a rare but serious condition that occurs when muscle cells break down and release their contents into the blood). A review of Resident 2's Care Plan developed on 7/12/2024 for Resident 2's Activities of Daily Living (ADLs) deficit related to rhabdomyolysis indicated to encourage independence, and to encourage resident to complete ADLs as many as possible. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 7/16/2024 indicated the resident had the ability to understand and be understood. The MDS indicated Resident 2 required substantial to maximal assistance (helper does more than half the effort) with showering, lower body dressing, and putting on and taking off footwear. During an interview on 8/19/2024 at 11:33 a.m. with Resident 2 stated Shower room [ROOM NUMBER] is missing the shower valve. Resident 2 stated has a hard time turning the valve in Shower room [ROOM NUMBER]. Resident 2 stated because of this he uses the Shower room [ROOM NUMBER] but it can be difficult because there are other residents who need to use the shower. Resident 2 stated he feels rushed when he showers. During a concurrent observation and interview on 8/19/2024 at 12:41 p.m. with the Maintenance Supervisor (MS) in Shower room [ROOM NUMBER], MS stated the shower valve to the cold water is missing. The MS stated was not aware of the shower valve missing, MS stated this can be fix right now. During a concurrent observation and interview on 8/19/2024 at 1:03p.m. with the MS stated Shower room [ROOM NUMBER] is now fixed, observed Shower room [ROOM NUMBER] with both shower valves. The MS stated not having the shower valve working will mean the shower will not be working as it was intended, the cold water would still turn on, but it would be difficult for the residents and staff to use it. The MS stated there is another shower room, but it would be preferable to have 2 showers for resident the facility has. During an interview on 8/19/2024 at 3:13 p.m. with Certified Nursing Assistant 2 (CNA 2) stated knew the shower room valve was broke last week, CNA 2 stated not sure if anyone reported to maintenance, but it is fixed now. During an interview on 8/19/2024 at 3:39 p.m. with the Administrator (Adm) stated was not aware the shower valve was broken. The Adm stated usually when we find an item not working or broken the staff will report verbally to MS or if MS is not in building will write it down in the Maintenance Communication Log. The Adm stated also have maintenance who works weekends does not know how it could have not been reported and why it was not fixed. The Adm stated the shower valve controls the hot and cold water and if it is not working would not be able to use the shower, the water can be either too cold or too hot. During an interview on 8/19/2024 at 4:16 p.m. with the Director of Nursing (DON) stated not aware of shower room valve being broken. The DON stated there can be a risk for not having control of the water temperature, can be a hazard to the resident. The DON stated would also affect the home like environment. A review of the facility's policies and procedures titled, Quality of Life- Homelike Environment, last revised on 4/2014 indicated residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

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 a comfortable and homelike environment for two of three sampled residents (Resident 1 and Resident 2) when the smell of cigarette smoke entered the facility from the smoking patio into a resident's room, through the hallway, and into Resident 1 and Resident 2's room. This deficient practice had the potential for Residents 1 and 2 to become uncomfortable making them leave their room and wander around the facility. This can also affect their psychosocial wellbeing. Findings: A review of Resident 1's Face Sheet (admission Record) indicated the facility originally admitted Resident 1 on 5/10/2024 and readmitted the resident on 5/31/2024 with diagnoses including, but not limited to, heart failure (long-term condition in which the heart does not pump blood as well as it should), lack of coordination, and acute pulmonary edema (condition caused by excess fluids in the lungs). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/17/2024, indicated Resident 1 had the capacity to understand and make decisions, indicated it was very important to go outside to get fresh air when the weather is good, and required set up to maximal assistance with activities of daily living, such as eating, toileting, hygiene, dressing, and surface-to-surface transfers. A review of Resident 1's History and Physical (H&P), dated 5/31/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 2's Face Sheet indicated the facility originally admitted Resident 2 on 12/21/2023 and readmitted the resident on 5/20/2024 with diagnoses including, but not limited to, generalized osteoarthritis (when tissues between where two bones meet break down over time), lack of coordination, and generalized muscle weakness. A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had the capacity to understand and make decisions, used a walker for mobility, and required setup to moderate assistance with activities of daily living, such as eating, toileting, hygiene, dressing, and surface-to-surface transfers. The MDS further indicated Resident 2 was able to walk 10 feet (a unit of measure for length) with supervision and walk 50 feet with two turns with moderate assistance. A review of the facility's floor plan, undated, indicated Resident 1 and Resident 2's room was across the hallway from a room connected to the courtyard/smoking patio. A review of the facility's document titled, Smoking Schedule, undated, indicated a smoking time between 1 p.m. to 1:30 p.m. During an interview with Resident 1, on 7/17/2024, at 12:05 p.m., Resident 1 stated she lies in bed most of the time and will smell cigarette smoke inside her room. Resident 1 stated there are residents in the facility that have sliding glass doors connected to the smoking area and the cigarette smoke smell comes from those rooms during certain time periods during the day. Resident 1 further stated the smells make her uncomfortable and nauseated. During a concurrent observation and interview, on 7/17/2024, at 1:32 p.m., with Certified Nursing Assistant (CNA) 1, inside the hallway outside of Resident 1 and Resident 2's room, the door to the resident room across from Resident 1 and Resident 2's room was open. Inside the room, the glass sliding door leading to the smoking patio was open and the screen door leading to the smoking patio was closed. Multiple residents were smoking in the smoking patio. CNA 1 confirmed the glass sliding door connected to the smoking patio was open and the hallway smelled like cigarette smoke. CNA 1 stated the sliding glass door should be closed to prevent the cigarette smoke from entering residents' rooms. CNA 1 further stated the cigarette smoke can be unpleasant for other residents. During an interview with the Activities Director (AD), on 7/17/2024, at 1:39 p.m., the AD stated residents smoke in the courtyard. The AD stated there are rooms that connect directly into the courtyard. The AD stated when smoking, residents enter the courtyard from the double doors next to the nursing station and not through the glass sliding doors in their rooms. The AD stated the sliding doors in the resident's rooms should be closed when residents are smoking so that the cigarette smoke smell does not come in. The AD further stated residents can feel uncomfortable if they are exposed to the cigarette smoke smell. During an interview with Resident 2, on 7/17/2024, at 1:54 p.m., Resident 2 stated she is sensitive the cigarette smoke and can smell the cigarette smoke in the hallway. Resident 2 stated the cigarette smoke smell is stronger during certain times of the day. Resident 2 stated she sometimes walks in the hallway, but if the smell of cigarette smoke is too much, she stays in her room. Resident 2 further stated the smell of cigarette smoke makes it difficult for her to breathe. During an interview with the Quality Assurance Nurse (QA Nurse), on 7/17/2024, at 2:25 p.m., the QA Nurse stated during smoking time, the sliding glass door should ideally be closed so that the cigarette smoke will not go into residents' rooms. The QA Nurse further stated residents who smell cigarette smoke coming into their rooms or the hallway can potentially make them upset. A review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, last reviewed 1/25/2024, indicated residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting with characteristics including pleasant neutral scents.

Jun 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who has impaired cognition (ability to think and make decisions), was supervised and monitored by failing to: 1. Ensure Resident 1 did not leave the facility unnoticed and unsupervised. 2. Ensure all the exit alarms were checked for functionality. These deficient practices resulted to Resident 1 ' s elopement on 6/8/2024 from an unknown exit in the facility. The resident had the potential to experience harsh environment/weather conditions, deterioration in mental and physical health due to interrupted medical care and treatment, suffer injury, pain, serious impairment, or death. On 6/12/2024 Resident 1 went to police station and asked for assistance in contacting the resident ' s conservator. Resident 1 ' s conservator informed the facility that the resident refused to return to the facility. Findings: a. A review of Resident 1 ' s Face Sheet (admission record) indicated the facility admitted the resident on 5/3/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), unspecified (inadequate information to make the diagnosis) psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), and bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Resident 1 ' s History and Physical, dated 5/3/2024, indicated the resident had capacity to understand and make decisions. A review of Resident 1 ' s Baseline Care Plan Summary, dated 5/3/2024, indicated the resident required supervision and assistance when smoking. A review of Resident 1 ' s Care Plan on psychoactive (a chemical substance that changes the way the brain works, affecting thoughts, feelings, and behaviors) medications, dated 5/3/2024, indicated the resident was on antipsychotic (drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) medication. The Care Plan Intervention indicated to supervise and give reassurance of well-being. A review of Resident 1 ' s Care Plan on smoking, dated 5/3/2024, indicated the resident was at risk for hazards and injury related to smoking. The Care Plan indicated the intervention to provide precautionary measures and supervision during smoking schedule if possible. A review of Resident 1 ' s Elopement Risk Assessment, dated 5/3/2024, indicated the resident was cognitively (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impaired with poor decision-making skills. The assessment indicated Resident 1 ambulates (walks) independently with or without the use of an assistive device and wander aimlessly or non-goal directed. A review of Resident 1 ' s Care Plans indicated there were no care plans addressing the resident ' s wandering behavior. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/9/2024, indicated the resident ' s cognition was moderately impaired. The MDS indicated Resident 1 required moderate assistance (helper lifts or holds trunk or limbs but provided less than half the effort) on sit to stand, walking 50 feet with two turns, and picking up objects. On 6/11/2024 at 9:37 a.m., during an observation, observed Resident 1 ' s room located next to the hallway exit door that exits to the left side of the building leading to the driveway of the facility staff parking lot. Resident 1 ' s bed was beside the room ' s sliding door leading to the back smoking patio. On 6/11/2024 at 11:53 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated that on 6/8/2024 at around 2:30 p.m., LVN 1 stated that Resident 1 was not in the resident ' s room. LVN 1 stated that he did not look for Resident 1 and he did not inform other staff that the resident was not in the room because he was getting ready for medication pass. LVN 1 stated that he started looking for Resident 1 at 4 p.m. after Registered Nurse 1 (RN 1) and LVN 2 informed him that the facility staff were not able to locate Resident 1. On 6/11/2024 at 12:11 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated that Resident 1 was observed to be on a telephone call for longer than the resident ' s normal telephone calls. CNA 1 stated that he did not report this to the nursing staff. On 6/11/2024 at 3:03 p.m., during an interview, RN 1 stated that on 6/8/2024 at 3 p.m., Resident 1 walked pass the nurse station to the facility lobby carrying a green shopping bag. RN 1 stated that at 4:30 p.m., Resident 1 was not in the resident ' s room. RN 1 stated that she did not look for Resident 1 because she did not hear any alarms go off and she assumed that the resident was somewhere in the facility. RN 1 stated that she should have checkedthe resident ' s whereabouts to prevent the resident from eloping. RN 1 stated that Resident 1 ' s elopement had the potential for the resident to get into an accident on the street because the street outside the facility is a busy street. RN 1 stated that there was lack of supervision for Resident 1. On 6/12/2024 at 3:46 p.m., during an interview, CNA 2 stated that at 3:40 p.m. she checked Resident 1 ' s room and did not see the resident in the room. CNA 2 stated she was not worried that Resident 1 was not in the room because she the resident walks around the facility and liked to smoke in the front patio. On 6/12/2024 at 5:16 p.m., during an interview, RN 2 stated that residents ' whereabouts should be checked to ensure the residents were inside the facility premises. RN 2 stated that the facility failed to ensure all the residents in the facility were accounted for. RN 2 stated that there was lack of supervision for Resident 1. On 6/12/2024 at 2:45 p.m., during an interview, the Social Service Director (SSD) stated that Resident 1's conservator called to inform the facility that the resident was with the conservator. The SSD stated that Resident 1 went to the police station to ask for help in calling the resident's conservator. The SSD stated that Resident 1's conservator informed the facility that the resident refused to return to the facility. On 6/12/2024 at 5:20 p.m., during an interview, the Administrator (ADM) stated that the facility failed to provide supervision to Resident 1 that resulted to the resident leaving the facility unattended. On 6/17/2024 at 4:06 p.m., during a telephone interview, Department of Mental Health (DMH) Case Manager 1 (CM 1) stated that Resident 1 went to the police station to ask for help to call the Outreach Program Team 1 (OP 1). CM 1 stated that OP 1 called the DMH to inform CM 1 that Resident 1 was at the police station. CM 1 stated that when they arrived at Resident 1's location, the resident was in front of the building adjacent to the police station. CM 1 stated Resident 1 refused to return to the facility, refused to go to a hospital, and refused to be assessed. CM 1 stated that Resident 1 was taken to a housing program and will be transferred to a board and care facility (a residential home that has been licensed by the California Department of Social Services to house and provide non-medical care for elderly residents) on 6/18/2024. A review of the facility ' s policy and procedure titled, Safety and Supervision of Residents, dated 1/25/2024, indicated resident safety, supervision, and assistance to prevent accidents were facility -wide priorities. The policy indicated that the type and frequency of resident supervision were determined by the individual resident ' s assessed needs and identified hazards in the environment. The Resident Risks and Environmental Hazards section indicated the risk factors and environmental hazards include . e. unsafe wandering. b. On 6/12/2024 at 4:12 p.m., during a concurrent interview and record review, the Alarm Doors log, dated 6/2024, was reviewed with the Maintenance Supervisor (MS). The Alarm Doors log indicated there were five exit doors that were checked daily. The five exit doors were marked as checked every seven days. The MS stated there were a total of eight exit alarms in the facility but only five were documented as checked. The three exit doors that were not on the Alarm Doors log were the gate on the right side of the facility, the second gate on the right side of the facility leading out to the main road, and the gate at the smoking patio that leads to the driveway going out to the main road. The MS stated that there were three facility doors leading to outside the facility that did not have an alarm which were the gate in the dining room patio leading to the facility staff parking lot, the gate leading to the MS office, and the gate at the front patio. The MS stated that incomplete documentation of all facility alarms maintenance had the potential for residents to go out of the facility unattended. A review of the facility ' s policy and procedure titled, Safety and Supervision of Residents, dated 1/25/2024, indicated resident safety, supervision, and assistance to prevent accidents were facility -wide priorities. The policy indicated that the type and frequency of resident supervision were determined by the individual resident ' s assessed needs and identified hazards in the environment. The Resident Risks and Environmental Hazards section indicated the risk factors and environmental hazards include . e. unsafe wandering. A review of the facility ' s policy and procedure titled, Maintenance Service, dated 1/25/2024, indicated the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The policy indicated the Maintenance Director was responsible for maintaining the following records and reports . a. inspection of building.

Apr 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 observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 4) was assisted on eating safely and treated with respect and dignity in a manner that promoted maintenance or enhancement of the quality of life. Certified Nursing Assistant 3 (CNA3) was not at eye level to Resident 4 while assisting the resident to eat. This deficient practice had the potential for Resident 4 to choke and had the potential to affect the resident ' s sense of self-worth and self-esteem. Findings: A review of Resident 4 ' s Face Sheet indicated the facility admitted the resident on 6/24/2021 with diagnoses including hemiplegia (inability to move one side of the body) following cerebral infarction (a lack of adequate blood supply to the brain cells depriving it of oxygen and vital nutrients which caused parts of the brain to die off) affecting the left non dominant side, epilepsy (a group of disorders marked by problems in the normal functioning of the brain), and chronic obstructive pulmonary disease (COPD – a group of disease that cause airflow blockage and breathing-related problems). A review of Resident 4 ' s History and Physical Exam, dated 9/10/2023, indicated the resident did not have the capacity to make decisions. A review of Resident 4 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool) dated 2/15/2024, indicated the resident ' s cognition (involving conscious intellectual activity such as thinking, reasoning, or remembering) was moderately impaired. Resident 4 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on eating. The Swallowing and Nutritional Status section indicated Resident 4 had coughing or choking during meals or when swallowing medications as signs and symptoms of possible swallowing disorder. A review of Resident 4 ' s Speech Therapy Treatment Encounter Note, dated 12/12/2023, indicated the resident ' s precautions included aspiration pneumonia (occurs when food or liquid enter the airways or lungs instead of being swallowed) and choking. On 4/1/2024 at 12:24 p.m., during a concurrent observation and interview, observed Resident 4 sitting in the dining room with the food tray in front of the resident. CNA 3 was observed mixing Resident 4 ' s food while standing on the resident ' s right side. Resident 4 ' s head was below CNA 3 ' s shoulder level. CNA 3 used a spoon to scoop food from Resident 4 ' s food tray and placed it inside the resident ' s mouth. The Director of Staff Development (DSD) stated that CNA 3 should be sitting down beside Resident 4 while assisting the resident with meals. On 4/1/2024 at 1:11 p.m., during an interview, CNA 3 stated that she was not sitting down while assisting Resident 4 with the lunch meal. CNA 3 stated that she should sit down on a chair and at eye level with Resident 4. CNA 3 stated Resident 4 had the potential to choke if the person assisting the resident was standing up. CNA 3 further stated that she placed Resident 4 at risk for choking and failed to provide dignity to the resident. On 4/1/2024 at 1:40 p.m., during an interview, the Director of Nursing (DON) stated that CNAs should be sitting on a chair while assisting the resident with meals. The DON stated that the facility staff should be at eye level with the resident to be able to identify or see if the resident had difficulty swallowing or if the patient is choking. The DON stated that standing up while assisting the residents with meals had the potential for the resident to choke. The DON stated that Resident 4 was not provided with dignity and safety during meals. A review of the facility ' s policy and procedure titled, Assistance with Meals, dated 1/25/2024, indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The policy indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. The policy indicated an example given included but not limited to not standing over residents while assisting them with meals. A review of the facility policy and procedure titled, Quality of Life - Dignity, dated 1/25/2024, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with respect and dignity at all times. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

Dec 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the right to be free from physical abuse (willful infliction of injury resulting physical harm, pain, or mental anguish) on 12/6/2023 at 7 a.m. when Resident 1, who had recent history of striking out, was impulsive, aggressive and was able to walk around unassisted, hit Resident 2 several times on the face and body. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility, causing Resident 2 to have a nosebleed, generalized pain (sensation of unpleasant feeling indicating potential or actual damage to some body structure felt all over, or throughout the body) and nasal (relating to the nose) pain, and requiring first aid (first and immediate assistance given to any person with either a minor or serious illness or injury). Resident 2 manifested feelings of anxiety (feeling of worry, nervousness, or restlessness [uneasiness]), and feeling physically and emotionally violated. Findings: A review of Resident 2 ' s admission Record indicated the facility initially admitted Resident 2 on 11/22/2023 with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), anxiety disorder (persistent and excessive worry that interferes with daily activities), and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy). A review of Resident 2 ' s History and Physical exam, completed by the attending physician upon admission, dated 11/22/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 11/28/2023, indicated Resident 2 had some memory problems and was able to make her needs known. Resident 2 was able to walk and transfers without the use of a wheelchair or another mobility device. The Mood Section of the MDS indicated Resident 2 had little interest or pleasure in doing things, was feeling depressed (feeling of sadness that will not go away), or hopeless. A review of Resident 2 ' s Situational-Background-Assessment-Recommendation (SBAR, communication form between members of the health care team caring for a resident about his/her condition), dated 12/6/2023, indicated Resident 2 was observed with blood on the nose (no time specified). Resident 2 claimed Resident 1 hit her. The SBAR indicated Resident 2 required first aid treatment to stop the bleeding, pain medication, and emotional support (is related to the expressions that include caring and concern). A review of Resident 2 ' s Departmental Notes (nursing notes), dated 12/6/2023, indicated the following: - At 7 a.m., Resident 1 hit Resident 2 in the face three times and Resident 2 was heard shouting for help. - At 11:10 a.m., Resident 2 verbalized generalized pain with an intensity of seven over 10 (7/10, on a pain scale from zero to 10, zero indicating no pain and 10 the worst pain possible). - At 11:37 a.m., Resident 2 complained of nasal pain and pain medication and non-medication interventions (such as applying ice pack to the affected area) were provided but not effective. Resident 2 ' s attending physician was informed and ordered X-rays (create pictures of the inside of the body) of Resident 2 ' s facial (relating to the face) bones and pain medication every six hours as needed for pain. - At 12:51 p.m., indicated Resident 2 talked with the Social Service Director (SSD) and stated feeling safe in the facility after Resident 1 was taken by the police. - At 10:42 p.m., indicated the X-ray results were received and Resident 2 had no broken facial bones. A review of Resident 2 ' s Medication Administration Record (MAR) for the month of 12/2023, indicated Resident 2 was monitored for behavior of anxiety manifested by physical restlessness. Resident 2 had two episodes of anxiety on 12/6/2023 and 12/7/2023. Resident 2 ' s anxiety increased to three episodes on 12/8/2023 and 12/9/2023. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 1/26/2021 and readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood) and type two diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]). A review of Resident 1 ' s MDS, dated [DATE], indicated Resident 1 had impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering). Resident was able to walk and transfer without the use of a wheelchair or other mobility device (are considered any device that assists individuals with limited ability to move). The MDS Behavior Section indicated Resident 1 had verbal behavior symptoms such as threatening, screaming, and cursing directed toward others. Resident 1 was also assessed as manifesting hallucination (the experience of seeing, hearing, feeling, or smelling something that does not exist) and delusions (a false belief or opinion). A review of Resident 1 ' s SBAR, dated 11/8/2023, indicated Resident 1 was observed eating other resident ' s (not identified) food. Resident 1 hit a staff member (not identified) on the back when she (staff member) took the food tray away from Resident 1. A review of Resident 1 ' s Departmental Notes for 1/15/2023 and 11/17/2023, indicated Resident 1 was sent to the hospital twice due to behavioral problems: - On 11/15/2023, at 1:45 p.m., Resident 1 was sent to General Acute Care Hospital 1 (GACH 1) and returned on the same day at 8:15 pm. - On 11/17/2023, at 4:24 p.m., Resident 1 was sent to GACH 2 and returned on 11/22/2023. A review of Resident 1 ' s Psychiatric (related to the study of mental illness) Evaluation, dated 11/23/2023 (a day after re-admission), indicated Resident 1 had poor impulse control and poor judgment. Resident 1 was receiving routine (regular) and as needed psychotropics (medications that affect the mind, emotions, and behavior). The Psychiatric Evaluation Assessment Section indicated Resident 1 was impulsive, yelling, and striking out towards staff. A review of Resident 1 ' s Departmental Notes, dated 12/6/2023, indicated that: - At 7:16 a.m., Resident 1 was monitored 1 on 1 (1:1, one staff with the resident always) because of violent behavior to others. - At 8:30 a.m., the police picked up Resident 1. On 12/18/2023 at 9:56 a.m., during an interview, Resident 2 stated that the day of the incident (did not recall the exact date), she saw Resident 1 in her (Resident 2) room, sitting on her (Resident 2) bed, drinking her (Resident 2) soda. Resident 2 said she told Resident 1 to get out of the room and then, Resident 1 threw the soda, punched her (Resident 2) on the face about five times, then punched her (Resident 2) on the body and threw her (Resident 2) on the floor. Resident 2 stated she was yelling for help, but nobody came. Resident 2 said that Resident 1 left the room, and she (Resident 2) was able to get up from the floor and noticed blood on her face. Resident 2 stated she went out of the room and saw a staff (Housekeeper 1 [HKP 1]), who assisted her to go to the SSD ' s office. Resident 2 stated the nurses cleaned her face, applied ice pack, and gave her pain medications. Resident 2 stated that she felt physically and emotionally violated. Resident 2 stated she had to be more cautious because she does not know if someone else will unexpectedly do the same thing to her again. On 12/18/2023 at 10:21 a.m., during an interview, HKP 1 stated that on 12/6/2023, at around 7 a.m., she heard someone saying help and saw Resident 1 coming out of Resident 2 ' s room. HKP 1 stated that Resident 2 walked out of the room with the resident ' s (Resident 2) hands on the face and there was blood on Resident 2 ' s hands and face mask. HKP 1 stated she assisted Resident 2 to the SSD ' s office. On 12/18/2023 at 10:33 a.m., during an interview, the SSD stated that on 12/6/2023, she came to work at 5 a.m. and was in her office when around 7 a.m., HKP 1 brought Resident 2 to her office, who had a bloody nose. The SSD stated Registered Nurse 1 (RN 1) was walking by and assisted Resident 2. The SSD stated Resident 2 reported to her (SSD) that Resident 1 was in her room and punched her on the face. SSD also stated that Certified Nursing Assistant 3 (CNA 3) from the night shift went to Resident 1 ' s room after the incident with Resident 2, and Resident 1 hit CNA 3. SSD stated she called the police and Resident 1 was taken by the police. On 12/19/2023 at 9:15 a.m., during an interview, the Director of Nursing (DON) stated that the physical altercation incident (12/6/2023) between Residents 1 and 2 was the first. The DON stated Resident 2 sustained physical harm from the physical abuse inflicted by Resident 1. A review of the current facility provided policy and procedure titled, Abuse Prevention Program, dated 1/2023, indicated that as part of the resident abuse prevention, the administration will protect the resident from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of the current facility provided policy and procedure titled, Resident Rights, dated 1/2023, indicated that federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the resident ' s right to be free from abuse, neglect, misappropriation of property (is the unauthorized or improper use of someone else ' s property or funds, usually for personal gain or advantage), and exploitation (the action of treating someone unfairly for your advantage).

Nov 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

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 comprehensive person-centered care plan for one of three sample residents (Resident 1) by: a. Failing to develop and implement Resident 1 ' s care plan interventions regarding risk for disturbance in sleep pattern related to insomnia (trouble falling and/or staying asleep). b. Failing to develop an individualized care plan with interventions for Resident 1 ' s behavior, psychotropic medication (any drug that affects behavior, mood, thoughts, or perception), and schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problems) care plans. These deficient practices placed the resident at risk for not receiving the necessary services and treatment to meet his medical, physical, mental, and psychosocial needs. Findings: a. A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 9/24/2021 and readmitted the resident on 11/2/2023, with diagnoses including schizoaffective disorder, lumbago with sciatica (pain that travels from the lower back through the hips and buttocks and down each leg), epilepsy (brain disorder that causes people to have recurring involuntary muscle movements, sensory disturbances and altered consciousness), and Parkinson's disease (a progressive disorder of the nervous system that affects movement). A review of Resident 1 ' s History and Physical, dated 11/3/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 10/6/2023, indicated the resident was severely impaired cognitively (unable to understand and make decisions) and required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with lying to sitting on side of bed, sit-to-stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet, oral and toilet hygiene and upper body dressing. Resident 1 ' s MDS indicated he required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermittently) with sitting-to-lying position and eating. A review of Resident 1 ' s insomnia care plan, dated 11/2/2023, indicated the following interventions: - Provide a quiet environment. - Monitor side effects from medication. - Medication as ordered. - Encourage resident to stay up during day for sleep at night. - Monitor causes for insomnia medication for depression, caffeine over stimulation and anxiety. - Try nondrug intervention as in back rub, warm milk, pleasant conversation prior to medication. - Encourage resident to attend activity daily. - Visual monitoring of resident ' s activity. - Keep call lights, bed control within reach. During a concurrent interview and record review on 11/28/2023, at 11:14 a.m., reviewed Resident 1 ' s care plans with the Director of Nursing (DON). The DON stated eating pizza and drinking soda were effective interventions for calming Resident 1 down. The DON also stated that talking to him, walking around, or giving him a glass of water or a cookie were other interventions that were effective. She stated that these interventions should have been on the resident ' s insomnia care plan. The DON stated that Resident 1 ' s care plans should have been individualized and the interventions could have been more specific. The DON stated Resident 1 ' s insomnia interventions were not being documented anywhere and if they were not documented, they were not done. The DON further stated that Resident 1 was not taking any insomnia medication, and this should have been clarified on his insomnia care plan. b. A review of Resident 1 ' s Order Summary Report indicated physician orders dated 11/2/2023 for: - Quetiapine (Seroquel, an antipsychotic used to alter brain chemistry to help reduce hallucinations [false perception of objects or events involving the senses], delusions [believing thoughts to be real but are actually false or unreal], and disordered thinking) medication 200 milligrams (mg-unit of measure) one tablet by mouth three times a day for schizoaffective disorder manifested by verbal aggression. - Risperidone (also known as Risperdal, antipsychotic medication) mg one tablet by mouth at bedtime for schizoaffective disorder manifested by hallucinations and hearing voices telling him to walk into traffic. A review of Resident 1 ' s Medication Administration Record (MAR) indicated the following interventions were completed from 11/3/2023-11/20/2023: - Seroquel: Monitor schizoaffective disorder manifested by verbal aggression every shift and tally by hashmark. - Risperdal: monitor schizoaffective disorder manifested by hallucinations as evidenced by hearing voices telling him to walk into traffic every shift tally by hashmark. - Monitor vital signs every shift. - Monitor pain every shift. During a concurrent interview and record review on 11/28/2023, at 11:14 a.m., reviewed Resident 1 ' s care plans with the Director of Nursing (DON). The DON stated that the monitoring of Resident 1 ' s side effects to Risperdal and Seroquel, and the medication indications need to be specified on the resident ' s care plan. The DON stated that care plan interventions need to be specific, so nurses know what they are monitoring for, what medications the resident is on, why the resident is on these medications, and what potential side effects they need to watch out for. During a concurrent interview and record review on 11/29/2023, at 2:29 p.m., reviewed Resident 1 ' s MAR with Licensed Vocational Nurse 3 (LVN 3). LVN 3 stated that if Resident 1 had ever said that that he was hearing voices telling him to go out into traffic she would have been concerned. LVN 3 stated that Resident 1 never told her this but Resident 1 has generalized hallucinations and that is what she thought was needed to be documented in the MAR. LVN 3 stated that she thinks Resident 1 hearing voices was an old behavior. LVN 3 stated that she only updates the care plans for Resident 1 if he had a change in condition. LVN 3 stated that Resident 1 ' s behavior, psychotropic medication, and schizoaffective disorder care plans should have more specific interventions for Resident 1 that were more updated and individualized to his plan of care. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person Centered, last reviewed on 1/2023, 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. Care plan interventions are chosen only after careful data gathering, proper sequencing, of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making. A review of the facility ' s P&P titled, Charting and Documentation, last reviewed on 1/2023, indicated, The following information is to be documented in the resident medical record: Progress toward or changes in the care plan goals and objectives.

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 Resident 1 did not exit the facility without the facility staff's knowledge on 11/21/2023 for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to sustain an accidental injury while outside the facility's premises. Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 9/24/2021 and readmitted the resident on 11/2/2023, with diagnoses including schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problems), lumbago with sciatica (pain that travels from the lower back through the hips and buttocks and down each leg), epilepsy (brain disorder that causes people to have recurring involuntary muscle movements, sensory disturbances and altered consciousness), and Parkinson's disease (a progressive disorder of the nervous system that affects movement). A review of Resident 1 ' s History and Physical, dated 11/3/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 10/6/2023, indicated the resident was severely impaired cognitively (unable to understand and make decisions) and required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with lying to sitting on side of bed, sit-to-stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet, oral and toilet hygiene and upper body dressing. Resident 1 ' s MDS indicated he required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermittently) with sitting-to-lying position and eating. A review of Resident 1 ' s Elopement Risk Assessment, dated 11/2/2023, indicated Resident 1 was at high risk for elopement. A review of Resident 1 ' s Q 4 Hours (every 4 hours) Elopement Monitoring Sheet, dated 11/6/2023 to 11/21/2023, indicated Resident 1 was last seen on 11/21/2023 at 2 a.m. in his bedroom with pizza and soda. A review of Resident 1 ' s paramedic Patient Care Report, dated and timed 11/21/2023 at 4:16 a.m., indicated the resident was outside of a gas station with a complaint of suicidal ideation (SI). The report indicated Resident 1had voices in his head telling him to walk into traffic. Resident 1 was transferred to a general acute care hospital. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR-framework for communication between members of the health care team about a resident ' s condition), dated 11/21/2023, indicated the following: 2 a.m. - Resident 1 was offered pizza and soda and took them. 2:30 a.m. - Resident 1 refused to change into his night gown and was assisted to bed. 3 a.m. - Resident 1 was given Norco (pain medication) due to complain of low back pain. 3:45 a.m. - Resident was reassessed for pain, had eyes closed and appeared to be sleeping. 4 a.m. - CNA reported resident remained in bed, appeared to be sleeping. 5:20 a.m. – Received a call from General Acute Care Hospital 1 (GACH 1) informing the facility that Resident 1 was brought in to GACH 1 at around 4:44 a.m. GACH 1 staff will do basic work-up and will send the resident back to the facility. 5:30 a.m. – Licensed Vocational Nurse 1 (LVN 1) notified the Director of Nursing (DON) of the incident. 5:40 a.m. – LVN 1 notified police department and obtained Incident Number 692. Per police officer, since resident has been located, no police officer needs to come out to the facility 6:00 a.m. – The primary medical doctor (PMD) and psychiatrist were notified; resident was self-responsible. A review of Resident 1 ' s Final Investigative Report (conclusion report), dated 11/21/2023, indicated the resident had severe cognitive impairment and was able to make his needs known. The report also indicated Resident 1 ambulated using his wheelchair to go around the facility, and he was able to go in and out of his wheelchair with limited to extensive assist. Resident did not have a history of elopement. A review of Resident 1 ' s GACH 1 Emergency Department Report, dated 11/21/2023, indicated the resident was brought in by ambulance (BIB) from a gas station with suicidal plan of running in to traffic. During an interview, on 11/27/2023 at 9:25 a.m., the Director of Nursing (DON) stated Resident 1 never wandered or had ever tried to leave the facility in the past, and the resident was alert and oriented. The DON stated Resident 1 had not verbalized any thoughts of suicide, and she did not know what caused the resident to try to leave. During an interview, on 11/27/2023 at 10:05 a.m., the DON stated Resident 1 did not have a reassessment (follow-up assessment) from his Elopement Risk Assessment on 11/2/2023. The DON stated Resident 1 was no longer an elopement risk after the interdisciplinary team (IDT - a group of health care professionals from different fields who coordinate resident care) meeting conducted on 11/6/2023, and Resident 1 ' s IDT meeting acted as the reassessment for the Elopement Risk Assessment. The DON stated that the facility should have completed a follow-up elopement risk assessment after the initial 72 hours of incident. The DON stated the facility already knew Resident 1 was no longer an elopement risk even though the Elopement Risk Assessment was high upon admission. The DON stated that Elopement Risk Assessments should be done upon admission, as needed, or if a resident has a change in condition. During an interview, on 11/27/2023 at 10:53 a.m., LVN 1 stated the last time she saw Resident 1 was on 11/21/2023 around 3:40 a.m.-3:45 a.m. after she reassessed the resident after giving him a pain pill. LVN 1 stated Resident 1 had tried to leave the facility before and had tried to push through every door of the facility. LVN 1 stated that Resident 1 had not tried to leave the facility recently. LVN 1 stated that she will just redirect the resident and talk to him about what he wants. LVN 1 stated that Resident 1 always wants pizza and soda and once he gets what he wants, he is very calm. The only time Resident 1 wanted to leave the facility was if he cannot get his way with getting money or pizza. LVN 1 stated that she first found out Resident 1 was missing on 11/21/2023 around 5:15 a.m. when GACH 1 staff called the facility. LVN 1stated that CNA 1 did not tell her Resident 1 was missing. During an interview, on 11/27/2023 at 11:23 a.m., Certified Nursing Assistant 1 (CNA 1) stated that he first found out that Resident 1 left the facility after they received a call from GACH 1. CNA 1 stated the last time he saw Resident 1 was when he did his rounds at 4:00 a.m. on 11/21/2023. During an interview, on 11/27/2023 at 3:10 p.m., the DON stated Resident 1 can walk for short distances with no assistance and did not always use a wheelchair or walker. The DON stated when she wrote Resident 1 ' s conclusion report (Final Investigative Report), that was all the information that she had at that time. The DON stated the information that needed to be included in the conclusion report are the type of incident that occurred, what the facility did after the incident happened, and what the facility needed to do to minimize the incident from happening again. The DON stated the facility did not know if Resident 1 left with a wheelchair as they were not able to get that information from the paramedics or GACH 1. The DON stated that Resident 1 ' s conclusion report could have been clearer and more detailed. A review of the facility ' s policy and procedures (P&P) titled, Wandering and Elopements, last reviewed on 1/2023, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

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

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 implement their policies and procedures by not monitoring for specific target behaviors on the use of Quetiapine (Seroquel, antipsychotic medication used to alter brain chemistry to help reduce hallucinations [false perception of objects or events involving the senses], delusions [believing thoughts to be real but are actually false or unreal] and disordered thinking) and Risperidone (antipsychotic medication) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in inconsistent monitoring and placed the resident at risk for receiving unnecessary medication and unrecognized adverse reactions(any unexpected or dangerous reaction to a drug). Findings: A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 9/24/2021 and readmitted the resident on 11/2/2023, with diagnoses including schizoaffective disorder, lumbago with sciatica (pain that travels from the lower back through the hips and buttocks and down each leg), epilepsy (brain disorder that causes people to have recurring involuntary muscle movements, sensory disturbances and altered consciousness), and Parkinson's disease (a progressive disorder of the nervous system that affects movement). A review of Resident 1 ' s History and Physical, dated 11/3/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - an assessment and care screening tool), dated 10/6/2023, indicated the resident was severely impaired cognitively (unable to understand and make decisions) and required partial/moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with lying to sitting on side of bed, sit-to-stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, walking 10 feet, oral and toilet hygiene and upper body dressing. Resident 1 ' s MDS indicated he required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity; assistance may be provided throughout the activity or intermittently) with sitting-to-lying position and eating. A review of Resident 1 ' s Order Summary Report indicated physician orders dated 11/2/2023 for: - Quetiapine 200 milligrams (mg-unit of measure) one tablet by mouth three times a day for schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problems) manifested by verbal aggression. - Risperidone 3 mg one tablet by mouth at bedtime for schizoaffective disorder manifested by hallucinations and hearing voices telling him to walk into traffic. A review of Resident 1 ' s Medication Administration Record (MAR), dated 11/1/2023-11/30/2023, indicated the following interventions were completed from 11/3/2023-11/20/2023: - Seroquel: Monitor schizoaffective disorder manifested by verbal aggression every shift and tally by hashmark. - Risperdal: monitor schizoaffective disorder manifested by hallucinations as evidenced by hearing voices telling him to walk into traffic every shift tally by hashmark. - Monitor vital signs every shift. - Monitor pain every shift. On 11/29/2023 at 12:37 p.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated that Resident 1 never reported hearing voices telling him to go into traffic. RNA 1 stated that Resident 1 will try to go out the doors but once you give him what he wants, he will not try to leave anymore. On 11/29/2023 at 1:37 p.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 never told him that he heard voices telling him to go into traffic. During a concurrent interview and record review, on 11/29/2023, at 1:47 p.m., reviewed Resident 1 ' s MAR with the Director of Nursing (DON). The DON stated that the nurses are charting just to Resident 1 ' s hallucinations but not the specific type of hallucination that the resident was having. The DON stated that Resident 1 refers to his mom calling him this morning and she is not in his life, or he accuses the facility of stealing his money. The DON stated that the nurses should be more vigilant when they chart Resident 1 ' s hallucination manifestation. During a concurrent interview and record review, on 11/29/2023 at 2:29 p.m., reviewed Resident 1 ' s MAR with LVN 3 who confirmed that she had charted on the order for Risperdal (monitor schizoaffective disorder manifested by hallucinations as evidenced by hearing voices telling him to walk into traffic every shift tally by hashmark). LVN 3 stated if Resident 1 had ever said that that he was hearing voices telling him to go out into traffic she would have been concerned. LVN 3 stated that Resident 1 never told her this but Resident 1 has generalized hallucinations and that is what she thought was needed to be documented in the MAR. LVN 3 stated that she felt Resident 3 ' s medication was working well, and he was having less manifestation of accusing people of taking his money, holding his money hostage. LVN 3 stated that she thinks Resident 1 hearing voices was an old behavior. A review of the facility's policies and procedures (P&P) titled, Antipsychotic Medication, reviewed 11/2023, indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. A review of the facility's P&P titled, Medication Utilization and Prescribing-Clinical Protocol, reviewed 11/2023, indicated, when a medication is prescribed for any reason, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent), considering the resident's age, medical and psychiatric conditions, risks, health status, and existing medication regimen. Symptoms should be characterized in sufficient detail (onset, duration, frequency, intensity, location, etc.) to help identify whether a problem exists or whether a symptom is just a variation of normal. A symptom (confusion, pain, etc.) may have diverse causes, so it is usually relevant to try to identify likely causes and pertinent non-pharmacologic interventions.

Nov 2023 6 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide quality of care in accordance with professional standards of practice to meet the resident's physical, mental, psychosocial needs for one of one sampled resident (Resident 5) by failing to follow-up the resident's hematologist (a doctor who specializes in researching, diagnosing, treating, and preventing blood disorders and disorders of the lymphatic system (lymph nodes and vessels)/oncologist's (a doctor qualified to diagnose and treat tumors) recommendations for a urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) consult. This deficient practice had the potential to result in a delay of care and services for Resident 5. Findings: A review of Resident 5's Face Sheet (admission Record) indicated the facility originally admitted the resident on 9/24/2021 and readmitted on [DATE] with diagnoses including sepsis (a life-threatening complication of an infection) and epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain]). A review of Resident 5's History and Physical, dated 8/8/2023, indicated that the resident had the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/1/2023, indicated the resident had moderately impaired cognitive skills (decisions poor; cues/supervision required) for daily decision making. A review of Resident 5's General Acute Care Hospital 1's (GACH 1's) Hematology Oncology Consultation Note, dated 11/2/2023, indicated the resident with recommendation for urologist consult for possible cystoscopy (a procedure to look inside the bladder using a thin camera called a cystoscope) with elevated carcinoembryonic antigen (CEA, a tumor marker [substances that are often made by cancer cells or by normal cells in response to cancer]) and bladder wall thickening on computed tomography (CT, a medical imaging technique used to obtain detailed internal images of the body). During a concurrent interview and record review, on 11/7/2023 at 11:03 a.m., reviewed Resident 5's Physician Orders 11/2023, Nursing Progress Notes, and GACH 1's Hematology Oncology Consultation Note, the Quality Assurance (QA) Nurse stated the GACH records are reviewed upon admission and should have communicated with the resident's physician if they would place an order for the urologist consult. The QA nurse stated there was no documented evidence about the recommendation for the urologist consult. The QA nurse stated she will call the resident's physician and inform him of the recommendation. The QA nurse stated if physician is not informed of the recommendation the resident may miss this consult. A review of the current facility provided policy and procedure titled, Medication and Treatment Orders, indicated a Policy Statement, Orders for medications and treatments will be consistent with principles of safe and effective order writing.

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 observation, interview, and record review, the facility failed to dispose a medication that was refused by one of four sampled residents (Resident 4). Resident 4 was refusing molnupiravir (Lagevrio, an antiviral medication) and the licensed nurse refused to take it back and left the medication with Resident 4, who was not assessed as able to do self-administration (the act of administering something to oneself) of medications. This deficient practice denied Resident 4's right to refuse a medication and the potential for the medication to be taken by another resident if not properly disposed. Findings: A review of Resident 4's Face Sheet (admission Record) indicated the facility admitted the resident on 9/8/2023 with diagnoses including chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems) and chronic viral hepatitis C (a long-term inflammation of the liver caused by the hepatitis C virus). A review of Resident 4's History and Physical, dated 9/8/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 4's Medication Administration Record for the month of 11/2023, indicated an order for Lagevrio (monulpiravir) 200 milligrams (mg, a unit of measure in weights) capsule, may administer four (4) tablets by mouth twice a day, every day for five (5) days, dated 11/4/2023. The MAR indicated the resident received a total of three doses on 11/5/2023 at 9 a.m., 5 p.m., on 11/6/2023 at 9 a.m., and refused two doses on 11/6/2023 at 5 p.m. and 11/7/2023 at 9 a.m. A review of Resident 4's Self-Administration Assessment, dated 9/9/2023, indicated the resident was unable to differentiate different colors and/or shapes. The assessment indicated the resident did not want to give medications to himself. During a concurrent observation and interview on 11/7/2023 at 8:40 a.m., Resident 4 stated on 11/5/2023, Sunday afternoon, the medication nurse gave him another dose of the anti-COVID-19 medication. Resident 4 stated he refused to take it, but the nurse refused to take it back. Resident 4 stated he has been holding on to it because it is not safe for him to throw in the trash as another resident may take it. Observed four (4) red capsules inside a medication cup (one ounce [a unit of measure] plastic, translucent cups are suitable for dispensing both liquid and dry medications) at the resident's bedside. During a concurrent observation and interview on 11/7/2023 at 1:11 p.m., at Resident 4's door with the Quality Assurance (QA) nurse, Resident 4 stated he has the four red pills. Resident 4 stated he tried giving them back to the nurse, but they would not take them, so he has the pills with him. Resident 4 stated this was the first day the second time they gave to him, and he refused it. Resident 4 stated he refused it because he looked it up and it was not approved by the Food and Drug Administration (FDA, a federal government agency that works to make sure our foods, medicines, and other products we use are safe and effective). Observed Resident 4 handed the four pills to the QA nurse. The QA nurse stated she will dispose the medications. During an interview on 11/7/2023 at 1:26 p.m., the QA nurse stated there should be no medication left at the bedside for Resident 4. The QA nurse stated for safety because other residents may accidentally ingest the medication not intended for them. A review of the facility's policy and procedure titled, Administering Medications, reviewed 1/2023, indicated that it is the facility's policy that medications shall be administered in a safe, timely manner, and as prescribed. The policy implementation indicated residents may only self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team (responsible for the initial and periodic assessments, plan of care, and coordination of 24-hour care delivery), has determined that they have the decision-making capacity to do so safely.

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 one of three sampled residents (Resident 1) was free from any significant medication errors (administration of medication which as not in accordance with accepted professional standards and principles) by: 1. Failing to administer molnupiravir (medication used to treat Coronavirus Disease 2019 [COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets released when an infected person cough, sneezes or talks]) to Resident 1 as ordered by physician. 2. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) obtain a physician's order for molnupiravir before offering to Resident 1 after the stop date. These deficient practices placed the resident at risk for experiencing complications related to COVID-19 virus and adverse reaction (any unexpected or dangerous reaction to a drug) from the medication. Findings: a. A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 5/3/2023, with diagnoses that included urinary tract infection (when bacteria gets into your urine and travels up to your bladder), generalized osteoarthritis (the cartilage that lines your joints is worn down over time and your bones rub against each other) and hypokalemia (refers to a lower than normal potassium [a mineral that your body needs to work properly] level in your bloodstream). A review of Resident 1's History and Physical (H&P) dated 5/3/2023 indicated the resident had fluctuating capacity to make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 8/4/2023, indicated resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 required extensive assistance from staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). A review of Resident 1's Care Plan on Coronavirus Disease 2019 (COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets released when an infected person cough, sneezes or talks) dated 10/31/2023, indicated an intervention to administer prescribe medications and notify medical doctor and responsible party as needed. A review of Resident 1's Physician Orders dated 11/1/2023, indicated an order for molnupiravir (medication used to treat COVID-19, 200 milligrams (mg- unit of measurement) capsule, give four capsules by mouth every 12 hours for five days. A review of facility's Pharmacy Consolidated Delivery Sheets dated 11/1/2023 at 9:46 p.m., indicated Resident 1's molnupiravir (40 tablets) were delivered and received by the facility. During a concurrent interview and record review on 11/7/2023 at 10:40 a.m., with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), dated 11/2023 was reviewed. The MAR indicated molnupiravir was not signed off by licensed nurses on 11/1/2023 to 11/6/2023. The DON stated the resident should have already completed the course of medication. The DON stated the blank spaces in the MAR meant the medications were not given. During an interview on 11/7/2023 at 11: 34 a.m., LVN 1 stated she gave the first dose, which is four capsules of molnupiravir on 11/2/2023 at 9 a.m. LVN 1 stated the course of medication should have been completed on 11/6/2023 but the nurses were not giving the medication because there are a lot of capsules left in the bottle. During a concurrent observation and interview on 11/7/2023 at 11:39 a.m., with the Quality Assurance Nurse (QA), observed the QA nurse counting the remaining capsules in Resident 1's molnupiravir bottle. Observed and verified with the QA nurse, the bottle had 20 capsules. A review of facility's policy ad procedure titled, Documentation of Medication Administration dated 4/2007 and reviewed on 1/2023, indicated, The facility shall maintain a medication administration record to documents all medications administered. Administration of medication must be documented immediately after (never before) it is given. b. During a concurrent observation and interview on 11/7/2023, at 11:34 a.m., with Licensed Vocational Nurse 1 (LVN 1), in the dining area, observed LVN 1 carrying a small plastic pouch with four red capsules. LVN 1 stated she tried to give molnupiravir to Resident 1 at 9 a.m., but the resident refused. LVN 1 stated she offered the medication today, 11/7/2023 because she does not want to waste the rest of the medication. LVN 1 stated a course of molnupiravir should have been completed yesterday, 11/6/2023 but the nurses were not giving the medication because there were still a lot of capsules left in the bottle. LVN 1 stated she should have called the doctor and ask for an order to continue the medication before attempting to give it to the resident. During an interview on 11/8/2023 at 10:05 a.m., with the Director of Staff Development (DSD), the DSD stated the licensed nurse should not offer medication beyond the prescribed completion date. The DSD stated LVN 1 should have called the doctor and get an order to continue the medication to prevent overmedicating the residents. During an interview on 11/8/2023 at 10:50 a.m., with Pharmacist 1 (PH 1), PH 1 stated nurses should administer molnupiravir consistently and as ordered. A review of policy and procedure titled, Administering Medications, dated 12/2012 and reviewed on 1/2023 indicated, Medications must be administered in accordance with the orders, including any required time frame.

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 three of three sampled residents (Resident 7, 8 and 9) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore protective goggles while providing care for residents who were placed on isolation precautions, (are used to help stop the spread of germs from one person to another) for Coronavirus Disease 2019 (COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets released when an infected person cough, sneezes or talks) for Residents 7, 8, and 9. This deficient practice had the potential to result in the spread of the COVID-19 to all residents and staff. Findings: a. A review of Resident 7's admission Record (Face Sheet) indicated the facility admitted the resident on 6/14/2023 with diagnoses that included old myocardial infraction (refers to tissue death of the heart muscle), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and diabetes mellitus (uncontrolled elevated blood sugar). A review of Resident 7's History and Physical (H&P) dated 10/31/2023 indicated the resident had no capacity to make decisions. A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/11/2023, indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 7 required limited assistance from staff for activities of daily living (ADL- transfers, dressing and personal hygiene). The MDS indicated Resident 7 was always incontinent (unable to control) of bowel and bladder functions. A review of Resident 7's Final Report COVID-19 reported date 11/2/2023 indicated the resident had COVID-19. A review of Resident 8's admission Record indicated the facility admitted the resident on 3/2/2023 with diagnoses that included osteomyelitis (inflammation or swelling that occurs in the bone), pressure ulcer (a type of injury that breaks down the skin and underlying tissue when an area of skin is placed under constant pressure for certain period) of sacral region (a triangular bone at the base of the spine) and skin transplant (a patch of skin that is removed by surgery from one area of the body and transplanted, or attached, to another area). A review of Resident 8's H&P dated 3/2/2023 indicated the resident had capacity to understand and make decisions. A review of Resident 8's MDS dated [DATE] indicated the resident had intact cognition. The MDS indicated Resident 8 needed limited assistance from staff for dressing, toilet use and personal hygiene. A review of Resident 8's Final Report COVID-19, reported date 11/2/2023 indicated resident had COVID-19. A review of Resident 9's admission Record indicated the facility admitted the resident on 9/12/2023 with diagnoses that included necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), metabolic encephalopathy and lack of coordination. A review of Resident 9's H&P dated 9/12/2023 indicated the resident had the capacity to understand and make decisions. A review of Resident 9's MDS dated [DATE] indicated the resident had intact cognition. The MDS indicated the resident needed extensive assistance from staff for walking, dressing, toilet use and personal hygiene. Resident 9 was also incontinent for bowel. A review of Resident 9's Final Report COVID-19, reported date 11/1/2023 indicated resident had COVID-19. During an observation on 11/7/2023 at 9:19 a.m., outside of Resident 7, 8, and 9's room, observed Certified Nursing Assistant 1 (CNA 1) without protective goggles, assisting Resident 7 with his blanket. During an interview on 11/7/2023 at 9:21 a.m. with CNA 1, CNA stated she was in Resident 7, 8 and 9's room to change Resident 7's bed linen. CNA 1 admitted that she did not wore protective goggles because she already had an eyeglasses on. b. During a concurrent observation and interview on 11/7/2023 at 9:26 a.m., with Infection Preventionist 2 (IP 2), outside of Resident 9's room, observed CNA 1 wearing her protective goggles upside down. IP 2 stated CNA 1 was not wearing her protective goggles correctly inside a COVID-19 room. IP 2 stated residents in the facility are reluctant to wear masks and staff need to protect themselves from contracting COVID-19. During an interview on 11/7/2023 at 10:40 p.m., with the Director of Nursing (DON), the DON stated the facility 17 COVID-19 positive residents. The DON stated staff should wear protective googles or face shield when providing care for COVID-19 positive residents in their rooms for infection control. The DON stated staff wear protective goggles correctly. During an interview on 11/8/2023 at 10:05 a.m., with the Director of Staff Development (DSD) stated Residents 7, 8 and 9, who were COVID 19 positive, were placed on contact (touching an infected person and their dirty items such as clothing and surfaces) and droplet (used to prevent contact with other secretions from the nose and sinuses, throat, airways, and lungs when a person talks, sneezes or coughs) isolation. The DSD stated staff should wear protective goggles for infection control when entering COVID-19 rooms. The DSD stated eyeglasses is not an acceptable eye protection for COVID. A review of facility's policy and procedure titled, Coronavirus Disease (COVID-19)- Infection Prevention and Control measures dated 4/2020 and reviewed on 1/2023, indicated While in the building, personnel are required to strictly adhere to established infection control polices including; c. Appropriate use of Personal Protective Equipment (PPE- wearable equipment that is intended to protect healthcare personnel and the public from exposure to or contact with infectious agents). For a resident with known or suspected COVID-19, a. Staff wear gloves, isolation gown eye protection and an N95 or higher level of respirator if available. If there are COVID-19 cases in the facility; a. Staff wear all recommended PPE (gloves gown, eye protection and respirator or face mask) for the care of all residents on the unit (or facility -wide based on the location of affected residents), regardless of symptoms (based on availability).

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to offer the pneumococcal vaccine (a drug that helps the immune system develop immunity from pneumococcal pneumonia [an infectious bacterial lung disease]) to one of five sampled residents (Resident 2), when Resident 2 became eligible to receive the vaccine. This deficient practice had the potential to result in increased risk for pneumococcal infections which may lead to serious health complications such as pneumonia (an infection that inflames your lungs' air sacs), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), and bloodstream infections. Findings: A review of Resident 2's Face Sheet indicated the facility originally admitted the resident on 7/25/2023 and readmitted the resident on 8/14/2023, with diagnoses including chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems) and chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/18/2023, indicated the resident had the ability to usually make self-understood and usually understand others. During a concurrent interview and record review, on 11/7/2023 at 12:20 p.m., with the Quality Assurance (QA) nurse, reviewed Resident 2's Informed Consent for Pneumococcal Polysaccharide Vaccine. The QA nurse stated the resident is 65 years and is eligible to receive the pneumococcal vaccine. The QA nurse stated the resident should have been offered the vaccine when the resident became eligible to receive the vaccine. The QA nurse stated the vaccine offers protection from pneumococcal infection complications. A review of the facility's policy and procedure titled, Pneumococcal Vaccine, reviewed 1/2023, indicated that it the facility's policy that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The procedure indicated prior to or upon admission, residents will be assessed for eligibility to receive pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.

CONCERN (E) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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d. 1. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 6/14/2023 with diagnoses that included old myocardial infraction (refers to tissue death of the heart muscle), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood) and diabetes mellitus (uncontrolled elevated blood sugar). A review of Resident 7's History and Physical dated 10/31/2023 indicated the resident had no capacity to make decisions. A review of Resident 7's Final Report COVID-19, reported dated 11/2/2023, indicated the resident had positive COVID-19 results. d. 2 A review of Resident 8's Face Sheet indicated the facility admitted the resident on 3/2/2023 with diagnoses that included osteomyelitis (inflammation or swelling that occurs in the bone), pressure ulcer (a type of injury that breaks down the skin and underlying tissue when an area of skin is placed under constant pressure for certain period) of sacral region (a triangular bone at the base of the spine) and skin transplant (a patch of skin that is removed by surgery from one area of the body and transplanted, or attached, to another area). A review of Resident 8's H&P dated 3/2/2023 indicated the resident had capacity to understand and make decisions. A review of Resident 8's Final Report COVID-19, reported dated 11/2/2023, indicated the resident had positive COVID-19 results. A review of Resident 9's Face Sheet indicated the facility admitted the resident on 9/12/2023 with diagnoses that included necrotizing fasciitis (a rare bacterial infection that spreads quickly in the body and can cause death), metabolic encephalopathy and lack of coordination. d. 3. A review of Resident 9's H&P dated 9/12/2023 indicated the resident had the capacity to understand and make decisions. A review of Resident 9's Final Report COVID-19, reported dated 11/1/2023, indicated the resident had positive COVID-19 results. During a concurrent interview and record review on 11/7/2023 at 12:05 p.m., with the Director of Nursing (DON), Resident 7, 8 and 9's care plans were reviewed. The DON stated there was no care plan developed addressing Resident 7, 8 and 9's positive COVID-19 test results. The DON stated the residents' care plan indicated the residents had COVID-19 exposure with an intervention to place the residents on enhanced contact and droplet isolation. The DON stated the residents should have had a care plan addressing their COVID-19 positive status and should have indicated the appropriate isolation precautions, which is the novel respiratory precautions to ensure the staff are providing the right care and observing the necessary precautions to prevent the spread of infection. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, reviewed 1/2023, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The policy implementation indicated that each resident's comprehensive care plan is designed to incorporate identified problem areas and reflect currently recognized standards of practice for problem areas and conditions. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six of nine sampled residents (Resident 2, 3, 4, 7, 8, and 9), by failing to: 1. Develop a care plan addressing Resident 2 and Resident 3's refusal to receive coronavirus disease (COVID-19, an acute disease in human caused by coronavirus). 2. Develop a care plan addressing Resident 2' refusal to receive pneumococcal vaccine (an injected medicine that can protect against and often prevent pneumococcal [a type of bacteria] infections [when the immune system fights off the bad germs to get better]). 3. Develop an accurate care plan addressing the resident's COVID-19 transmission-based precautions (a combination of Contact [used for infections, diseases, or germs that are spread by touching the patient or items in the room] and Droplet Precautions [used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit] where staff dons full personal protective equipment [PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries] prior to entering care area or providing care) for Residents 4, 7, 8, and 9. These deficient practices had the potential to result in the delay of necessary care and services for the residents. Findings: a. A review of Resident 2's Face Sheet indicated the facility originally admitted the resident on 7/25/2023 and readmitted the resident on 8/14/2023, with diagnoses including chronic obstructive pulmonary disease (COPD, a common lung disease causing restricted airflow and breathing problems) and chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys [filter waste and excess fluid from the blood]). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/18/2023, indicated the resident had the ability to usually make self-understood and usually understand others. During a concurrent interview and record review, on 11/7/2023 at 12:15 p.m., with the Quality Assurance (QA) nurse, Resident 2's Care Plans were reviewed. The QA nurse stated Resident 2 did not have a care plan addressing the resident's refusal to receive pneumococcal vaccine and COVID-19 vaccine. During an interview on 11/7/2023 at 12:22 p.m., with the QA nurse, the QA nurse stated a care plan should have been developed when the vaccines were offered to Resident 2. The QA nurse stated the care plans indicate the resident's problems and the interventions needed to enable the resident to reach their goals. The QA nurse stated the care plan needs to be evaluated to determine if the resident's goals were met. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, reviewed 1/2023, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The policy implementation indicated that each resident's comprehensive care plan is designed to incorporate identified problem areas and reflect currently recognized standards of practice for problem areas and conditions. b. A review of Resident 3's Face Sheet indicated the facility originally admitted the resident on 2/10/2023 and readmitted the resident on 8/7/2023, with diagnosis including chronic obstructive pulmonary disease (COPD-a group of lung disease that block airflow and make it difficult to breathe) and metabolic encephalopathy (a condition that affects brain function due to problems with the body's metabolism). A review of Resident 3's History and Physical Exam (H&P), dated 8/7/2023, indicated the resident had fluctuating capacity. A review of Resident 3's Minimum Data Set (MDS, MDS, a standardized assessment and care screening tool) dated 8/10/2023, indicated the resident had the ability to usually make self-understood and usually understood others. A review of Resident 3's COVID-18 Consent Form, dated 8/8/2023, indicated the resident refused to be vaccinated with COVID-19 vaccine. During a concurrent interview and record review, on 11/7/2023 at 12:15 p.m., with the QA nurse, reviewed Resident 2's Care Plans. The QA nurse stated there was no care plan developed addressing the resident's refusal to receive COVID-19 vaccine. During an interview on 11/7/2023 at 12:22 p.m., the QA nurse stated a care plan should have been developed when the vaccines were offered to Resident 3. The QA nurse stated the care plans indicate the resident's problems and the interventions needed to enable the resident to reach their goals. The QA nurse stated the care plan needs to be evaluated to determine if the resident's goals were met. A review of the facility's policy and procedure titled, Care Plans - Comprehensive, reviewed 1/2023, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The policy implementation indicated that each resident's comprehensive care plan is designed to incorporate identified problem areas and reflect currently recognized standards of practice for problem areas and conditions. c. A review of Resident 4's Face Sheet indicated the facility admitted the resident on 9/8/2023 with diagnoses including COPD and chronic viral hepatitis C (a long-term inflammation of the liver caused by the hepatitis C virus). A review of Resident 4's History and Physical, dated 9/8/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 4's Final Report COVID-19, reported dated 11/4/2023, indicated the resident had positive COVID-19 results. During an interview on 11/7/2023 at 8:40 a.m., with Resident 4, Resident 4 stated that on 11/3/2023, he was tested for COVID-19 and on 11/4/2023, he was told by the nurse that he has COVID-19. During an observation on 11/7/2023 at 9:05 a.m., observed outside of Resident 4's door a signage that indicated Novel Respiratory Precautions. During a concurrent interview and record review on 11/7/2023 at 1:28 p.m. with the QA Nurse, Resident 4's care plans were reviewed. The QA nurse stated Resident 4's care plan for COVID-19 indicated the resident was placed on enhanced contact and droplet isolation (precaution). The QA nurse stated the care plan should have indicated novel respiratory precautions because the resident is COVID-19 positive.

Aug 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to implement its policies and procedures for one out of seven sampled residents (Resident 1) when the facility: 1. Failed to remove Certified Nursing Assistant 1 (CNA 1) from Resident 1 ' s care and from the facility immediately when the abuse allegation was made. 2. Failed to perform background check on CNA 1 prior to working with residents. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from a staff member accused of alleged abuse. Findings: a. A review of the Face Sheet indicated the facility admitted Resident 1 on 6/23/2023 and readmitted the resident on 7/28/2023, with diagnoses including unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), essential (primary) hypertension (blood is pumping with more force than normal through the arteries), and hyperglycemia (high blood glucose [blood sugar]). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/27/2023, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding), was able to understand other, and was able to make himself understood. The MDS further indicated Resident 1 required limited assistance with transfer, dressing, eating, toilet use, personal hygiene, walking in room and corridor, and locomotion on and off unit. A review of Resident 1 ' s Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) Conference Record, dated 7/31/2023, indicated the IDT met to discuss the resident ' s allegation of abuse against staff. A review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR- a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations) Communication Form, dated 7/25/2023 and timed 6:48 a.m., indicated Resident 1 exited the restroom at 3:45 a.m. and started yelling at CNA 1 who was attempting to care for Resident 7. When CNA 1 attempted to leave, Resident 1 attacked her from behind and fell on the floor on top of CNA 1, pinning CNA 1 on the floor. CNA 2 had to physically remove Resident 1 off of CNA 1. Resident 1 was bleeding from the lip and had a small laceration to the posterior (back) head. A review of CNA 1 ' s Timecard for 7/24/2023 to 7/25/2023 indicated CNA 1 clocked in on 7/24/2023 at 11:03 p.m. and clocked out at 7:13 a.m. on 7/25/2023. During an interview, on 8/8/2023 at 9:52 a.m., Resident 1, stated on the night of the incident, (7/25/2023), he saw a person in his room. Resident 1 told that person to get out and then they began to argue. Resident 1 stated he told the person some swear words and then the person began to punch him in many areas. Resident 1 he grabbed the person to stop her and that was when he saw that the person was Certified Nursing Assistant (CNA 1). Resident 1 stated they both fell to the floor, he was on top of CNA 1, then he felt a hard hit and lost consciousness. Resident 1 stated that CNA 1 punched him in the face, his lip was swollen, and his tooth became loose. During an interview, on 8/8/2023 at 10:03 a.m. Certified Nursing Assistant 2 (CNA 2), stated that on 7/25/2023 around 3:30 a.m. after his break, he was going to answer a call light when he heard someone shouting. CNA 2 went to check it out and saw Resident 1 shouting at CNA 1. CNA 2 stated a few minutes later, he heard CNA 1 shouting for CNA 2. When CNA 2 went to the room, he saw Resident 1 body on the floor and Resident 1 ' s feet on the bed and CNA 1 was under him. CNA 2 stated he separated Resident 1 and CNA 1. During an interview, on 8/7/2023 at 3:16 p.m., Registered Nurse (RN 1) stated around 3:30 a.m. after her break on 7/25/2023, she heard CNA 1 crying very loudly. RN 1 stated she saw CNA 1 on floor outside Resident 1 ' s room crying, and RN 1 asked her what happened; CNA 1 did not answer but just cried. RN 1 stated she went inside Resident 1 ' s room and she saw Resident 1 ' s bathroom door open. RN 1 reported seeing Resident 1 was bleeding from his face. When RN 1 asked Resident 1 what happened, he pointed to CNA 1. RN 1 stated she assessed Resident 1 ' s bleeding which was coming from a wound in the head. RN 1 stated when there are altercations, the involved individuals need to be separated immediately. RN 1 stated CNA 1 stayed in the facility building and completed her shift which could have still placed Resident 1 at risk for abuse. During an interview, on 8/9/2023 at 11:09 a.m., the IDON stated CNA 1 should have been suspended immediately. The IDON stated when suspension occurred, CNA 1 would have been escorted out of the facility immediately. The IDON stated not removing CNA1 placed the resident at risk for danger, for further abuse and/or injury. During an interview, on 8/9/2023 at 11:33 a.m., the Adm stated for CNA 1, their policy indicated to separate them, suspend staff, and have the staff go home to protect the resident. The Adm stated not removing CNA 1 from the building placed Resident 1 at risk for further abuse. A review of facility ' s policy and procedures titled Abuse Reporting and Investigation, last revised on 11/2018 indicated if the suspected perpetrator is an employee, remove the employee immediately from the care of the resident(s) and immediately suspend the employee pending the outcome of the investigation in accordance with the facility policies. b. A review of the Background Check for Certified Nursing Assistant (CNA 1) indicated background check was completed on 2/14/2023. A review of the Front Desk/Activities Schedule for 1/2023 and 2/2023 indicated CNA 1 started orientation on 1/27/2023. CNA 1 worked from 1/27/2023 to 1/31/2023, from 2/4/2023 to 2/7/2023, and from 2/11/2023 to 2/13/2023, for a total of 12 shifts prior to her background check being completed. During an interview, on 8/7/2023 at 2:03 p.m., the Interim Director of Nursing (IDON) stated that CNA 1 started as activities staff from 1/27/2023 to 3/3/2023 then transitioned to a CNA on 3/4/2023. The Director of Staff Development (DSD) stated the background check indicated it was completed on 2/14/2023. The DSD stated staff should not be working until their background check is completed. During an interview, on 8/9/2023 at 11:09 a.m., the IDON stated staff who have direct care contact with resident need to have background check completed prior to working with residents. The IDON stated background checks per policy indicated background check needs to be completed prior to employment. The IDON stated not completing background for the staff can place residents in danger. During an interview, on 8/9/2023 at 11:33 a.m., the Administrator (Adm) stated staff should have background check completed before working in the facility. The Adm stated not completing background check prior to employment is a risk; staff can have something on their background like violent history, and that would place residents at risk for abuse. A review of facility ' s policy and procedures titled, Background Screening Investigation, last revised 3/2019, indicated the facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. The policy and procedures further indicated background and criminal checks are initiated within two days of an offer of employment or contract agreement and completed prior to employment.

CONCERN (E) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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b. A review of Resident 2 ' s Face Sheet indicated the facility admitted the resident on 9/30/2021 with diagnoses including polyneuropathy (damage to multiple nerves located outside the brain and spinal cord called peripheral nerves), bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), and Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements). A review of Resident 2 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 6/1/2023, indicated the resident ' s cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills was moderately impaired. The MDS indicated Resident 1 exhibited physical and verbal behavioral symptoms such as hitting, kicking, pushing, screaming, and cursing at others. A review of Resident 3 ' s Face Sheet indicated the facility admitted the resident on 7/18/2023, with diagnoses including anemia (a condition that develops when the blood produces a lower-than-normal amount of healthy red blood cells), chronic obstructive pulmonary disease (COPD – a group of diseases that cause airflow blockage and breathing-related problems), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). A review of Resident 3 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 7/24/2023, indicated the resident ' s cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills was intact. The MDS indicated Resident 2 exhibited physical and verbal behavioral symptoms such as hitting, kicking, pushing, screaming, and cursing at others. On 8/9/2023 at 11:21 a.m., during an interview, the Activity Director (AD) stated that Resident 2 was sitting in the activity room watching television when Resident 1 entered. The AD stated that Resident 2 was commenting on the show they were watching when Resident 1 engaged and started shouting at Resident 2. There was verbal altercation between the two residents. The AD stated that she had to separate the two residents and reported the verbal altercation to the Administrator (ADM). On 8/9/2023 at 2:27 p.m., during an interview, the ADM stated that the resident-to resident verbal altercation happened on 8/1/2023 at 3 p.m., reported to the SSA on 8/1/2023 at 4:10 p.m., and the five-day report was faxed to the SSA on 8/4/2023. The ADM was not able to provide proof confirming the five-day report was faxed to the SSA. The ADM stated he did not call the SSA office to confirm that the report was received. A review of the facility ' s policy and procedure titled Abuse Reporting and Investigation, dated 1/26/2023, indicated that the facility will provide a written report of the results of all abuse investigations and appropriate actions taken to the California Department of Public Health (CDPH) Licensing and Certification and others that may be required by state or local laws, within five working days of the reported allegation. Based on interview and record review, the facility failed to implement its abuse prevention policy for three of seven sampled residents (Resident 1, 2, and 3) by: 1. Failing to ensure an allegation of physical abuse was reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA) for Resident 1. 2. Failing to ensure the results of the investigation of a resident-to-resident verbal abuse allegation were reported to the SSA within five working days of the incident for Resident 2 and Resident 3. The facility submitted the five-day investigation report on 8/9/2023, 6 working days after the alleged incident. These deficient practices had the potential to result in unidentified abuse and placed the residents at risk for abuse. Findings: a. A review of the Face Sheet indicated the facility admitted Resident 1 on 6/23/2023 and readmitted the resident on 7/28/2023, with diagnoses including unspecified dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), essential (primary) hypertension (blood is pumping with more force than normal through the arteries), and hyperglycemia (high blood glucose [blood sugar]). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 6/27/2023, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding), was able to understand other, and was able to make himself understood. The MDS further indicated Resident 1 required limited assistance with transfer, dressing, eating, toilet use, personal hygiene, walking in room and corridor, and locomotion on and off unit. A review of Resident 1 ' s Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) Conference Record, dated 7/31/2023, indicated the IDT met to discuss the resident ' s allegation of abuse against staff. A review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR- a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations) Communication Form, dated 7/25/2023 and timed 6:48 a.m., indicated Resident 1 exited the restroom at 3:45 a.m. and started yelling at CNA 1 who was attempting to care for Resident 7. When CNA 1 attempted to leave, Resident 1 attacked her from behind and fell on the floor on top of CNA 1, pinning CNA 1 on the floor. CNA 2 had to physically remove Resident 1 off of CNA 1. Resident 1 was bleeding from the lip and had a small laceration to the posterior (back) head. During an interview, on 8/8/2023 at 9:52 a.m., Resident 1, stated on the night of the incident, (7/25/2023), he saw a person in his room. Resident 1 told that person to get out and then they began to argue. Resident 1 stated he told the person some swear words and then the person began to punch him in many areas. Resident 1 he grabbed the person to stop her and that was when he saw that the person was Certified Nursing Assistant (CNA 1). Resident 1 stated they both fell to the floor, he was on top of CNA 1, then he felt a hard hit and lost consciousness. Resident 1 stated that CNA 1 punched him in the face, his lip was swollen, and his tooth became loose. Resident 1 stated he did not feel safe in facility requested to be transferred to an assisted living facility. During an interview, on 8/8/2023 at 10:03 a.m. Certified Nursing Assistant 2 (CNA 2), stated that on 7/25/2023 around 3:30 a.m. after his break, he was going to answer a call light when he heard someone shouting. CNA 2 went to check it out and saw Resident 1 shouting at CNA 1. CNA 2 stated a few minutes later, he heard CNA 1 shouting for CNA 2. When CNA 2 went to the room, he saw Resident 1 body on the floor and Resident 1 ' s feet on the bed (like a wheelbarrow position) and CNA 1 was under him. CNA 2 stated he separated Resident 1 and CNA 1. CNA 2 stated he is a mandated reporter and must report abuse immediately, but he did not report the abuse. During an interview, on 8/7/2023 at 2:20 p.m., LVN 3 stated she is aware to report any abuse to IDON and/or Administrator (Adm) within 2 hours and it was not done for this incident. During an interview, on 8/7/2023 at 3:16 p.m., Registered Nurse (RN 1) stated around 3:30 a.m. after her break on 7/25/2023, she heard CNA 1 crying very loudly. RN 1 stated she saw CNA 1 on floor outside Resident 1 ' s room crying, and RN 1 asked her what happened; CNA 1 did not answer but just cried. RN 1 stated she went inside Resident 1 ' s room and she saw Resident 1 ' s bathroom door open. RN 1 reported seeing Resident 1 was bleeding from his face. When RN 1 asked Resident 1 what happened, he pointed to CNA 1. RN 1 stated she assessed Resident 1 ' s bleeding which was coming from a wound in the head. RN 1 stated staff must report abuse allegations within 2 hours to the Adm; the reporting was not done within the timeframe for reporting abuse. RN 1 stated she told IDON around 8 a.m. but the incident occurred around 3:30 a.m. During an interview, on 8/7/2023 at 1:27 p.m., the Director of Staff Development (DSD) stated the incident occurred around 3 a.m. to 4 a.m. on 7/25/2023, but she called the police around 8:15 a.m. and reported it as a possible assault. The DSD stated all staff are aware to report allegations of abuse, and that it would have been LVN 1 to report the abuse allegation right away since they are mandated reporters. During an interview, on 8/9/2023 at 11:09 a.m., the IDON stated abuse should be reported immediately within 2 hours and should be reported to the police, Department of Health and Services (DHS), and the Ombudsman. The IDON stated the incident was an allegation of abuse and should have been reported. The IDON stated everyone is a mandated reporter, any of the staff should have contacted the IDON and/or Adm who is the abuse coordinator; the IDON stated that did not occur. The IDON stated the abuse was reported around 9 to 9:30 a.m. but incident occurred between 3 a.m. and 5 a.m. on 7/25/2023; the IDON stated there was a delay of a minimum of four hours. The IDON stated there was a risk for delay in investigation which may compromises resident ' s condition. During an interview, on 8/9/2023 at 11:33 a.m., the Adm stated abuse should be reported within two hours. The Adm stated the incident occurred between 3 a.m. and 5 a.m. on 7/25/2023; it should have been reported immediately after the incident. The Adm. stated it was not reported to anyone. The Adm stated staff should have called him and if he did not answer, the staff are mandated reporters, and they can do the paperwork and report it. The Adm stated not reporting within two hours is a risk for escalated safety concern and risk for further abuse. A review of the facility ' s policy and procedures titled, Abuse Reporting and Investigation, last revised in 11/2018, indicated the facility will report all allegations of abuse as required by law and regulation to the appropriate agencies within two hours.

Jun 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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to inform the resident of the right to participate in the development and implementation of his person-centered care plan (describes the strategies that the facility and staff will use to enhance, restore, or maintain a person ' s optimal physical, mental, and psychosocial well-being) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in violating the resident ' s right to participate in their assessment and care planning process. Findings: A review of Resident 1 ' s Face Sheet indicated the facility admitted the resident on 3/2/2023 with diagnoses including osteomyelitis (an infection of the bone) and skin transplant status. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/7/2023, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS indicated Resident 1 required limited assistance with dressing, toilet use, personal hygiene, and required supervision with bed mobility and eating. During an interview on 5/23/2023 at 8:16 a.m., Resident 1 stated since his admission, no one in the facility has invited or informed him about his right to participate in care plan meetings. Resident 1 stated he does not know what his plan of care is and its expected goals. During a concurrent interview and record review of Resident 1 ' s Interdisciplinary (IDT, different disciplines meet to address resident ' s problem) Conference Record, dated 3/8/2023, with Social Services Director (SSD) on 5/24/2023 at 8:11 a.m., the SSD stated there is no signature indicating attendance during the IDT conference by the resident and or family in the IDT conference record form. The SSD stated it is not a practice of the facility to have the resident or family/responsible party (RP) sign the IDT conference record form during the IDT conference. During a concurrent interview and record review of Resident 1 ' s IDT Conference Record, dated 3/8/2023, with the Director of Nursing (DON) on 5/24/2023 at 1:35 p.m., the DON stated different disciplines attend the IDT conference including the rehabilitation department, dietary services, social services, nursing, and the resident or their family/RP. The DON stated at the end of the IDT conference all the attendees including the resident or family/RP are asked to sign the form. The DON stated if the resident or family/RP do not want to sign the IDT conference record, the refusal is documented by the SSD or the nurse on the form. The DON stated there was no signature or refusal to sign by the resident or family/RP documented on the form. A review of the facility ' s policy and procedure titled, Care Planning – Interdisciplinary Team, reviewed and approved on 1/2023, indicated that 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. A review of the facility ' s policy and procedure titled, Charting and Documentation, reviewed and approved on 1/2023, indicated all services provided to the resident, or any changes in the resident ' s medical or mental condition, shall be documented in the resident ' s medical record. The procedure indicated the documentation of procedures and treatments shall include care-specific details and shall include at a minimum whether the resident refused the procedure notification of family, physicians, or other staff, if indicated.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure three of three sampled residents (Resident 1, 2, and 3) with limited mobility, received the appropriate treatment and services to increase and/or prevent decline in the residents ' range of motion (ROM, the extent of movement of a joint) and maintain or improve mobility, by: 1. Failing to complete a Restorative Nursing Assistant (RNA) Committee Meeting (a weekly meeting discussing the residents ' progress and response to treatment) from 3/11/2023 to 5/23/2023, attended by the Physical Therapist 1, Director of Staff Development (DSD), and RNA for Residents 1, 2, and 3. 2. Failing to develop range of motion care plan for Resident 1, 2, and 3, who were receiving restorative nursing care. These deficient practices had the potential to promote the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the resident ' s extremities. Findings: a. A review of Resident 1 ' s Face Sheet indicated the facility admitted the resident on 3/2/2023 with diagnoses including osteomyelitis (an infection of the bone) and skin transplant status. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/7/2023, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS indicated Resident 1 required limited assistance with dressing, toilet use, personal hygiene, and required supervision with bed mobility and eating. A review of Resident 1 ' s Physician Orders indicated the following orders: - RNA to implement bilateral upper extremity active range of motion (AROM, movement of a segment within the unrestricted ROM that is produced by active contraction of the muscles crossing that joint) as tolerated every day, five times a week, dated 3/3/2023. - RNA to implement bilateral lower extremity active-assisted ROM (AAROM, assistance is provided manually or mechanically by an outside force because the prime mover muscles need assistance to complete the motion) as tolerated every day, five times a week, dated 3/3/2023. During a concurrent interview and record review of Resident 1's Care Plans on 5/23/2023 at 10:42 a.m., the Quality Assurance (QA) Nurse confirmed there was no ROM care plan developed for Resident 1. b. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 10/15/2022 with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and end stage renal disease (ESRD, (last stage of chronic kidney disease when the kidneys fail leading to the need of long-term dialysis [blood purifying treatment] or a kidney transplant to maintain life). A review of Resident 2 ' s History and Physical (H&P), dated 10/16/2022, indicated the resident has the capacity to understand and make decisions. A review of Resident 2 ' s Physician Orders indicated the following orders: - RNA for AROM to bilateral upper extremity every day, five times a week, as tolerated, dated 10/21/2022. - RNA for passive ROM (PROM, an exercise provided by therapist or the RNAs who will have to do full ROM for the person without any help from the resident). A review of Resident 2's MDS, dated [DATE], indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS indicated the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene with one-person physical assistance. During a concurrent interview and record review of Resident 2's Care Plans on 5/23/2023 at 10:51 a.m., the QA Nurse confirmed there was no ROM care plan developed for Resident 2. c. A review of Resident 3's Face Sheet indicated the facility admitted the resident on 3/6/2023 with diagnoses including COPD and metabolic encephalopathy (disorders where medical problems such as blood infections or liver or kidney failure cause brain damage). A review of Resident 3 ' s H&P dated 3/6/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 3 ' s Restorative Record indicated RNA for ambulation with front wheeled walker as tolerated, every day, five times a week, dated 5/12/2023. The record indicated the resident has received seven restorative treatment days. During a concurrent interview and record review of Resident 3's Care Plans on 5/23/2023 at 10:51 a.m., the QA Nurse confirmed there was no ROM care plan developed for Resident 3. During an interview on 5/23/2023 at 10:58 a.m., the Director of Staff Development (DSD) stated her roles and responsibilities include scheduling of RNAs and arranging the RNA weekly meetings. The DSD stated the RNA Committee Meeting composed of the RNA, the DSD and the physical therapist, conduct weekly RNA meetings. The DSD stated during the meeting they review the resident ' s orders and current range of motion, to determine if the residents are maintaining or improving their range of motion. The DSD stated the meetings are done weekly and the team utilizes the RNA Committee Meeting Record and IDT Minutes to record the residents ' progress and is signed by the attendees during or after the meeting. The DSD confirmed that the RNA Committee Meeting record dated 3/11/2023 through 5/23/2023 for Resident 1, 2, and 3, were not completed. During an interview on 5/23/2023 at 1:58 p.m., the Director of Nursing (DON) stated the ROM care plan should be developed as soon as the resident is placed on the RNA program. The DON stated any licensed nurse, registered nurses (RN) or licensed vocational nurses (LVN), may create the care plan. The DON stated the DSD is responsible for keeping track of residents who are on the RNA program. The DON stated if there is a new order or changes in the RNA treatment, then the care plan should be updated right away. The DON stated the purpose of the ROM care plan is to ensure the staff involved in the residents are aware of the interventions and the recommended ROM exercises. During an interview on 5/25/2023 at 1:53 p.m., the DON stated during RNA Committee Meeting members discuss the resident ' s progress and changes in the resident ' s range of motion to ensure they provide the necessary care and treatment the resident needs. During an interview on 5/25/2023 at 2:14 p.m., the DON stated they do not have a policy and procedure specific to RNA Committee Meetings. The DON stated the RNA Committee Meetings meet weekly and utilizes the RNA Committee Meeting Record and IDT Minutes to keep track of theresident ' s progress. A review of the facility ' s policy and procedure titled, Restorative Nursing Services, reviewed and approved on 1/2023, indicated that residents will receive restorative nursing care as needed to help promote optimal safety and independence. The policy indicated that the restorative goals and objectives are individualized and resident-centered and are outlined in the resident ' s plan of care. A review of the facility ' s policy and procedure titled, Charting and Documentation, reviewed and approved on 1/2023, indicated that all observations and services performed must be documented in the resident ' s clinical records. The documentation of procedures and treatments shall include care-specific details and shall include a minimum of the date and time the procedure/treatment was provided; the assessment date and/or unusual findings obtained during the procedure/treatment; whether the resident refused the procedure/treatment; and the signature and title of the individual documenting.

CONCERN (E) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to timely complete, accurately document and sign the residents ' restorative nursing assistant (RNA) committee meetings record and interdisciplinary (IDT, when different disciplines meet to address resident's problem) minutes for two of three sampled residents (Resident 1 and 2). These deficient practices resulted in the residents ' restorative nursing assistant (RNA) committee meetings record and interdisciplinary minutes containing inaccurate information necessary to provide the complete picture of the resident assessment, interventions, and the residents ' response to the treatments provided. Findings: a. A review of Resident 1 ' s Face Sheet indicated the facility admitted the resident on 3/2/2023 with diagnoses including osteomyelitis (an infection of the bone) and skin transplant status. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/7/2023, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS indicated Resident 1 required limited assistance with dressing, toilet use, personal hygiene, and required supervision with bed mobility and eating. A review of Resident 1 ' s Physician Orders indicated the following orders: · RNA to implement bilateral upper extremity active range of motion (AROM, movement of a segment within the unrestricted ROM that is produced by active contraction of the muscles crossing that joint) as tolerated every day, five times a week, dated 3/3/2023. · RNA to implement bilateral lower extremity active-assisted ROM (AAROM, assistance is provided manually or mechanically by an outside force because the prime mover muscles need assistance to complete the motion) as tolerated every day, five times a week, dated 3/3/2023. b. A review of Resident 2's Face Sheet indicated the facility admitted the resident on 10/15/2022 with diagnoses including chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and end stage renal disease (ESRD, (last stage of chronic kidney disease when the kidneys fail leading to the need of long-term dialysis [blood purifying treatment] or a kidney transplant to maintain life). A review of Resident 2 ' s History and Physical (H&P), dated 10/16/2022, indicated the resident has the capacity to understand and make decisions. A review of Resident 2 ' s Physician Orders indicated the following orders: · RNA for AROM to bilateral upper extremity every day, five times a week, as tolerated, dated 10/21/2022. · RNA for passive ROM (PROM, an exercise provided by therapist or the RNAs who will have to do full ROM for the person without any help from the resident). A review of Resident 2's MDS, dated [DATE], indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS indicated the resident required extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene with one-person physical assistance. During a concurrent observation, interview, and record review on 5/23/2023 at 10:11 a.m., inside the rehabilitation room, observed RNA 1 signing multiple pages of the RNA Committee Meeting Record and Interdisciplinary Team Minutes dated 3/17/2023 and 3/24/2023 for multiple residents, including Resident 1 and 2. RNA 1 stated the RNA Committee Meeting meets every Wednesdays and Fridays and discuss the resident ' s exercises, progress, reasons for refusals. RNA 1 stated the Director of Staff Development (DSD) gave her instructions to sign the RNA Committee Records and the IDT Minutes dated 3/17/2023 and 3/24/2023. During an interview on 5/23/2023 at 11:20 a.m., RNA 1 stated she should have not signed the RNA Committee Record and IDT Minutes because she does not remember if she attended the meetings on 3/17/2023 and 3/24/2023. During an interview on 5/23/2023 at 10:58 a.m., the DSD stated the RNA Committee Meeting composed of the RNA, the DSD and the physical therapist, conduct weekly RNA meetings. The DSD stated during the meeting they review the resident ' s orders and current range of motion, to determine if the residents are maintaining or improving their range of motion. The DSD stated the meetings are done weekly and the team utilizes the RNA Committee Meeting Record and IDT Minutes to record the residents ' progress and is signed by the attendees during or after the meeting. The DSD stated she instructed RNA 1 to sign the RNA Committee Meetings and IDT minutes. The DSD stated she should have not told RNA 1 to sign the documents. The DSD stated the attendees should have signed it as soon as the meetings were done to ensure the information documented on the residents were accurate. During an interview on 5/25/2023 at 1:53 p.m., the DON stated during RNA Committee Meeting members discuss the resident ' s progress and changes in the resident ' s range of motion to ensure they provide the necessary care and treatment the resident needs. During an interview on 5/25/2023 at 2:14 p.m., the DON stated they do not have a policy and procedure specific to RNA Committee Meetings. The DON stated the RNA Committee Meetings meet weekly and utilizes the RNA Committee Meeting Record and IDT Minutes to keep track of theresidents ' progress. During a concurrent interview and record review of RNA 1 ' s timecard and Certified Nursing Assistant Monthly Work Schedule for 3/2023, on 5/25/2023 at 2:25 p.m., the DON confirmed RNA 1 was not scheduled and was off on 3/17/2023 and 3/24/2023. A review of the facility ' s policy and procedure titled, Restorative Nursing Services, reviewed and approved on 1/2023, indicated that residents will receive restorative nursing care as needed to help promote optimal safety and independence. The policy indicated that the restorative goals and objectives are individualized and resident-centered and are outlined in the resident ' s plan of care. A review of the facility ' s policy and procedure titled, Charting and Documentation, reviewed and approved on 1/2023, indicated that all observations and services performed must be documented in the resident ' s clinical records. The documentation of procedures and treatments shall include care-specific details and shall include a minimum of the date and time the procedure/treatment was provided; the assessment date and/or unusual findings obtained during the procedure/treatment; whether the resident refused the procedure/treatment; and the signature and title of the individual documenting.

May 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the discharge information for one of two sampled residents (Resident 3) by failing to document any discharge information when Resident 3 was discharged to home on 5/2/2023. This deficient practice resulted to incomplete documentation of Resident 3's discharge information in the resident's medical record and placed the resident at risk for not receiving the care and services necessary to meet the resident's needs. Findings: A review of Resident 3 ' s Face Sheet indicated the facility admitted the resident on 2/16/2022 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and schizoaffective disorder (a mental health disorder a condition where symptoms of both psychotic and mood disorders are present together during one episode [or within a two-week period of each other]), bipolar type. A review of Resident 3 ' s MDS dated [DATE], indicated the resident ' s cognitive status was intact. The MDS indicated the resident required supervision with bed mobility, transfer, walk in room and in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene with setup help. A review of Resident 3 ' s Physician Order indicated an order for resident's discharge on [DATE] to [home location]. A review of Resident 3 ' s Nursing Progress Notes, dated 5/1/2023 at 12:16 p.m., indicated that the resident will be discharged to [home location] and assisted with belonging inventory on 5/1/2023 to be picked up the next day, 5/2/2023 at 9 a.m. by Family Member 1 (FM 1). During a concurrent interview and record review of Resident 3 ' s medical record on 5/10/2023 at 3:09 p.m., the Director of Nursing (DON) confirmed the resident's discharge on [DATE] was not doumented. The DON stated Resident 3 ' s discharge information on 5/2/2023 should have been documented in the resident's medical record. During a follow-up interview on 5/10/2023 at 3:53 p.m., the DON stated the facility ' s discharge procedure in documentation should include documentation of where the resident was discharged , if home health was arranged, the location the resident is discharging to and will arrange for home health, date, and time when the resident was discharge or picked up, and who picked up the resident, and /or the mode of transportation. The DON stated the purpose of documenting the discharge information was to have documentation that the resident was discharged safely. A review of the facility ' s policy and procedure titled, Discharging the Resident, reviewed and approved on 1/2023, indicated the facility ' s documentation procedure of the information that should be recoded in the resident ' s medical record including: the date and time the discharge was made, the name and title of the individual(s) who assisted in the discharge, all assessment data obtained during the procedure, if applicable; and the signature and titled of the person recording the data.

CONCERN (E) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop an individualized plan of care for three of three sampled residents (Resident 1, 2, and 3), by failing to update the care plans with the interdisciplinary team's recommendations addressing Residents 1, 2, and 3's emotional and psychosocial needs. These deficient practices had the potential to results in a delay of delivery of care and services to the residents. Findings: a. A review of Resident 1 ' s Face Sheet indicated the facility admitted the resident on 4/14/2023 with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and polyneuropathy (a condition where simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/19/2023, indicated the resident made self understood and understood others. The MDS indicated the resident required supervision with bed mobility and limited assistance with transfer, walking in room and corridor, locomotion on and off unit, dressing, toilet use, and personal hygiene with one-person physical assist. A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, system for identifying, evaluating, and reporting deterioration in resident ' s condition) Communication Form, dated 4/18/2023, indicated the resident had a verbal altercation with other resident in the patio and the activity director (AD) separated them immediately. A review of Resident 1 ' s IDT notes dated 4/19/2023, indicated the resident will be referred to facility psychologist for emotional and psychosocial support. During a concurrent interview and record review of Resident 1 ' s clinical record on 5/10/2023 at 9:56 a.m., the QA nurse confirmed Resident 1 is at risk for emotional distress care plan dated 4/18/2023 was not individualized. The QA nurse stated that during the IDT meeting on 4/19/2023, the IDT recommended a psychology consult and visit for the resident. The QA nurse stated the IDT's recommendation was not indicated in the resident's care plan. b. A review of Resident 2 ' s Face Sheet indicated the facility readmitted the resident on 12/30/2022 with diagnosis including Parkinson ' s disease (a progressive nervous system disorder that affects movement) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 2 ' s MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated the resident required supervision with bed mobility, transfer, walk in room, locomotion on and off unit, eating, toilet use and limited assistance with walk in corridor, dressing, and personal hygiene with one-person physical assist. A review of Resident 2 ' s History and Physical, dated 12/30/2022, indicated the resident has the capacity to understand and make decisions. A review of Resident 2 ' s Physician Order indicated psychologist consult and treatment if indicated, dated 12/30/2022. A review of Resident 2 ' s SBAR dated 4/18/2023, indicated verbal altercation with another resident and separated the residents. A review of Resident 2 ' s IDT notes dated 4/19/2023, indicated the resident will be referred to facility psychologist for emotional and psychosocial support. During a concurrent interview and record review of Resident 2 ' s clinical record on 5/10/2023 at 10:00 a.m., the QA nurse confirmed Resident 2 ' s at risk for emotional distress care plan dated 4/18/2023 was not individualized. The QA nurse stated the resident's care plan did not include interventions to address the resident's at risk for emotional distress. The IDT's recommendation to refer the resident to facility psychologist for emotional and psychosocial support was not indicated in the resident's care plan. c. A review of Resident 3 ' s Face Sheet indicated the facility admitted the resident on 2/16/2022 with diagnoses including major depressive disorder and schizoaffective disorder (a mental health disorder a condition where symptoms of both psychotic and mood disorders are present together during one episode [or within a two-week period of each other]), bipolar type. A review of Resident 3 ' s MDS dated [DATE], indicated the resident ' s cognitive status was intact. The MDS indicated the resident required supervision with bed mobility, transfer, walk in room and in corridor, locomotion on and off unit, dressing, eating, toilet use, and personal hygiene with setup help. A review of Resident 3 ' s Physician Order indicated psychological eval and follow-up treatment as indicated, dated 2/16/2022. A review of Resident 3 ' s SBAR, dated 4/21/2023 at 3:30 p.m., indicated that resident has episode of verbalizing to someone that she does not feel safe here and no verbalization during rounds. During a concurrent interview and record review of Resident 3 ' s clinical record on 5/10/2023 at 10:18 p.m., the QA nurse confirmed stated Resident 3 ' s care plan developed for resident ' s verbalization of not feeling safe in the facility was not individualized. The QA nurse stated the psychologist referral was not indicated in the resident ' s care plan. During an interview on 5/10/2023 at 3:47 p.m., the Director of Nursing (DON) stated the licensed nurses, registered nurse, or licensed vocational nurse, modifies the care plans as it applies to the problem. The DON stated the care plans are specific to the resident ' s problems and the interventions intended for the resident and potential response to the interventions. A review of the facility ' s policy and procedure titled, Care Planning, reviewed and approved on 1/2023, indicated that it is the facility ' s policy that the facility ' s Care Planning/IDT is responsible for the development of an individualized comprehensive care plan for each resident.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 provide care in accordance with professional standards of nursing practice for one of three sampled residents (Resident 3) by failing to ensure the resident's physician was notified of the resident-initiated discharge against medical advice (AMA). This deficient practice placed the resident at risk for not receiving care and services necessary to meet their medical, physical, mental ans psychosocial needs. Findings: A review of Resident 3's Face Sheet indicated the facility admitted the resident on 3/13/2023 at 6:00 p.m, and dicharged the resident on 3/13/2023 at 8:00 pm. The face sheet indicated the resident's diagnoses included alcohol abuse and alcoholic liver disease. The face sheet indicated the resident was self-responsible. During a concurrent interview and record review with the Quality Assurance Nurse (QA nurse) on on 3/15/2023 at 10:18 a.m., Resident 3's Nurses Notes dated 3/13/2023 was reviewed. The QA Nurse stated there was no documented evidence that indicated Resident 3's Attending Physician was notified of the resident's request to leave the facility against medical advice (AMA). During an interview on 3/17/2023 at 12:50 p.m., the Director of Nursing (DON) stated the licensed nurses should have documented the reason why the resident wants to leave, the intervenitons that were done to keep the resident from leaving, and education provided explaining the risks and benefits of leaving AMA. The DON stated the licensed nurses should have documented that the physician was notified of the resident's background and diagnoses because the resident might have an underlying condition that needed to be addressed and leaving the facility might be harmful for the resident. During a follow-up phone interview with the DON on 4/13/2023 at 11:52 a.m., the DON stated the resident was admitted to the facility on [DATE] at 6:00 p.m and left AMA on 3/13/2023 at 8:00 p.m The DON stated that there was no documented evidence that the physician was notified of Resident 3 leaving AMA. The DON stated that if it was not documented then it was not done. A review of the facility's policy and procedure titled, Discharging a Resident without a Physician's Approval, reviewed and approved 01/2023, indicated tha it is the facility's policy a physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice. The procedure indicated should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's Attending Physician will be promptly notified.

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 F0943 (Tag F0943)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide abuse in-service (training) upon hire for one of five sampled staff (Registered Nurse 1 [RN 1]) and track facility staff attendance for one of five sampled staff (Licensed Vocational Nurse 1 [LVN 1]) according to the facility ' s abuse policy and procedure. This deficient practice had the potential to result in delay of recognizing, addressing, and reporting of alleged abuse incidents and placed residents at further risk of abuse. Findings: During a concurrent interview and record review on 3/7/2023 at 12:12 p.m., the Director of Staff Development (DSD) confirmed there was no abuse training documentation maintained on RN 1 ' s employee file. RN 1 ' s date of hire was 3/29/2021. The DSD confirmed LVN 1 did not attend the abuse in-service provided on 2/1/2023. The DSD stated she does not have a process of tracking the facility staff in attendance of the mandatory abuse in-service. During an interview on 3/7/2023 at 12:17 p.m., the Director of Nursing (DON) stated abuse in-service/training is provided upon hire, during annual performance review, and as needed. TheDON stated the in-service attendance should be tracked using a list of staff. The DON stated it is important that all facility staff receive the mandatory abuse in-service, so they are up to date with the regulations. Once staff identify the types of abuse, they have to report it right away. The DON further stated abuse related in-services are mandatory. The DON stated if the facility staff attendance is not tracked, there is a potential of delay in recognizing, addressing, and reporting of the abuse, and places the residents from further abuse. A review of the Facility Assessment Tool, dated 3/25/2023, indicated that the facility has developed, implemented, and maintained an effective training program for all new and existing staff, including providing services under a contractual arrangement consistent with their expected roles which included training calendars and mandatory in-services of abuse prevention training.

Feb 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his quality of life for one of nine sampled residents (Resident 8) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) sat at eye level to a resident while assisting the resident to eat. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem. Findings: A review of Resident 8's Face Sheet indicated the facility admitted the resident on 6/24/2021 and readmitted the resident on 1/9/2023 with diagnoses including hemiplegia (inability to move one side of the body), epilepsy (brain disorder that causes people to have recurring involuntary muscle movements, sensory disturbances and altered consciousness), and chronic obstructive pulmonary disease (COPD - a group of disease that cause airflow blockage and breathing-related problems). A review of Resident 8's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/15/2022, indicated the resident's cognition (involving conscious intellectual activity such as thinking, reasoning, or remembering) was moderately impaired and the resident required limited assistance with one person assist with eating. During an observation on 2/2/2023 at 12:35 p.m., observed Resident 8 sitting in a wheelchair in the dining room with the lunch tray on the table in front of the resident. Observed LVN 1 stood beside Resident 8's left side while the resident was looking up as LVN 1 placed the food in the resident's mouth. Observed Resident 8 coughing and LVN 1 offered the resident a drink while patting the resident's back. During an interview on 2/2/2023 at 12:45 p.m., LVN 1 stated that staff should be at eye level with the resident while assisting the resident with eating. LVN 1 further stated that if the staff and the resident were not at eye level, the resident could potentially choke. LVN 1 stated that resident rights on dignity and safety were violated. During an interview on 2/28/2023 at 12:20 p.m. the Director of Nursing (DON) stated that staff should be sitting down at eye level with the resident while assisting the resident with eating. The DON stated it could potentially cause choking and the impression that the staff was in a hurry. The DON further stated that safety protocol and dignity were violated. A review of the facility policy and procedure titled, Quality of Life - Dignity, last reviewed 8/2009, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with respect and dignity at all times. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.

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 maintain an infection prevention and control program regarding Coronavirus 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of nine sampled residents (Resident 4, Resident 5, and Resident 6), by failing to: a. Ensure facility staff's personal protective equipment (PPE – equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was properly worn inside the facility. The face mask was not covering the Social Service Director's (SSD) nose and mouth while talking to Resident 5. b. Ensure the facility staff performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) and disinfected the equipment before and after use. Licensed Vocational Nurse 2 (LVN 2) did not perform handwashing or used hand sanitizer before and after care to Resident 4 and Resident 6. LVN 2 did not disinfect the blood pressure machine between resident use. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19. Findings: a. A review of Resident 5's Face Sheet indicated the facility admitted the resident on 4/9/2020 and readmitted the resident on 1/5/2023 with diagnoses including Wernicke's encephalopathy (a degenerative brain disorder caused by the lack of vitamin B1), epilepsy (brain disorder that causes people to have recurring involuntary muscle movements, sensory disturbances and altered consciousness) and essential hypertension (an abnormally high blood pressure that was not the result of a medical condition). A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/10/2023, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was severely impaired. During a concurrent observation and interview on 2/2/2023 at 12:05 p.m., observed the SSD pull the face mask down exposing the SSD's nose and mouth. The SSD and Resident 5 were talking in the hallway without a face mask covering both their nose and mouth. The SSD stated the face mask should be worn while in the facility. The SSD further stated infection could potentially spread to other residents and staff. The SSD stated that infection control protocol was violated. During an interview on 2/2/2023 at 12:45 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that to prevent spread of infection, the facility follows the Center for Disease Control and Prevention (CDC) guidelines and face mask should be worn over the nose, covering the mouth, and not tampered with. LVN 1 further stated that spread of infection to other residents and staff can potentially happen if protocols were not followed. During an interview on 2/28/2023 at 12:20 p.m. with the Director of Nursing (DON), the DON stated face mask should be worn covering the nose and mouth. The DON stated that facility staff were required to wear mask while inside the facility to prevent spread of COVID 19 to other residents and staff. The DON further stated that it can potentially spread infections to other residents and staff. The DON stated that infection control protocols and safety of staff and residents were violated. A review of the facility's policy and procedure titled Infection Control Guidelines for All Nursing Procedures, dated 8/2012, indicated the purpose to provide guidelines for general infection control while caring for residents. A review of the facility's policy and procedure titled Coronavirus Disease (COVID-19) – Infection Prevention and Control Measures, dated 4/2020, indicated while in the building, personnel were required to strictly adhere to established infection prevention and control policies, including .c. appropriate use of PPE. b. A review of Resident 6's Face Sheet indicated the facility admitted the resident on 11/4/2022 with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 6's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 2/7/2023, indicated the resident's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. A review of Resident 4's Face Sheet indicated that the facility admitted the resident on 2/16/2022 with diagnoses including type 2 diabetes mellitus (an impairment in the way the body regulates the used sugar), asthma (a condition that affects the airway in the lungs), and bipolar schizoaffective (a mental illness that can affect the thoughts, mood, and behavior). A review of Resident 4's MDS, dated [DATE], indicated the resident's cognition was intact. During a concurrent observation and interview on 2/28/2023 at 8:54 a.m., observed Licensed Vocation Nurse 2 (LVN 2) assist Resident 6 and took the resident's blood pressure without performing hand washing or using hand sanitizer. LVN 2 went to Resident 4 and took the resident's blood pressure using the same blood pressure machine without performing hand washing or using hand sanitizer, and without disinfecting the machine before and after resident use. LVN 2 stated that handwashing or use of hand sanitizer should be done before and after resident care. LVN 2 further stated that equipment used by multiple residents should be disinfected between resident use. LVN 2 stated infection control procedures were violated. A review of the facility's policy and procedure titled Infection Control Guidelines for All Nursing Procedures, dated 8/2012, indicated the purpose to provide guidelines for general infection control while caring for residents. The policy indicated the employees must wash their hands for 10 to 15 seconds using antimicrobial or non-antimicrobial soap and water before and after direct contact with residents. The policy also indicated that hand hygiene with use of alcohol-based hand sanitizer if hands are not visibly soiled .before and after direct contact with residents. A review of the facility's policy and procedure titled Coronavirus Disease (COVID-19) – Infection Prevention and Control Measures, dated 4/2020, indicated that dedicated or disposable non-critical resident-care equipment such as blood pressure cuff were used, the equipment were to be cleaned and disinfected according to manufacturer's instructions using an Environmental Protection Agency (EPA)-registered disinfectant for healthcare setting prior to use on another resident.

Jan 2022 12 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 32 had provided his/her right for privacy and dignity by not knocking prior to entering the resident's room for one of one sampled resident (Resident 32). This deficient practice has the potential to affect the resident`s sense of self-esteem and self-worth. Findings: A review of the admission record indicated Resident 32 was admitted to the facility, on 08/15/2021 and readmitted on [DATE], with diagnoses including dementia (loss of cognitive functioning - thinking, remembering, and reasoning), polyarthritis (condition where pain and inflammation occur in multiple joints at once), and Parkinson`s disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination). A review of the Minimum Data Set (MDS- an assessment and care screening tool), dated 11/18/2021, indicated Resident 32's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 32 required extensive assistance from staff for bed mobility, dressing, and was totally dependent on staff for toilet use, personal hygiene, and bathing. During an observation and interview, on 01/18/22 at 12:06 p.m., Licensed Vocational Nurse 3 (LVN 3) entered Resident 32`s room without knocking and asking permission from the resident. LVN 3 stated she usually knocked on the door to let the resident know that she was entering the room in respect for their privacy. During an interview, on 01/19/22 at10:38 a.m., the Director of Nursing (DON) stated staff must knock and ask permission before entering the resident`s room. A review of the facility's policy, dated , titled, Quality of Life-Dignity, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Resident`s private space and property shall be respected at all times. Staff will knock and request permission before entering resident`s rooms.

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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Based on observation, interview, and record review, the facility failed to ensure resident's call light was within reach for one (Resident 9) out of two sampled residents investigated for accommodation of needs. This deficient practice had the potential to result in the residents' needs not being met. Findings: A review of admission record indicated Resident 9 was admitted to the facility, on 09/16/2020, with diagnoses including encephalopathy (disease in which the functioning of the brain is affected by some agent or condition [such as viral infection or toxins in the blood]), adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), and muscle wasting and atrophy (loss of muscle tissue). A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 12/14/2021, indicated Resident 9 had severely impaired cognition and required extensive assistance from staff for walking in the room and in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 9's care plan for activities of daily living (ADL - skills required to manage one's basic physical needs) deficit, dated 07/25/2021, indicated to have the resident's call light within reach and for staff to answer promptly. During an observation and interview, on 01/18/2022 at 9:04 a.m., Resident 9 was asleep in bed. Resident 9's call light was hanging behind the resident's headboard. The Nurse Consultant (NC) verified the resident's call light was not within reach and was behind the resident's headboard. During an interview, on 01/20/2022 at 9:02 a.m., Licensed Vocational Nurse 1 (LVN 1) stated staff were taught to answer call lights right away and to make sure when they leave the room, the call light was within the resident's reach. During an interview, on 01/20/2022 at 9:04 a.m., Registered Nurse 1 (RN 1) stated the call lights should always be left within the resident's reach. During an interview, on 01/21/2022 at 8:49 a.m., the Director of Nursing (DON) stated call lights should be within reach of the resident. The DON stated this was important to ensure that residents' needs were being met. A review of the facility's policy titled, Answering the Call Light, revised on 10/2010, indicated the purpose of the policy was to respond to the resident's request and needs. The policy and procedure indicated to answer the resident's call as soon as possible.

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 ensure that a resident's care plan (CP - helps nurses and other care team members organize aspects of patient care according to a timeline) for activities of daily living (ADL) was revised and updated, for one of one resident (Resident 43) reviewed under the care area care plan timing and revision. This deficient practice had the potential to affect the provision of necessary care and services for Resident 43. Findings: A review of the admission record indicated Resident 43 was admitted to the facility, on 10/14/2021, with diagnoses that included dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). A review of the Minimum Data Set (MDS- as assessment and care screening tool) dated 10/21/2021, indicated Resident 43's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 43 required limited assistance from staff with dressing, toilet use, personal hygiene, and extensive assistance with bathing. A review of the physician's order indicated Resident 43 was to receive oxygen at 2 liters per minute via nasal cannula (use of nasal cannulas is common for patients with chronic obstructive pulmonary disease) as needed for COPD. A review of Resident 43`s CP for ADL, indicated no interventions were checked under the section Approaches/Plan. During a concurrent interview and record review, on 01/19/2022 at 08:56 a.m., the Director of Nursing (DON) confirmed the CP did not indicate the interventions/approaches/plan that were to be provided for the identified problem and needs of the resident. DON stated the intervention or approaches had to be marked or checked in the CP form to indicate the approaches to be included in caring for the resident. DON stated the CP if not checked would create confusion among the staff as to which interventions were to be provided and appropriate for the resident. A review of the facility`s undated policy titled Care Plans, Comprehensive Person- Centered, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial and functional needs is developed and implemented for each resident.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss (LAL) mattress (designed to prevent and treat pressure ulcers [injuries to skin and underlying tissue resulting from prolonged pressure on the skin]) was set to the correct setting based on the resident's weight for one (Resident 206) out of three sample residents investigated for pressure ulcers. This deficient practice had the potential to place the resident at risk of poor wound healing. Findings: A review of the admission record indicated Resident 206 was admitted to the facility, on 01/11/2022, with diagnoses that included hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke - disrupted blood flow to the brain due to problems with the blood vessels that supply it) and pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (bottom of the spine). A review of the History and Physical Exam (starting point of a patient's story as to why they sought medical attention or are now receiving medical attention), dated 01/11/2022, indicated Resident 206 had the capacity to understand and make decisions. A review of Resident 206's care plan (provides direction on the type of nursing care the individual/family/community may need) for sacral pressure ulcer indicated interventions listed were to use a pressure redistribution device (low air loss [LAL] mattress - a mattress designed to prevent and treat pressure ulcers) while in bed/chair. During an observation, on 01/18/2022 at 10:41 a.m., Resident 206 was awake in bed. LAL mattress was set to 350 pounds (lbs) and was firm. During a concurrent interview and record review, on 01/18/2022 at 10:57 a.m., Registered Nurse 1 (RN 1) checked the resident's medical record for her current weight. RN 1 stated Resident 206 was currently 155 lbs. RN 1 stated Resident 206's LAL mattress was not set to the correct setting and should have been set between 150-160 lbs. During an interview, on 01/21/2022 at 8:49 a.m., the Director of Nursing (DON) stated it was important to make sure the resident's LAL mattress was on the correct setting according to her weight to prevent further skin breakdown on different pressure points and to aid in wound healing. A review of the facility's policy titled, Support Surface Guidelines, revised in 09/2013, indicated the purpose of the policy was to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. Redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Support surfaces are modifiable. Individual resident needs differ.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe environment for residents as evidenced by: 1. Resident 36, who smoked cigarettes was not supervised by the designated staff while smoking outside her room, for one of two sampled residents in the Red Cohort (designated area for residents with confirmed Covid-19 - coronavirus is a respiratory disease-causing difficulty breathing). 2. Failure to bolt or anchor a television to the stand or table for one out of one resident (Resident 35) investigated under the care area accidents. These deficient practices had the potential to cause hazard or injury for the residents. Findings: a. A review of the admission record indicated Resident 36 was admitted to the facility, on 5/26/2021, with diagnoses including seizure disorder (condition in which nerve cell activity in the brain is disturbed, causing seizures), mood disorder (mental health problem that primarily affects a person's emotional state), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and nicotine dependence (chemical in tobacco and a person can't stop using it). A review of Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/26/21, indicated Resident 36 had an intact cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated Resident 36 required supervision with all activities of daily living (ADL - a term used to collectively describe fundamental skills required to independently care for oneself). A review of History and Physical, dated 5/27/2021, indicated Resident 36 had the capacity to understand and make decisions. A review of Physician's Orders, dated 05/26/2021, indicated Resident 36 may smoke per facility's protocol. A review of the Safe Smoking Assessment, dated 12/14/2021, indicated Resident 36 was able to smoke independently under supervision from staff. A review of the Care Conference Meeting (meeting of everyone involved in a resident's care to share information and work together to meet the resident's needs), dated 11/24/2021, indicated smoking would be in a designated area under staff supervision. A review of the care plan, initiated on 11/3/2021, indicated Resident 36 was at risk for hazards or injury related to injury related to smoking. The goal indicated Resident 36 would not experience injuries associated with smoking. The care plan's interventions indicated for facility staff to provide precautionary measures and supervision during smoking schedule if possible. During a concurrent observation and interview, on 01/18/2022 at 10:30 a.m., Resident 36 was observed smoking in the small patio outside her room unsupervised. Resident 36 stated nobody watched her while smoking. Resident 36 stated she was aware of the risk of injury or hazard if she was smoking unsupervised. During an interview, on 01/18/2022 at 10:45 a.m., Licensed Vocational Nurse 1 (LVN 1) stated activities department was supposed to supervise residents while smoking at the small patio outside Resident 36's room. During an interview, on 01/18/2022 at 11:00 a.m., the Activities Director (AD) stated designated Red Cohort staff were supposed to supervise Resident 36 while smoking. During an interview, on 01/19/2022 at 8:00 a.m., the Activities Director (AD) stated Resident 36 was supposed to be supervised while smoking by designated Red Cohort staff in the patio outside her room for safety and to avoid possible injury. During an interview, on 01/19/2022 at 2:17 p.m., the Director of Nursing (DON) stated that the designated staff in the Red Cohort should supervise Resident 36 while smoking. The DON also stated that it was a safety issue and a potential for injury if Resident 36 was left unsupervised by staff. A review of the facility's policy titled, Smoking by Residents dated 09/2018, indicated, residents who requires assistance or monitoring for smoking safety are not allowed to be smoke unaccompanied or unsupervised. b. A review of the admission record indicated Resident 35 was admitted to the facility, on 06/03/2021, with diagnoses including major depressive disorder (mental illness characterized by sadness, severe or persistent enough to interfere with daily activities of life), and anxiety disorder (a group of mental disorders characterized by significant feelings of fear and worry). A review of the MDS, dated [DATE], indicated Resident 35 could understand others and made self-understood. The MDS indicated Resident 35 required limited assistance from staff with transfer, dressing, toilet use, and bathing. During a concurrent observation and interview, on 01/18/22 03:03 p.m., Resident 35 was in bed sleeping. Beside the resident`s bed was a television placed on top of a bedside table. Upon closer inspection, it was noted that the television had no anchor or was not bolted to the table. The Maintenance Assistant (MA) stated the television had to be secured to avoid any accidents that may cause the television to fall. The MA stated the staff should strap the television and screw it to the tables because if the resident was using a wheelchair, the resident could bump into the table and cause the television to fall and injure a resident. A review of the facility`s undated policy titled Hazardous Areas, Devices and Equipment, indicated that all hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document pain preassessment indicating pain severity and location prior to administration of oxycodone and post-medication pain assessment timely according to physician`s order for one of one sampled resident (Resident 13) investigated under the care area of pain. This deficient practice may lead to confusion in the delivery of care and services rendered and may lead to inadequate management of Resident 13's polyosteoarthritis (joint pain that affects five or more joints simultaneously). Findings: A review of Resident 13's Face Sheet (admission Record) indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of, including but not limited to, polyosteoarthritis (joint pain that affects five or more joints simultaneously), osteoarthritis (disease that causes the joints to become very painful and stiff), and chronic right knee pain. A review of Resident 13's History and Physical (an important reference document that provides concise information about a patient's history and exam findings at the time of admission) dated 10/03/2021 indicated the resident has the capacity to understand and make decisions. A review of Resident 13's Minimum Data Set (MDS- a resident assessment and care-screening tool) dated 08/31/2021, indicated that the resident can understand others and can make self-understood. The MDS indicated that Resident 13 required limited assistance from staff with transfer, dressing, toilet use, personal hygiene, and bathing. A review of Resident 13's physician`s orders in 5/18/2021, included, but not limited to oxycodone hydrochloride (used to help relieve moderate to severe pain) 10 milligram (mg - unit of measurement) tablet, 1 tablet by mouth every four hours as needed for severe pain at 8-10 pain level (Numerical Pain Rating Scale [NPRS] is a subjective measure of pain on an eleven-point numerical scale between 0 and 10 where 0 indicates no pain and 10 indicates maximum pain). During a concurrent interview and record review with the Director of Nursing (DON) on 1/20/2022 at 02:25 p.m., the DON stated Resident 13's electronic Medication Administration Record (eMAR) indicated that oxycodone hydrochloride (HCL) 10 mg were administered with no pain preassessment on the following dates: a. 1/3/2022 at 12:02 a.m. b. 1/5/2022 at 12:15 a.m. c. 1/6/2022 at 12:01 a.m. d. 1/7/2022 at 12:30 a.m. e. 1/7/2022 at 08:00 a.m. f. 1/8/2022 at 08:00 a.m. e. 1/13/2022 at 01:33 p.m. g. 1/13/2022 at 05:33pm The DON added stated that pain level and location should be asked right before the medication is given and which medication is appropriate for the resident's pain level. The DON stated that staff can document on the nurse's notes but was not done. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 1/21/2022 at 09: 22 a.m., RN 1 stated that Resident 13 had two pain medications to be administered as needed which were the following: a. Oxycodone HCL 10 mg one tablet by mouth every 4 hours as needed for pain scale of 8/10 to 10/10. b. Naproxen (relieve symptoms of arthritis) 500 mg one tablet by mouth every six hours as needed for pain scale of 4/10 to 7/10 not to exceed 1,500 mg in 24 hours. RN 1 stated that if the resident reported pain level of 7 or less, they will give naproxen and if the pain level was 8 and above, they will administer oxycodone. RN 1 stated that before she gives pain medication, she does an assessment of the resident's pain, pain level and location, and look for other signs and symptoms such as grimacing, crying, or guarding behavior. RN 1 added that pain assessment after one hour of administering the medication should also be documented. RN 1 stated there is no documentation of pre-assessment of pain level and location in the eMAR prior to medication administration for oxycodone for the reviewed dates. Post pain assessments for the above medication administration were also not documented within one hour of administration as written on resident's care plan in 10/1/20 for dates as follows: a. 01/03/2022 at 09:51 a.m. (due at 09:23 a.m.) b. 01/05/2022 at 02:08 a.m. (due at 01:15 a.m.) c. 01/06/2022 at 01:43 a.m. (due at 01:01 a.m.) A review of Resident 13`s Care Plan for At Risk for Pain related to Diagnosis of Chronic Right Knee Pain, indicated in the goals that pain will be resolved within one hour after pain medication is given for 90 days. A review of the facility`s policy and procedure titled Medication Administration-General Guidelines, last reviewed and approved on 4/17/19, indicated that the individual who administers the medication dose records the administration on the resident`s eMAR directly after the medication is given and resident`s response to medication, if applicable such as pain medication.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered, and/or, including the process of disposition by failing to account for residents' controlled medications (substances that have accepted medical use, have potential for abuse, and may also lead to physical and or psychological dependence) for two (Resident 106 and Resident 207) sampled residents during review of medication storage task. This deficient practice resulted in inaccurate reconciliation of controlled medications for Residents 106 and 207, and placed the facility at potential for inability to readily identify loss, theft and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes). Findings: a. A review of Resident 106's Face Sheet indicated the resident was initially admitted to the facility on [DATE], and was last admitted on [DATE], with diagnoses including hypertension (HTN - elevated blood pressure) and encephalopathy (damage or disease that affects the brain). The Face Sheet indicated the resident was discharged on 07/29/2021. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 07/29/2021, indicated the resident had a memory problem and had some difficulty in making decisions regarding tasks of daily life. The MDS indicated the resident required supervision with activities of daily living. A review of the Physician Orders dated 07/04/2021, indicated an order for Norco (hydrocodone/acetaminophen [APAP]- medication used to relieve moderate to severe pain; it contains an opioid pain reliever [hydrocodone] and a non-opioid pain reliever [acetaminophen]) 10-325 milligrams (mg-unit of measurement) tablet by mouth every six hours as needed for moderate to severe pain. A review of Resident 106's Medication Administration (MAR) for the month of 07/2021, indicated Norco 10-325 milligrams (mg) tablet by mouth every six hours as needed for moderate to severe pain was discontinued on 07/29/2021. During a concurrent interview and record review on 01/19/2022 at 12:11 p.m., with the Director of Nursing (DON), facility's disposition of controlled medication records including Resident 106's Record of Controlled Substances was reviewed. During the review, Resident 106's Record of Controlled Substances indicated there were 60 tablets of Hydrocodone-APAP 10-325 mg left unused. The record did not have documentation of disposition of the resident's remaining doses of Hydrocodone-APAP 10-325 mg. The DON stated the record did not have the DON's and the pharmacist's signature as witnesses for the disposition of the medication. The DON also stated the record did not indicate the date of disposition, the quantity of the medication disposed, and the method of disposition. The DON stated the record should have been signed by the DON and the pharmacist during disposition and contained the appropriate documentation. The DON stated she is the only one who has access to the medication storage for controlled medications in the DON's office. The DON stated the facility policy for disposition of controlled medications should be followed because there is the potential risk for diversion and abuse of controlled medications. A review of the facility's policy and procedure titled, Discarding and Destroying Medications, revised on 10/2014, indicated all unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. The name and the strength of the medication; d. The name of dispensing pharmacy; e. The quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses. b. A review of Resident 207's Face Sheet indicated the resident was initially admitted to the facility on [DATE] and was last readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a group of lung disease that block airflow and make it difficult to breathe) and opioid dependence (chronic medical condition affecting the brain that involves a physical, psychological, and behavioral need for opioids [used to treat moderate to severe pain]). A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 10/22/2021, indicated Resident 207's cognition was intact. The MDS indicated the resident required supervision with activities of daily living (ADLs). A review of the Physician Orders for Resident 207 indicated the order for Percocet (a combination of Oxycodone and acetaminophen [APAP] used to relieve moderate to severe pain) 10-325 milligrams (mg-unit of measurement) tablet, take one tablet by mouth four times a day as needed for pain was discontinued on 06/26/2021. A review of the Situation, Background, Assessment, Recommendation (SBAR-framework for communication between members of the health care team about a resident's condition) dated 11/19/2021, indicated Resident 207 was discharged to general acute care hospital (GACH) on the same day (11/19/2021). During a concurrent interview and record review on 01/19/2022 at 12:11 p.m., with the Director of Nursing (DON), facility's disposition of controlled medication records including Resident 207's Record of Controlled Substances was reviewed. During the review, Resident 207's Record of Controlled Substances indicated there were 30 tablets of Oxycodone-APAP 10-325 mg left unused. The record did not have documentation of disposition of the resident's remaining doses of Oxycodone-APAP 10-325 mg. The DON stated the record did not have the DON's and the pharmacist's signature as witnesses for the disposition of the medication. The DON also stated the record did not indicate the date of disposition, the quantity of the medication disposed, and the method of disposition. The DON stated the record should have been signed by the DON and the pharmacist during disposition and contained the appropriate documentation. The DON stated she is the only one who has access to the medication storage for controlled medications in the DON's office. The DON stated the facility policy for disposition of controlled medications should be followed because there is the potential risk for diversion and abuse of controlled medications. A review of the facility's policy and procedure titled, Discarding and Destroying Medications, revised on 10/2014, indicated all unused controlled substances shall be retained in a securely locked area with restricted access until disposed of. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. The name and the strength of the medication; d. The name of dispensing pharmacy; e. The quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses.

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 pharmacist's medication regimen review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage) recommendation dated 12/20/2021 for levetiracetam (an anti-seizure medication) laboratory monitoring to assess current therapy for one of four sampled residents (Resident 36) for unnecessary medications. This deficient practice had the potential to place Resident 36 at risk for receiving an unnecessary dose of the medication and can lead to adverse effects (any unexpected or dangerous reaction to a drug). Findings: A review of Face Sheet indicated Resident 36 was admitted on [DATE] with diagnoses which included but not limited to seizure disorder (a condition in which nerve cell activity in the brain is disturbed, causing seizures), mood disorder (a mental health problem that primarily affects a person's emotional state), depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and nicotine dependence (a chemical in tobacco and a person can't stop using it). A review of Resident 36's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/26/21 indicated resident had an intact cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The resident required supervision with all activities of daily living (ADL - a term used to collectively describe fundamental skills required to independently care for oneself). A review of Resident 36's History and Physical dated 5/27/2021 indicated that the resident has the capacity to understand and make decisions. A review of the Physician Order dated 5/28/2021 indicated an order of levetiracetam 1000 mg tablet give 1 tablet by mouth twice a day for seizure. The orders also indicated a clarification of order date of 06/04/2021 to monitor for seizure activity every shift. A review of the Consultant Pharmacist's Medication Regimen Review (MRR- review of a resident's drug therapy to assure appropriateness of medication usage) dated 12/20/2021 indicated to consider attaining labs to assess current therapy for the current use of levetiracetam. During a concurrent interview and record review on 01/20/2022 at 9 a.m., Registered Nurse Supervisor (RN 1) confirmed the pharmacy recommendation to consider attaining labs for levetiracetam dated 12/20/2021 and stated she is unable to find the order in the chart. RN 1 further stated the pharmacist recommendation was not followed thru and it's important to monitor resident's levetiracetam level to ensure resident is getting the right dose of medication for proper management of seizure disorder. During a concurrent interview and record review on 01/20/2022 at 9:30 a.m., the Quality Assurance Nurse (QAN), confirmed pharmacist recommendation dated 12/20/2021 to consider attaining labs for levetiractam and she was unable to find the order in the chart. QAN further stated that the recommendation was not relayed to the physician and it's important to obtain order for laboratory monitoring for dose adjustment, to ensure resident is getting the right dose of the medication, and for proper management of resident's seizure disorder. During a concurrent interview and record review on 01/20/2022 at 10:30 a.m., the Director of Nursing (DON) confirmed that the pharmacist recommendation for attaining laboratory monitoring for levetiractam dated 12/20/2021 was not relayed to the physician. The DON also stated it's important to obtain orders for laboratory monitoring for levetiractam to ensure resident is getting the right dosage of medication to prevent complications or adverse effects. A review if facility's policy and procedure titled, Monthly Drug Regimen Review, dated 4/2021, indicated that the resident's response to drug treatment is evaluated thru the use of laboratory data and that recommendations and findings will be documented and acted upon by the facility and/or physician.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was free from significant medication error by failing to administer the scheduled dose of Trileptal (medication to manage epilepsy [disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain]), and gabapentin (medication to manage neuropathy [weakness, numbness, and pain from nerve damage, usually in the hands and feet]) as ordered by the physician for one out of four sampled residents (Resident 14). This deficient practice had the potential to place the resident at risk for worsening of condition and recurrence of seizure. Findings: A review of the Face Sheet indicated Resident 14 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included paranoid schizophrenia (a mental disorder characterized by delusions [a belief of altered reality] and hallucinations [an experience involving the apparent perception of something not present]), epilepsy (disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), and lumbago (low back pain) with sciatica (pain that includes numbness in the buttocks, back or leg, along with a tingling feeling that radiates down the leg to the foot). A review of Resident 14's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 10/15/2021 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was able to understand and be understood. The MDS also indicated that the resident required limited assistance with dressing, personal hygiene, and bathing, and supervision with all other activities of daily living (ADLs - a term to refer to people's daily self-care activities). A review of the History and Physical dated 01/15/2021 indicated Resident 14 had the capacity to understand and make decisions. A review of Resident 14's Physician's Order dated 01/10/2020 indicated, gabapentin 300 milligrams (mg-unit of measurement) by mouth three times a day for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), and oxcarbazepine (Trileptal) 300 mg by mouth three times a day for seizure management. A review of Resident 14's care plan for the seizure activity dated 01/10/2020 and revised 08/30/2021, indicated a goal that resident will be free from injury if seizure occurs The care plan also indicated an intervention of medication as ordered. A review of Resident 14's care plan for peripheral neuropathy dated 01/10/2020 and revised 08/30/2021, indicated, resident will be free from injury and will have no signs and symptoms of worsening condition. The care plan also indicated interventions such as medication as ordered and assess for worsening condition. A review of Resident 14's Medication Administration Record (MAR) for 01/2022 indicated gabapentin 300 mg and oxcarbazepine 300 mg were administered on 01/15/2022 at 1 p.m. During a concurrent observation, interview, and record review on 01/18/2022 at 12:50 p.m., Resident 14's Medication Administration Record (MAR), gabapentin bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) and oxcarbazepine bubble pack were reviewed with Licensed Vocational Nurse 1 (LVN 1). LVN 1 confirmed and stated the 1 p.m. dose on 01/15/5022 of gabapentin and oxcarbazepine were marked given by Licensed Vocational Nurse 5 (LVN 5) with a check mark but the tablets were still in the bubble pack. LVN 1 stated Resident 14's 1 p.m. dose of gabapentin and oxcarbazepine for 01/15/2022 may be considered a missed dose since the medications are still in the bubble pack and it has the potential for worsening of condition and recurrence of seizure. During a concurrent record review and interview on 01/19/2022 at 9:28 a.m., Registered Nurse 1 (RN 1) confirmed the 01/15/2022 1 p.m. doses of gabapentin and oxcarbazepine were marked as given by LVN 5 in the MAR. RN 1 stated check mark indicated medications were administered on 01/15/2022 at 1:00 p.m. RN 1 stated if medications were still in the bubble pack and marked given in the MAR, it is considered a missed dose and has the potential for the medications to be less effective which may result to worsening of condition and recurrence of seizure. During a concurrent record review and interview on 01/19/2022 at 9:30 a.m., the Director of Nursing (DON) confirmed the 01/15/2022 1 p.m. doses of gabapentin and oxcarbazepine were marked as given by LVN 5 in the MAR. RN 1 stated check mark indicated medications were administered on 01/15/2022 at 1:00 p.m. and medication should have been administered as ordered. RN 1 stated if medications were still in the bubble pack and marked given in the MAR, it is considered a missed dose and a medication error. The DON stated it has the potential for the medications to be less effective which may result to worsening of condition and recurrence of seizure. During a telephone interview on 01/21/2022 at 8:02 a.m., LVN 5 stated that she gave Resident 14's 1 p.m. gabapentin and oxcarbazepine on 01/15/2022 and that she may have removed the medications from the wrong date or time in the bubble pack. LVN 5 stated check mark in the MAR indicated the medications were given and if a medication is still in the bubble pack for a certain date and time, it can be considered a missed dose and medication error. LVN 5 stated she should have checked the medication label to verify the five medication rights prior to removing the medications from the bubble pack. LVN 5 stated a missed a dose of prescribed medications has the potential for the medications to be less effective for Resident 14's neuropathy and seizures. A review of facility's policy and procedure titled Administering Medications, revised 04/2019, indicated, the medication label has to be checked three times to verify for the right resident, right medication, right dosage, right time, and right method prior to giving the medication. The policy also indicated documentation in the MAR the signature and title of the person administering the medication.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to: 1. Ensure an open multi-dose of Afluria Quadrivalent (Influenza vaccine, vaccine that protects against flu [a viral infection]) vial stored in the refrigerator, had a label indicating the date it was opened. 2. Ensure medications were properly disposed of according to the facility's policy and procedures. These deficient practices increased the risk that the facility's residents could have received medication that had become ineffective or toxic due to improper storage or labeling. Findings: a. During a concurrent observation and interview on [DATE] at 09:43 a.m., with Registered Nurse 1 (RN 1) in the Medication Storage Room, observed an open multi-dose Influenza vaccine vial stored in the refrigerator without a date open label. RN 1 stated there should have been date open label on the vial because there is a risk that staff may give the vaccine that is not potent anymore to the residents. During an interview on [DATE] at 04:31 p.m., with the Director of Nursing (DON), the DON stated there should have been a date open label on the flu vaccine vial so the nursing staff will know when to discard vaccine. The DON stated using the vaccine beyond 28 days after it was opened could lose its potency. A review of the facility policy and procedures titled, Administering Medications, revised on 04/2019, indicated the expiration/beyond use date on the medication label is checked prior to administering; when opening a multi-dose container, the date opened is recorded on the container. A review of the Influenza vaccine 2021-2022 formula package insert indicated, once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. b. During a concurrent observation and interview on [DATE] at 10:13 a.m., with Registered Nurse 1 (RN 1) in the Medication Storage Room, observed the following medications: 1. Three bottles of lactulose (medication to treat constipation [difficult bowel movements]) 10 grams/15 ml 473 milliliters bottle prescribed for Residents 2, 16, and 104. 2. A bottle of levetiracetam (medication to treat seizures) 100 milligrams/ml 473 ml bottle prescribed for Resident 104. 3. A bottle of valproic acid (medication to treat seizures) 250 mg/5 ml 473 ml bottle prescribed for Resident 103. 4. A bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) medication quetiapine fumarate (medication used to manage abnormal condition of the mind described as involving a loss of contact with reality) 200 mg tablet containing 20 tablets prescribed for Resident 17. RN 1 stated the medications belong to a resident who had expired and residents who were discharged . RN 1 stated one of the medications was discontinued due to a dose change. RN 1 stated discontinued medications are to be removed from the cart and placed in the bin labeled for destruction, expired, and discontinued medications. RN 1 stated medications can potentially be used or given to other residents by nurses if not properly stored. A review of Resident 2's Physician's Discharge Summary indicated the resident was discharged to the hospital on [DATE]. A review of Resident 16's Face Sheet indicated the resident was admitted to the facility on [DATE] and discharged on [DATE]. A review of Resident 104's Face Sheet indicated the resident was admitted to the facility on [DATE] and discharged on [DATE]. A review of Resident 103's Face Sheet indicated the resident was admitted to the facility on [DATE] and discharged on [DATE]. A review of Resident 17's Face Sheet indicated the resident most recent admission date was on [DATE]. A review of the Resident 17's Physician Order indicated Seroquel (quetiapine fumarate) 200 mg tablet, give 1 tablet by mouth for schizophrenia (a disorder that affects a person's ability to think, feel, and behave manifested by anger outbursts as exhibited by screaming at others clearly) was discontinued on [DATE]. During an interview on [DATE] at 10:22 a.m., with the Director of Nursing (DON), the DON stated medications of residents who are no longer in the facility and discontinued medications should be placed in the destruction bin. The DON stated there is a potential risk that medications not destroyed can be misused by staff and/or accidentally given to other residents. A review of the facility policy and procedures titled, Storage of Medications, revised on 08/2007, indicated the nursing staff shall be responsible for maintaining the medication storage and preparation areas in a clean, safe, sanitary manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. A review of the facility policy and procedures titled, Discarding and Destroying Medications, revised on 04/2019, indicated non-controlled and Schedule V (non- hazardous) controlled substances will be disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications.

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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c. During a concurrent observation and interview on 01/18/2022 at 9:10 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed in the red zone (designated area for residents with confirmed coronavirus disease 2019 [COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms]) nurses station wearing N95 mask (a respiratory device used to protect the wearer from particles or from liquid contaminating the face) and regular eyeglasses. LVN 1 stated she is not wearing a face shield. LVN 1 stated she should be wearing a face shield at all times while working in the red zone. LVN 1 stated not wearing the proper personal protective equipment (PPE - equipment worn to minimize exposure to hazards like infections that cause serious workplace injuries and illnesses) can cause the spread of infection to other staff and residents. During an interview on 01/18/2022 at 9:56 a.m., the Director of Nursing (DON) stated LVN 1 should have been wearing a face shield with the N95 mask at all times while working in the red zone. The DON stated not wearing the required PPE has the potential to spread COVID-19 infection in the facility. A review of the facility policy and procedure titled Personal Protective Equipment - Using Protective Eyewear, revised 12/23/2021, indicated, eye protection devices such as goggles or chin-length face shields must be worn whenever potentially infectious materials maybe generated and eye, nose, mouth contamination can be expected to protect employees from potentially infectious materials. The policy also indicated personal eyeglasses are not considered as adequate protective eyewear. d. During a concurrent observation and interview on 01/19/2022 at 8:25 a.m., observed Certified Nursing Assistant (CNA 1) inside a red zone (designated area for residents with confirmed coronavirus disease 2019 [COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms]) resident room. CNA 1 was wearing a gown, N95 mask (respiratory protective device designed to achieve a very close facial fit and efficiently filter airborne particles), and face shield; CNA 1 was not wearing gloves. CNA 1 stated she removed her gloves while waiting for the resident to come out from the restroom. During a concurrent observation and interview on 01/19/2022 at 8:30 a.m., observed CNA 1 leave the red zone resident room while still wearing personal protective equipment (PPE - equipment worn to minimize exposure to hazards like infections that cause serious workplace injuries and illnesses). CNA 1 walked to the trash bin outside another red zone resident's room and removed her PPEs. CNA 1 did not perform hand hygiene. CNA 1 stated she should have been wearing gloves, gown, N95 mask, and face shield while inside the red zone resident's room. CNA 1 also stated she should have removed her PPEs upon exiting that room and performed hand hygiene. CNA 1 stated it had the potential to spread COVID-19 infection in the facility. During an interview on 01/19/2022 at 8:38 a.m., the Director of Staff Development (DSD) stated CNA 1 should have worn the proper PPEs while inside the red zone resident room, removed her PPEs before leaving the room, and performed hand hygiene to prevent the spread of infection in the facility. DSD performed on the spot in-service. During an interview on 01/19/2022 at 8:40 a.m., the Director of Nursing (DON) stated CNA 1 should wear required PPEs, remove PPEs, and perform hand hygiene prior to leaving the room. The DON stated it had the potential to spread COVID-19 infection in the facility. A review of the facility's policy and procedure titled Handwashing/Hand Hygiene, revised 12/23/2021, indicated, all staff should follow handwashing/hand hygiene procedures to prevent the spread of infection to other staff, residents, and visitors. The policy also indicated alcohol-base hand rubs (ABHRs) are used after removing gloves, before and after entering isolation precaution settings, and when in contact with a resident, or the equipment or environment of the resident on isolation. A review of the facility's policy and procedure titled Personal Protective Equipment - Using gowns, revised 12/23/2021, indicated, gowns must be discarded in the appropriate container in the room to prevent spread of infection. A review of the facility's policy and procedures titled Covid-19 - Infection Control Measures, revised 12/23/2021, indicated staff will wash or sanitize hands, put on gown, N95 mask, face shield or goggles, and gloves before entry in the room. Before exit, staff should remove gloves, gown, and wash hands. Based on observation, interview, and record review, the facility failed to: 1. Implement coronavirus disease-2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) infection control practices by failing to ensure Nurse Practitioner 1 (NP 1) wore an isolation gown and face shield when entering a resident's room who was on transmission- based precaution (used to help stop the spread of germs from one person to another). This deficient practice had the potential for increasing the risk of spreading COVID-19 to residents and staff members which could lead to complications including but not limited to, pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), acute respiratory distress syndrome (ARDS- a contagious and sometimes fatal respiratory illness caused by a coronavirus), multi-organ failure, septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection), and death. 2. Observe infection control measures for one out of two sampled residents (Resident 43) by failing to ensure oxygen nasal cannula tubing (device used to deliver supplemental oxygen placed directly on a resident's nostrils) was off the floor. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 3. Implement infection control policy and procedure by failing to ensure: a. Licensed Vocational Nurse 1 (LVN 1) was wearing a face shield while in the red zone (designated area for residents with confirmed coronavirus disease 2019 [COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms]) b. Certified Nursing Assistant 1 (CNA 1) was wearing gloves while working with a resident, doffed (to remove) proper personal protective equipment (PPE) upon exit, and performed hand hygiene. These deficient practices had the potential to spread COVID-19 infection in the facility. 4. Ensure Housekeeping 1 (HK 1) performed hand hygiene before and after removal of gloves while cleaning the residents' rooms in the yellow zone (residents who have been exposed to COVID, have an unknown exposure and are negative, have refused COVID testing, or have been admitted from another facility). This deficient practice had the potential for the spread of infections to residents, staff, and visitors. Findings: a. On 01/18/2022 at 10:52 a.m., during a facility observation tour and interview, observed all resident rooms to have transmission-based precautions signs (signs indicating ways to help stop the spread of germs from one person to another) including required personal protective equipment (PPE - equipment such as gloves, masks, and gowns worn by people who are at risk of injury or infection) to be worn when entering these rooms. Also observed isolation carts containing PPE outside each resident room. At that time of the facility observation tour, observed a staff went inside a resident room without donning (putting on) the required PPE. Upon exiting the room, staff identified herself as Nurse Practitioner 1 (NP 1) for one of the residents. During the concurrent observation and interview, NP 1 stated that the room she just went into was in the yellow zone (area for residents with possible exposure to coronavirus disease-2019 [COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms]), indicating that the resident was on transmission-based precaution. According to NP 1, residents in the yellow zone were either exposed to staff or other residents who have contracted COVID-19 or under observation for exposure. NP 1 added that she should have worn a gown, gloves, and googles when inside a resident room on transmission-based precaution to protect the resident and herself. Per NP 1 any staff that are not wearing the required PPE could potentially introduce infection to residents. A review of the facility's undated policy and procedure titled Covid-19 - Infection Control Measures, indicated staff will wash or sanitize hands, put on gown, N95 mask (respiratory protective device designed to achieve a very close facial fit and efficiently filter airborne particles), face shield or goggles, and gloves before entry in the room. b. On 01/18/2022 at 12:22 p.m., during the facility observation tour and interview, observed Resident 43 lying in bed, sleeping and with the nasal cannula (small, flexible tube that contains two open prongs intended to sit in the nostrils for oxygen delivery) prong connected to Resident 43`s nostril and part of the tubing was on the floor. At the time of observation, Certified Nurse Assistant 3 (CNA 3) was within proximity and confirmed the observation and stated that it should not be touching the floor as it is an infection control issue. During the observation, Registered Nurse 1 also confirmed by her own observation that the oxygen tubing was on the floor and stated that it needs to be replaced because it could get contaminated when it`s touching the floor and can introduce infection to the resident. A review of the Centers for Disease Control (CDC) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 07/19/2003, indicated floors can become rapidly recontaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. e. During an observation with Housekeeping 1 (HK 1) on 01/18/2022 at 09:22 a.m., observed HK 1 coming out of a yellow zone (area for residents with possible exposure to Coronavirus Disease 2019 [COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms]) resident room. HK 1 took off her gown and gloves and placed them in the trash bin. HK 1 did not wash her hands or use alcohol-based hand rub (ABHR) to sanitize her hands after removing her gloves and gown. HK 1 moved the housekeeping cart to the utility room and was observed putting on a new pair of gloves and proceeded to empty and rinse the water bucket. HK 1 then threw the trash from the cart, took off her gloves and went to another yellow zone resident room. HK 1 did not wash her hands or sanitize her hands with ABHR after removing her gloves and before putting on a new gown and new pair of gloves. During an interview with HK 1 on 1/18/2022 at 09:30 a.m., in the presence of the Environmental Supervisor (EVS), who was translating for HK 1, HK 1 stated she should have washed her hands or applied hand sanitizer before entering and leaving the rooms and after taking off gloves and gown because there is currently an outbreak in the facility. HK 1 stated handwashing helps prevent the spread of COVID-19. A review of facility policy and procedure titled, Handwashing/Hand Hygiene, revised on 08/2019, indicated the facility considers hand hygiene the primary means to prevent the spread of infections; all personnel shall follow handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; use an alcohol-based hand rub (ABHR) containing at least 62% alcohol; or alternatively, soap and water for the following situations including: after contact with objects in the immediate vicinity of the resident; after removing gloves. Hand Hygiene is the final step after removing and disposing of personal protective equipment (PPE). The use of gloves does not replace hand washing/hygiene. A review of the facility's policy and procedures titled Covid-19 - Infection Control Measures, revised 12/23/2021, indicated the use of isolation cart with PPE by staff for COVID 19 Positive Residents/PUI (Patient Under investigation)/New Admit with steps including: Staff will wash or sanitize hands before entry, put on gown, put on respiratory protection (N95, a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles), put on eye protection (face shield or goggles), put on gloves. Before exit, remove gloves, may remove gown if necessary, wash hands. Wash hands or sanitize after exiting room.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft.) per resident in 24 of 24 resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility. Findings: During the recertification survey from 01/18/2022 to 01/21/2022, the residents residing in the rooms with an application for variance were observed with a sufficient amount of space for residents to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents. On 01/18/2022, the Administrator submitted the application for the Room Variance Waiver for 24 resident rooms. The room variance letter indicated that these rooms did not meet the 80 square feet per resident requirement per federal regulation. The room waiver request showed the following: Room # Square Footage (sq ft) Bed Capacity Sq Ft per Resident 1 229.1 3 76.367 2 229.1 3 76.367 3 229.1 3 76.367 4 229.1 3 76.367 5 229.1 3 76.367 6 229.1 3 76.367 7 229.1 3 76.367 8 229.1 3 76.367 10 230.8 3 76.933 11 228.8 3 76.267 12 230.8 3 76.933 14 230.8 3 76.933 15 228.8 3 76.267 16 230.8 3 76.933 17 228.8 3 76.267 19 228.8 3 76.267 20 228.8 3 76.267 21 227.3 3 75.767 22 228.8 3 76.267 23 227.3 3 75.767 24 228.8 3 76.267 25 227.3 3 75.767 26 228.8 3 76.267 27 227.3 3 75.767 The minimum requirement for a 3 bedroom should be at least 240 sq. ft. A review of the room waiver letter dated 01/18/2022, indicated, The needs of the residents are fully accommodated. The residents are able to move about the room freely; bathrooms and closets are easily accessible and all required furniture is provided for each resident. Delivery of care is unimpeded in any way. Furthermore, the residents can be quickly and safely evacuated in the event of emergency . The rooms are in accordance with the special needs of the residents and would not have an adverse effect on the residents' health and safety or impede the ability of any of the residents in the rooms to attain his or her highest practicable wellbeing. On 01/19/2022 at 3:04 p.m., during an interview, Resident 18 stated he had plenty of space in his room to move around. Resident 18 stated he had no issues with space when his nurses needed to provide him with care. On 01/19/2022 at 3:12 p.m., during an interview, Resident 4 stated she had a lot of room to move around freely in her wheelchair. Resident 4 stated when her nurses needed to come into her room to assist her, they had a lot of space to do so.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 39% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 1 harm violation(s), $50,997 in fines, Payment denial on record. Review inspection reports carefully.
• 104 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $50,997 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Valley Vista Nursing And Transitional Care Llc's CMS Rating?

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

How is Valley Vista Nursing And Transitional Care Llc Staffed?

CMS rates VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 39%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 75%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Valley Vista Nursing And Transitional Care Llc?

State health inspectors documented 104 deficiencies at VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 99 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Valley Vista Nursing And Transitional Care Llc?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC 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 CRYSTAL SOLORZANO, a chain that manages multiple nursing homes. With 72 certified beds and approximately 66 residents (about 92% occupancy), it is a smaller facility located in NORTH HOLLYWOOD, California.

How Does Valley Vista Nursing And Transitional Care Llc Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC's overall rating (1 stars) is below the state average of 3.1, staff turnover (39%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Valley Vista Nursing And Transitional Care Llc?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.

Is Valley Vista Nursing And Transitional Care Llc Safe?

Based on CMS inspection data, VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Valley Vista Nursing And Transitional Care Llc Stick Around?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has a staff turnover rate of 39%, 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 Vista Nursing And Transitional Care Llc Ever Fined?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC has been fined $50,997 across 2 penalty actions. This is above the California average of $33,589. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Valley Vista Nursing And Transitional Care Llc on Any Federal Watch List?

VALLEY VISTA NURSING AND TRANSITIONAL CARE LLC 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: 72
Avg. Residents: 66
Occupancy: 92.1%
Ownership: For profit - Limited Liability company
Chain: CRYSTAL SOLORZANO
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Immediate Jeopardy citation: -12
1 Actual Harm citation: -5
104 Deficiencies: -10
Fines ($50,997): -10
Abuse Finding: -15
Final Score: 0/100

Nearby Alternatives

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555132