What is MAJESTIC MOUNTAIN CARE CENTER's CMS rating?

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

Does MAJESTIC MOUNTAIN CARE CENTER have any serious inspection findings?

Yes, MAJESTIC MOUNTAIN CARE CENTER has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 61 total deficiencies from recent inspections.

What are the staffing levels at MAJESTIC MOUNTAIN CARE CENTER?

MAJESTIC MOUNTAIN CARE CENTER has a one-star staffing rating from CMS with 0.30 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MAJESTIC MOUNTAIN CARE CENTER located?

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

How many beds does MAJESTIC MOUNTAIN CARE CENTER have?

MAJESTIC MOUNTAIN CARE CENTER has 66 certified beds.

Who owns MAJESTIC MOUNTAIN CARE CENTER?

MAJESTIC MOUNTAIN CARE CENTER is a for profit - corporation facility and is part of the BAYSHIRE SENIOR COMMUNITIES chain.

Is MAJESTIC MOUNTAIN CARE CENTER safe?

MAJESTIC MOUNTAIN CARE CENTER has documented safety concerns including 2 immediate jeopardy citations, placement on the CMS Special Focus Facility list. Families should ask about corrective actions taken.

Do nurses at MAJESTIC MOUNTAIN CARE CENTER stick around?

MAJESTIC MOUNTAIN CARE CENTER has high staff turnover at 67%. High turnover can mean less continuity of care as staff change frequently.

Was MAJESTIC MOUNTAIN CARE CENTER ever fined?

Yes, MAJESTIC MOUNTAIN CARE CENTER has been fined $100,597 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is MAJESTIC MOUNTAIN CARE CENTER on any federal watch list?

MAJESTIC MOUNTAIN CARE CENTER is currently an SFF Candidate, meaning CMS is monitoring it for potential placement on the Special Focus Facility list due to a history of serious quality issues.

What have inspectors found at MAJESTIC MOUNTAIN CARE CENTER?

Medicare inspectors have found 61 deficiencies at MAJESTIC MOUNTAIN CARE CENTER: 2 critical, 3 serious, 56 moderate. Each deficiency represents a violation of federal nursing home requirements.

How does MAJESTIC MOUNTAIN CARE CENTER compare to other nursing homes?

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

MAJESTIC MOUNTAIN CARE CENTER

Name: MAJESTIC MOUNTAIN CARE CENTER
Address: 40131 HIGHWAY 49, OAKHURST, CA, 93644, US
Telephone: (559) 683-2244
Rating: 1.0

40131 HIGHWAY 49, OAKHURST, CA 93644 · (559) 683-2244

For profit - Corporation 66 Beds BAYSHIRE SENIOR COMMUNITIES Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

0/100

#1063 of 1155 in CA

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MAJESTIC MOUNTAIN CARE CENTER nursing home in OAKHURST, CA

Last Inspection: August 2024

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

Overview

Majestic Mountain Care Center has a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #1063 out of 1155 facilities in California, placing it in the bottom half, and #5 out of 5 in Madera County, meaning there are no better local options available. While the facility is reportedly improving, with a decrease in issues from 18 in 2024 to 8 in 2025, the overall situation remains troubling. Staffing is a major weakness, with a rating of 1 out of 5 stars and a high turnover rate of 67%, which is well above the state average of 38%. Additionally, the facility has incurred $100,597 in fines, indicating serious compliance issues, and it has less RN coverage than 77% of facilities in California, meaning residents may not receive the level of oversight they need. Specific incidents include failures in infection control related to COVID-19, leading to significant risks for residents, and inadequate treatment for residents with pressure ulcers, which could lead to further health complications.

Trust Score: F
In California: #1063/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 67% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $100,597 in fines. Higher than 60% of California facilities. Some compliance issues.
Skilled Nurses: Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 61 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 18 issues

2025: 8 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

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: 67%

20pts above California avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $100,597

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: BAYSHIRE SENIOR COMMUNITIES

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (67%)

19 points above California average of 48%

The Ugly 61 deficiencies on record

2 life-threatening 3 actual harm

Sept 2025 3 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident environment remained free from accident hazards and that residents received assistance devices to prevent accidents for one of seven sampled residents (Resident 1) when nursing staff were aware Certified Nursing Assistant (CNA)s used a regular wheelchair to transport Resident 1 over an elevated threshold (a strip of wood, metal, or stone forming the bottom of a doorway) to the smoking area, CNA 5 wheeled Resident 1's wheelchair pulling him backwards in order to get Resident 1 over the threshold and tilted, causing Resident 1 to fall back. Nursing staff did not evaluate the hazardous nature of the path of travel or the unsafe technique to tilt the wheelchair. Nursing staff did not consider a physical therapy evaluation for a new wheelchair with anti-tilt bars.These failures resulted in the unsafe practice of transporting Resident 1 which caused an avoidable accident on 7/25/25, Resident 1 struck the back of his head onto the concrete floor, suffering avoidable pain and injury to his neck.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1, Resident 1 was observed sitting up in wheelchair and observed to limit movements with arms and neck. Resident 1 stated on 7/25/25, staff were wheeling him out to the courtyard using the fire escape door. Resident 1 stated for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated the wheelchair went backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture. Resident 1 stated that prior to the fall, he had preexisting pain due to a previous medical procedure but stated since the fall the pain had increased and was now consistent to the neck area and back.During a review of Resident1's, Situation, Background, Assessment and Recommendation (SBAR) Post Fall, dated 7/25/25, the SBAR indicated, . Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The documentation indicated Resident 1 fell in the hallway, but findings indicated Resident 1 experienced a fall going through the fire escape door.During a review of Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m., the note indicated, . Resident had a fall and refused vitals (indicators that reflect a person's basic body functions and overall health), just wanted smoke his cigarette.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results available to rule out an injury following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 1's, SBAR Post Fall, dated 7/25/25, Progress Note (PN), dated 7/25/25 at 9:50 a.m., SBAR dated 7/25/25 and Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, .Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The Progress Note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The Radiology Result Report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated after review of the SBAR and progress note, the documentation was not complete regarding Resident 1's fall. LVN 1 stated the facility process was to create a detailed progress note following a fall that would detail what happened and which interventions were completed. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the final results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of documentation and follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a concurrent interview and record review on 8/15/25 at 11:56 a.m. with LVN 2, Resident1's, SBAR Post Fall, dated 7/25/25, and Progress Note, dated 7/25/25 at 9:50 a.m. were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The Progress Note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. LVN 2 stated Resident 1 had a fall on 7/25/25, when his wheelchair tilted backwards in going through the fire escape door. LVN 2 stated she was the nurse present during the time of the fall. LVN 2 stated the SBAR, and progress note were incomplete. LVN 2 stated the progress note should have indicated what had occurred in detail to ensure all staff were aware of the cause of the fall and interventions used.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain). The progress note indicated Resident 1 was reporting increased pain related to the fall on 7/25/25 and was not given the correct information regarding the x-ray results obtained.During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident1's, SBAR Post Fall, dated 7/25/25, Progress Note, dated 7/25/25 at 9:50 a.m. and Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . Prior to fall [Resident 1] was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology results report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated it was the facility process to follow all nursing scope of practice when it comes to documentation. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be excluded until the x-ray results were obtained for Resident 1.During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated since the fall on 7/25/25, the pain that was previously present in the cervical area had now exacerbated. Resident 1 stated, because the pain was located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated his pain level decreased to 6/10 with pain medication since the fall, but it was not tolerable even with the pain medication administered. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury to his neck and back due to a medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall IDT, dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a review of Resident 1's, Therapy Note, dated 7/25/25 6:56 p.m., the therapy note indicated, . An appropriate reclining w/c with bilateral leg troughs was acquired on 7.25.25 for Resident 1 and needed to be washed. It is now ready 7/31/25 and should meet his needs .During a concurrent telephone interview and record review on 9/11/25 at 1:15 p.m. with the director of rehab (DOR), Resident 1's, Therapy Note, dated 7/25/25 6:56 p.m., was reviewed. The therapy note indicated, . An appropriate reclining w/c with bilateral leg troughs was acquired on 7.25.25 for Resident 1 and needed to be washed. It is now ready 7/31/25 and should meet his needs . The DOR stated Resident 1's recommended wheelchair was supposed to be used by Resident 1 beginning 7/25/25, but another resident in the facility was mistakenly sat on the wheelchair and it needed to be washed. The DOR stated the recommendation was given due to Resident 1 requesting a better wheelchair. The DOR stated that based on her visual assessment she did not like the way the previous original wheelchair looked and agreed to recommend a better wheelchair. When asked to elaborate on what constituted she did not like how the wheelchair looked, the DOR stated she . Just didn't like the way it looked . The DOR stated Resident 1 was not under her services, but it was something she observed and recommended a new wheelchair.During an interview on 9/12/25 at 10:42 a.m. with the administrator (ADM), the ADM stated Resident 1 had a fall on 7/25/25 when CNA 5 was backing him out through the fire escape door by his room. The ADM stated the general practice in the facility was not to tilt the wheelchairs. The ADM stated he was unaware if Resident 1's path to go outside had not been assessed for safety.During an interview on 9/12/25 at 11:17 a.m. with the DOR, the DOR stated that Resident 1's path was not assessed prior to the fall on 7/25/25 because it was a supervised path with staff having to push Resident 1 outside. The DOR stated, it was Resident 1's preference to utilize the fire escape door to enter and exit the facility when attending his smoke breaks. The DOR stated it was the staff taking Resident 1 outside, decision to determine if the wheelchair needed to be tilted or if they needed to pull Resident 1 backwards to get through the door. The DOR stated the fire escape door that Resident 1 was using, was not meant for daily access therefore it was not equipped to get Resident 1 outside safely. The DOR stated that ultimately if the staff member determined the safest way to get Resident 1 outside was to pull him backwards and tilt the wheelchair to keep him from falling, then that was the best way.During an interview on 9/12/25 at 11:23 a.m. with LVN 2, LVN 2 stated Resident 1 was being assisted outside by the staff on 7/25/25. LVN 2 stated the CNA 5 was pulling Resident 1 backwards going outside, once the threshold was passed, the concrete was slanted down. LVN 2 stated Resident 1's wheelchair wasn't tilted by the CNA 5 at the time of fall but rather the wheelchair tilted backwards during the path outside. LVN 2 stated the CNAs, and all staff members knew not to pull any residents into the facility backwards as LVN 2 had repeatedly informed the facility staff regarding this practice. LVN 2 stated Resident 1 had used that door every time he went outside and was not informed by anyone in the facility that the fire escape door could not be used.During a concurrent observation and interview on 9/12/25 at 12:07 p.m. with Resident 1, Resident 1's wheelchair located in Resident 1's room was observed, the wheelchair appeared new with anti-tilt bars located on the back of the wheelchair next to the wheels. Resident 1 stated staff would use the fire escape door before and at the time of the fall to take him outside for smoking breaks because it was wider and could fit his wheelchair without risk of injury. Resident 1 stated he was not pulled backwards all the time it was certain staff that would do that. Resident 1 stated he had requested a new wheelchair because the wheelchair that was given to him was not safe and would sometimes tilt, which he informed the facility staff of the issues. Resident 1 stated since the wheelchair was already tilting on its own, when the staff member took him outside on 7/25/25, the concrete going downhill caused the wheelchair to completely hit the ground backwards. Resident 1 stated the motion of pulling the wheelchair backwards could have caused the wheelchair to tilt backwards.During an interview on 9/12/25 at 1:20 p.m. with the minimum data set nurse (MDS), the MDS nurse stated Resident 1 had used the fire escape door when he was given a bigger wheelchair. The MDS nurse stated the facility made an exception to allow Resident 1 to use the fire escape door because it was a wider door for the wheelchair being used at the time of admission. The MDS nurse stated after Resident 1 received a new manual wheelchair that would fit through the designated resident door leading outside, Resident 1 continued to use the fire escape door. The MDS nurse stated the path leading outside was never assessed for safety.During an interview on 9/16/25 at 1:32 p.m. with the DON, the DON stated on 7/25/25 Resident 1 was being wheeled out by CNA 5 when he fell. The DON stated CNA 5 lost control of the wheelchair causing Resident 1 to fall going through the fire escape door. The DON stated the wheelchair itself was safer going backwards due to the risk of Resident 1's wheelchair bumping the threshold that would have caused him to go forward. The DON stated it was safer to use the designated resident door that all residents in the facility used because it had rails and the concrete wasn't made to go downward.During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, undated, 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. a fall is defined as unintentionally coming to rest on the ground, floor or other lower level.During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 7/2017, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0697 (Tag F0697)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pain management was provided to residents for one of five sampled residents, (Resident 1), when Resident 1 suffered a head and neck injury on 7/25/25, nursing staff did not assess Resident 1's pain, administer medications to effectively address the pain in accordance with professional standards of practice and the facility's policy and procedure Pain Management. On 7/25/25, staff tilted Resident 1's wheelchair backward in order to transport Resident 1 to the smoking area and Resident 1 fell backward, striking his head onto the concrete ground. Afterwards, Resident 1 complained of head and neck pain that radiated to the right side and nurses did not effectively treat the pain.These failures resulted in Resident 1 feeling unheard of, experiencing avoidable uncontrolled and unmanaged pain due to delay in assessment and treatment following the fall on 7/25/25.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status [BIMS screening tool used to assess resident cognitive (understanding through thought, experience and senses) level] score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed sitting up in wheelchair and observed to limit movements with arms and neck. Resident 1 stated on 7/25/25, staff were wheeling him out to the courtyard using the back door. Resident 1 stated for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated he fell backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor and offered to transfer him to the acute care hospital, but Resident 1 stated he refused. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture (break in a bone). Resident 1 stated that prior to the fall, he had preexisting pain due to a previous medical procedure but stated since the fall the pain had increased and was now consistent to the neck area and back.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results available to rule out an injury following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident1's, Radiology Results Report, dated 7/25/25, was reviewed. The report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident 1's, Radiology Results Report, dated 7/25/25, was reviewed. The report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be ruled out until the x-ray results were obtained for Resident 1. During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated that since the fall on 7/25/25, the pain that was previously present in the cervical area had now exacerbated. Resident 1 stated, because the pain is located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated his pain level decreased to 6/10 with pain medication since the fall, but it was not tolerable even with the pain medication administered. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury and medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall Interdisciplinary team (IDT- consisting of nurses, physician, resident and other members of the health team to discuss and plan resident treatment plan), dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's, Order Summary Report, dated 7/26/25, the order summary indicated, Oxycodone-Acetaminophen/APAP (medication with high risk for addiction and dependence used to treat moderate to severe pain) tablet 10-325 mg . give 1 tablet every 8 hours as needed for pain for 30 days. discontinued date 8/11/25. The order summary indicated Resident 1 had an as needed pain medication available for 15 days following the fall on 7/25/25.During a review of Resident 1's Nurse Note, dated 7/29/25, the note indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. The note indicated Resident 1 had verbalized medication was not managing his pain effectively after the fall on 7/25/25.During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a concurrent interview and record review on 8/29/25 at 10:33 a.m. with LVN 1, Resident 1's electronic medical record (EMR) for, Pain Levels, dated 7/26/25-8/25/25, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. LVN 1 stated the EMR for pain levels indicated Resident 1 complained of pain: 10/10 on 7/26/25 at 3:09 p.m. and 9/10 pain at 9:21 p.m. 9/10 p.m.7/28/25: 7:45 p.m. 10/10 pain, 7:45 p.m. 9/10 pain7/29/25: 1:31 p.m. & 9:06 p.m. 8/10 pain7/30/25: 12:45 a.m. 7/10 pain7/31/25: 9:57 a.m. & 3:00 p.m. 6/10 pain8/1/25: 2:22 p.m. 9/10 pain, 6:35 p.m. 10/10 pain8/4/25: 9:19 a.m. 9/10 pain8/7/25: 5:22 p.m. 9/10 pain8/8/25: 2:00 p.m. 9/10 pain, 5:31 p.m. 9/10 pain8/9/25: 11:55 a.m. 9/10 pain8/10/25: 11:03 p.m. 8/10 pain8/11/25: 6:05 p.m. 8/10 pain8/12/25: 9:54 a.m. 8/10 pain8/13/25: 3:36 a.m. 8/10 pain8/14/25: 9:13 a.m. & 3:00 p.m. 8/10 pain8/15/25: 10:19 a.m. & 2:32 p.m. 8/10 pain8/16/25: 10:01 a.m. & 4:15 p.m. 8/10 pain8/17/25: 10:12 p.m. 8/10 pain8/18/25: 10:57 p.m. 8/10 pain8/19/25: 8:28 a.m. & 12:54 p.m. & 5:05 p.m. & 11:15 p.m. 8/10 pain8/20/25: 8:02 a.m. & 4:03 p.m. 8/10 pain8/21/25: 12:42 p.m. & 4:43 p.m. 8/10 pain8/22/25: 6:05 a.m. 5/10 pain8/23/25: 4:08 p.m. 6/10 pain8/25/25: 12:05 a.m. 9/10 pain . LVN 1 stated Resident 1 pain levels averaged at an 8/10 pain based on the EMR pain levels reviewed. LVN 1 stated when Resident 1 complained of medication ineffectiveness and increased pain, it was the facility expectation that the nurse would complete an assessment to identify Resident 1's pain and severity, notify the physician and document. LVN 1 stated that based on the record review, Resident 1's pain was not effectively managed following the fall on 7/25/25.During a review of Resident 1's, Medication Administration Record (MAR), dated 7/2025 and 8/2025, the MAR indicated, . Oxycodone-Acetaminophen/APAP tablet 10-325 mg, administered:7/27/25: 3:47 p.m. Medication Effective No pain level.7/28/25: 7:45 p.m. Medication Ineffective pain level 9/10.7/29/25: 1:31 p.m. Medication Effective pain level 8/10.8/1/25: 2:22 p.m. Medication Effective pain level 9/10.8/2/25: 2:50 a.m. & 8:16 p.m. Medication Effective pain level 5/10.8/3/25: 12:10p.m. Medication Effective pain level 8/10.8/4/25: 1:19 a.m. Medication Effective pain level 7/10, 9:19 a.m. Effective pain level 9/10.8/5/25: 2:00 a.m. Medication Effective pain level 7/10.8/6/25: 5:59 a.m. Medication Effective pain level 7/10.8/7/25: 11:55 a.m. Medication Effective pain level 8/10.8/8/25: 8:43 a.m. Medication Effective pain level 9/10.8/9/25: 11:55 a.m. Medication Effective pain level 9/10.8/10/25: 9:57 p.m. Medication Effective pain level 7/10.8/11/25: 6:26 a.m. Medication Effective pain level 7/10, 3:20 p.m. Medication Unknown Effectiveness pain level 7/10. The MAR indicated Resident 1's pain medication was administered for pain and the follow up with the medication effectiveness was documented as medication was effective in managing Resident 1's pain even though Resident 1's pain levels reached 7/10-9/10.During a concurrent interview and record review on 8/29/25 at 11:12 a.m. with the DON, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. The DON stated Resident 1's medication for pain was ineffective. The DON stated Resident 1's cervical x-ray had unknown results and therefore could not rule out an injury that could have caused Resident 1's increased pain. The DON stated the facility expectation was for the facility staff to inform the physician of findings regarding increased pain in order to achieve proper pain management for Resident 1 which was not done.During a concurrent interview and record review on 8/29/25 at 11:20 a.m. with LVN 2, Resident 1's, Progress Note, dated 7/26/25, and Resident 1's Nurse Note, dated 7/29/25, were reviewed. The Progress note on 7/26/25 indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain) . The Nurse note on 7/29/25 indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request. LVN 2 stated, Resident had complained of 10/10 pain to his back during the day. LVN 2 stated Resident 1's pain levels ranged between 8-10/10 pain on a daily basis. LVN 2 stated the progress notes indicated Resident 1 was experiencing an increase in pain with unrelieved pain with medications ordered. LVN 2 stated the facility process was to complete an assessment of Resident 1, document in the EMR, and notify the physician of Resident 1's ineffective pain medication and increased pain. LVN 2 stated Resident 1's pain was not properly managed following the fall on 7/25/25.During a review of the facility's policy and procedure (P&P) titled, Pain Management, dated, 9/2/22, the P&P indicated, . The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents ' goals and preferences. The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. the facility will Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. Evaluate the resident for pain and the cause(s) upon. a significant change in condition or status occurs. Manage or prevent pain, consistent with. current professional standards of practice, and the resident's goals and preferences. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident. Identifying key characteristics of the pain, Duration of pain, Frequency, Location, Timing, Pattern (e.g. constant or intermittent), Radiation of pain, Obtaining descriptors of the pain (e.g. stabbing, aching, pressure, spasms). The resident's goals for pain management and his/her satisfaction with the current level of pain control. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain. The interdisciplinary team and the resident and/or the resident's representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment. The interdisciplinary team is responsible for developing a pain management regimen that is specific to each resident who has pain or who has the potential for pain. Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its policy and procedure (P&P) titled Charting and Documentation in accordance with professional standards of practice for one of five sampled residents (Resident 1), when the facility staff did not complete documentation of Resident 1's fall or possible injuries and did not follow up with cervical (neck) x-ray results for three weeks following Resident 1's fall on 7/25/25.This failure resulted in delay in assessment and treatment for Resident 1 due to a potential injury following the fall on 7/25/25.During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for fusion of spine cervical region (surgical procedure that joins two or more bones in the neck to create a stable structure), functional quadriplegia (not able to move all four limbs but no damage to the brain or spinal cord), inflammatory spondylopathy (disease that causes pain, stiffness and inflammation to areas that attach to bones), chronic pain syndrome, spinal stenosis cervical region (condition in which the spinal canal puts pressure on the spinal cord and nerves).During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 6/17/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact.During a concurrent observation and interview on 8/15/25 at 11:03 a.m. with Resident 1, Resident 1 was observed sitting up in wheelchair and appeared to limit movements with arms and neck. Resident 1 stated that on 7/25/254, staff were wheeling him out to the courtyard using the backdoor. Resident 1 stated that for the wheelchair to go through the door, the staff member had to tilt the chair backwards. Resident 1 stated he fell backwards instantly when the chair was tilted. Resident 1 stated he felt as if he had fallen forcefully onto the ground because he hit the back of his head and neck on the floor. Resident 1 stated the staff assisted him off the floor and offered to transfer him to the acute care hospital, but Resident 1 stated he refused. Resident 1 stated the pain was lingering following the fall but was informed by the facility staff that the x-rays taken were negative for injury or fracture. Resident 1 stated the pain did not go away due to a previous medical procedure but stated the pain had been felt at all times since the fall.During a review of Resident1's, Situation, Background, Assessment and Recommendation (SBAR) Post Fall, dated 7/25/25, the SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations.During a review of Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m., the note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette.During a review of Resident 1's, Progress Note, dated 7/25/25 10:25 a.m., the note indicated, . X-rays STAT (immediately) ordered. wrist, forearm, cervical, skull.During a review of Resident 1's, Radiology Results Report, dated 7/25/25, the report indicated, . Cervical spine 4 or 5 view, results to follow. The report indicated there were no results following Resident 1's cervical x-ray.During a concurrent interview and record review on 8/15/25 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident1's, SBAR Post Fall, dated 7/25/25, Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. and Resident 1's, Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology result report indicated, . Cervical spine 4 or 5 view, results to follow. LVN 1 stated that after review of the SBAR and progress note, the documentation was not complete regarding Resident 1's fall. LVN 1 stated the facility process was to create a detailed progress note following a fall that would detail what happened and which interventions were completed. LVN 1 stated the radiology report was incomplete and after reviewing the x-ray results in the electronic medical record (EMR), there was no indication that the facility staff followed up with obtaining the final results for the cervical x-ray. LVN 1 stated it was important to follow up with reports and complete all documentation to ensure there was no delayed trauma, to address all aspects of the situation, to find a root cause and to properly address any injury. LVN 1 stated the lack of documentation and follow up placed Resident 1 at risk for delayed diagnosis and treatment if there was a possible injury.During a concurrent interview and record review on 8/15/25 at 11:56 a.m. LVN 2, Resident1's, SBAR Post Fall, dated 7/25/25, and Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. LVN 2 stated Resident 1 had a fall on 7/25/25, when his wheelchair tilted backwards in the hallway. LVN 2 stated she was the nurse present during the time of the fall. LVN 2 stated the SBAR, and progress note were incomplete. LVN 2 stated the progress note should have indicated what had occurred in detail to ensure all staff were aware of the cause and interventions used.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a concurrent interview and record review on 8/15/25 at 1:29 p.m. with director of nursing (DON), Resident1's, SBAR Post Fall, dated 7/25/25, Resident 1's, Progress Note, dated 7/25/25 at 9:50 a.m. and Resident 1's, Radiology Results Report, dated 7/25/25, were reviewed. The SBAR indicated, . I am contacting you about a fall the above resident experienced. Prior to fall resident was in wheelchair/chair resident fell in hallway. assessment. injury, witnessed fall, fall details, other wheelchair tilted back. primary care clinician notified. recommendations. The progress note indicated, . Resident had a fall and refused vitals, just wanted smoke his cigarette. The radiology result report indicated, . Cervical spine 4 or 5 view, results to follow. The DON stated it was the facility process to follow all nursing scope of practice when it comes to documentation. The DON stated she was not aware the x-ray results were incomplete and would follow up with the radiology company to obtain the results. The DON stated an injury could not be ruled out until the x-ray results were obtained for Resident 1. The DON stated all nurses in the facility should have followed the process for documenting including the full completion of Resident 1's SBAR and progress note. The DON stated the nurses had been educated on the importance of complete and accurate documentation in the facility.During a telephone interview on 8/26/25 at 2:15 p.m. with Resident 1, Resident 1 stated that since the fall on 7/25/25, the pain that was previously present in the cervical area, had now exacerbated since the fall. Resident 1 stated, because the pain is located in the cervical area, it was radiating down his spine onto both arms causing an increase in pain to the right arm. Resident 1 stated that prior to the fall on 7/25/25, his numerical pain level (pain scale tool used to measure pain intensity, 0- no pain, 1-3 mild pain, 4-6 moderate pain, 7-10 severe pain) reached an 8/10, but now since the fall, he had been experiencing a pain level of 9/10. Resident 1 stated that his pain level decreased to 6/10 with pain medication since the fall. Resident 1 stated that prior to the fall he had chronic pain due to a previous injury and medical procedure, but the pain before the fall on 7/25/25 was tolerable and now it was not. Resident 1 stated he was receiving pain medication but did not feel it was managing his pain.During a review of Resident 1's, Progress Note, dated 7/26/25, the note indicated, . This evening writer went over x-ray results with resident, which were negative. earlier this evening, resident stated he is in much more pain related to fall, I reminded him he has a as needed (PRN) order for [Acetaminophen] (pain medication used for mild pain).During a review of Resident 1's document titled, Skilled Nursing-Post Accident/Fall IDT, dated 7/28/25, the document indicated, . Root cause analysis, certified nursing assistant (CNA) was wheeling the resident to have a smoke outside, CNA was pulling the resident to get over the doorway, CNA was pulling the resident's chair backwards, chair was reclined to resident's preference. Wheelchair tilted back and resident fell backwards.During a review of Resident 1's Nurse Note, dated 7/29/25, the note indicated, . Resident verbalizes oxycodone/APAP per prn ineffective yet no further requests for [pain medication] which he normally will request.During a review of Resident 1's, Order Summary Report, dated 8/15/25, the report indicated, . Oxycodone oral solution. give 15 ml (unit of measure) every 4 hours as needed for pain. During a review of Resident 1's, Progress Note, dated 8/16/25, the note indicated, . Writer placed a call to [Radiology company name] at approximately 1445 (military time) regarding incomplete cervical spine x-ray results. stated that the x-ray notes on date of service 7/25/25 stated lateral view was unattainable due to patient's inability to position. stated that a lateral view is necessary for all spinal x-rays. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2017, the P&P indicated, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary (IDT) team regarding the resident's condition and response to care. the following information is to be documented in the resident medical record, objective observations. treatments or services performed, changes in the residents condition, events, incidents or accidents involving the resident. documentation in the medical record will be objective, not opinionated or speculative, complete and accurate. documentation of procedures and treatments will include care-specific details, including, the date and time the procedure/treatment was provided. the assessment data and/or any unusual findings obtained during the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated.

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 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 medications were administered according to professional standards of practice for one of six sampled residents (Resident 1), when Resident 1 was not administered medication metformin (medication used for the treatment of diabetes a condition in which there is too much sugar in the blood), enoxaparin (medication used as a blood thinner to prevent blood clots), and nystatin powder (medication used to treat a fungal infection) according to physician orders due to medication unavailability in the facility. This failure had the potential to result in medication ineffectiveness resulting in blood clots that could have led to stroke (interruption in blood supply to the brain) or death, high blood sugar or uncontrolled blood sugar, and worsening of active fungal infection for Resident 1. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for cerebral infarction (condition in which blood flow to the brain is blocked, causing brain tissue to die), diabetes (elevated blood sugar), seizures (uncontrolled jerking, loss of consciousness, blank stares caused by abnormal electrical activity in the brain), aphasia (disorder that affects a persons ability to communicate). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 4/23/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 cognitively intact. During a telephone interview on 6/5/25 at 11:49 a.m. with family member (FM) 1, FM 1 stated the facility did not have enough medication enoxaparin to administer to Resident 1. FM 1 stated she did not have specific dates but recalled the incident occurred in May 2025. FM 1 stated she recalled an incident when the facility placed Resident 1 medication Enoxaparin on hold because they did not have enough of a supply to administer. FM 1 stated there were other incidents with other medications not being administered by the facility because of the lack of supply. During a review of Resident 1's Medication Administration Record (MAR), dated May 2025, the MAR indicated, . Enoxaparin Sodium Injection . inject 1 syringe subcutaneously (under the skin) every 12 hours for Deep Vein Thrombosis (blood clot in a deep vein) . Nystatin Powder 100000 unit/gm (unit of measure) apply to bilateral (both) groin, scrotum, topically every 2 hours for fungal infection . During a concurrent interview and record review on 6/5/25 at 12:12 p.m. with registered nurse (RN) 1, Resident 1's Medication Administration Record (MAR), dated May 2025, the MAR indicated, . Enoxaparin Sodium Injection . inject 1 syringe subcutaneously (under the skin) every 12 hours for Deep Vein Thrombosis (blood clot in a deep vein) . Nystatin Powder 100000 unit/gm (unit of measure) apply to bilateral (both) groin, scrotum, topically every 2 hours for fungal infection . The MAR indicated Resident 1 did not receive medication enoxaparin on 5/28/25 and 5/31/25 per physician order. The MAR also indicated, Resident 1 did not receive treatment order for medication nystatin powder, on 5/13/25 due to medication unavailability. RN 1 stated medication enoxaparin was not administered on 5/28/25 & 5/31/25 because medication was not available in the facility. RN 1 stated the medication nystatin powder was not administered on 5/13/25 due to the medication not being available in the facility. RN 1 stated the reason for the medication unavailability could have been due to staff not reordering medications in a timely manner to avoid disruption of medication administration. During an interview on 6/5/25 at 1:12 p.m. with the director of nurses (DON), the DON stated the facility process for reordering medications from the pharmacy was for the facility nurses to identify when the medication had at least three days worth of doses and reorder medication at that point. The DON stated it was not an acceptable practice to wait and order medications when there were no doses left to administer. The DON stated the expectation was for the nurses to submit the pharmacy request and follow up with the pharmacy to ensure request was received. During a telephone interview on 6/6/25 at 1:37 p.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility process for reordering medications was for the nurse in charge of resident, to reorder medications when there were two or three days worth of doses left. LVN 1 stated it was not acceptable to wait to reorder medications when there were no doses left and then not administer medication to residents. LVN 1 stated the importance of reordering medications and having enough to administer was to avoid disruption of medication regimen and to ensure effectiveness of treatment. During a review of Resident 1 ' s, MAR, dated 1/2025, the MAR indicated, Metformin oral tablet . give 1000 mg by mouth two times a day for [Diabetes Mellitus] give with meals . The MAR indicated two doses of medication metformin were not administered on 1/19/25 at 8:00 a.m. and at 6:00 p.m. The MAR was coded as medication was not available. During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated 9/2/2022, the P&P indicated, . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . keep medication cart . stocked with adequate supplies .compare medication source . with MAR to verify resident name, medication name, form, dose, route and time . administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician . During a review of a professional reference (PR) titled, National Library of Medicine, dated 2025, the PR indicated, . Right Time - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this right is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms .

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents at risk for elopement received adequate supervision and monitoring to prevent accidents for one of six sampled residents (Resident 2), when on 6/1/25 Resident 2 left the facility through the front door and walked half a mile to a grocery store. This failure had the potential for Resident 2 to result in injury caused by falls due to areas of uneven terrain (land that is not flat, varies in height, may have bumps or holes making it difficult to walk)), motor vehicle accident due to a busy highway located next to the facility, and heat exhaustion due to rise in temperature of over 90 degrees Fahrenheit (unit of measurment) for Resident 2. Findings: During a review of Resident 2's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Dementia (decline in menatal ability that interferes with daily life), cerebrovascular disease (condition that affects blood flow to the brain), Diabetes (high blood sugar due to lack of insulin production) and osteoporosis (condition in which bones become weak and brittle). During a review of Resident 2's Minimum Data Set (MDS a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/21/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 2 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8-12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 had severe cognitive impairment. During a review of Resident 2 ' s report titled, Elopement-Off Premises, dated 6/1/25, the report indicated, . at [2:00 p.m.] the facility received a phone call from [Law Enforcement-LE] this [LE] stated that he was at [grocery store name] approximately 0.1 miles from the facility and that he was with a woman matching the description of [Resident 2]. [Resident 2] was last seen by writer at approximately [1:30 p.m.] near the dining room at the facility . [LE] denied release of resident back to the facility stating he did not deem the facility fit to care for resident . this writer spoke with [LE] and he stated that he would be placing resident on a gravely disabled hold . During a review of Resident 2's Elopement Care Plan (CP), dated 4/18/25, the CP indicated, . Is at risk for wandering and/or Elopement . the residents safety will be maintained through the review date . interventions, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books . identify pattern of wandering, intervene as appropriate . During a review of Resident 2's, admission Initial Evaluation- Elopement Risk, dated 4/17/25, the evaluation indicated, . Score: 18 . If total score is 10 or greater, Resident is considered an elopement risk . During an interview on 6/5/25 at 10:43 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated Resident 2 had previous attempts of elopement from the facility. CNA 1 stated there was concern for Resident 2 due to the unavailability of a facility monitoring system for residents at risk for elopement. CNA 1 stated the facility used to have a [Brand name] system in which residents at risk for elopement, were given a bracelet that would trigger an alarm if residents were too close or walked through doors that led outside. CNA 1 stated the facility had implemented a 1 to 1 (CNA assigned to a specific Resident) for Resident 2 only and felt other at-risk for elopement residents were not being monitored enough. During an interview on 6/5/25 at 10:55 a.m. with licensed vocational nurse (LVN) 1, LVN 1 stated the facility process for monitoring Residents at risk for elopement was to observe residents every 15 minutes and complete a head count every six hours. LVN 1 stated Resident 2 was the only resident who was assigned a 1 on 1 staff for monitoring. LVN 1 stated the facility would have benefited from other interventions to effectively monitor residents as there were multiple residents in the facility at risk for elopement. During a concurrent observation and interview on 6/5/25 at 11:10 a.m. with the activity assistant (AA), the AA stated the back door of the dining room was observed unlocked and without an alarm when opened. The AA stated the back door of the dining room led to the back patio and did not sound an alarm unless the alarm system was set up. During an interview on 6/5/25 at 12:12 p.m. with registered nurse (RN) 1, RN 1 stated the facility doors leading outside had alarms, except the front entrance door. RN 1 stated the facility entrance door had an alarm in place that only sounded between the hours of 6:00 p.m. to 6:00 a.m. when opened. RN 1 stated the entrance door would not sound an alarm when opened during the hours of 6:00 a.m. to 6:00 p.m. unless the alarm system was initiated during those times. During an interview on 6/5/25 at 12:35 p.m. with the receptionist (RST), the RST stated part of the receptionist job duties was to monitor the front entrance door. The RST stated if a resident was attempting to go outside, she would alert the nursing staff to ensure the residents had adequate supervision. The RST stated the facility entrance door had a functioning alarm that would sound between the hours of 6 p.m. and 6 a.m. when opened. The RST stated the facility had an available receptionist Monday through Friday. The RST stated the facility entrance door was monitored by the facility staff present on the weekends. During an interview on 6/5/25 at 12:44 p.m. with CNA 2, CNA 2 stated there was a lack of monitoring in the facility for residents at risk for elopement. CNA 2 stated the facility used to have a system in place for [brand name] to detect residents at risk for elopement when they were either exiting the facility or getting close to exit doors, but the system had been removed. CNA 2 stated, when Resident 2 eloped from the facility on 6/1/25, none of the facility door alarms sounded to alert staff that Resident 2 was leaving the facility and due to the lack of monitoring of the front entrance door, staff had not detected Resident 2 left the facility. CNA 2 stated there was concern for all residents at risk for elopement due to the lack of monitoring of the doors, especially the entrance door and the back door of the dining room. CNA 2 stated if a resident wanted to elope from the facility, they could have left without being detected. During an interview on 6/5/25 at 1:12 p.m. with the director of nurses (DON), the DON stated the facility had implemented 15-minute monitoring of all residents at risk for elopement. The DON stated, Resident 2 had eloped through the facility entrance door undetected by the facility staff on 6/1/25. The DON stated the front entrance door was supposed to be monitored by the facility staff. The DON stated all doors leading outside the facility had alarms in place that sounded when opened. When asked about the dining room back door, the DON stated she was not aware of the back door in dining room and was not aware it did not have a working alarm when opened. During an interview on 6/5/25 at 1:52 p.m. with the facility assistant administrator (AADM), the AADM stated Resident 2 eloped from the facility through the facility entrance door undetected by facility staff. The AADM stated Resident 2 was located by LE 0.1 miles away from the facility at a grocery store. the AADM stated All doors leading outside the facility had an alarm in place to sound when opened. The AADM stated the only door that did not have an alarm, was the facility entrance door from 6 a.m. to 6 p.m. in which staff would be monitoring the door. The AADM stated he was not aware the dining room back door leading to the back of the facility did not have an active alarm in place. The AADM stated the facility was in the process of obtaining a new system that would detect residents at risk for elopement when they attempted to exit the facility. During a telephone interview on 6/6/25 at 1:13 p.m. with medical records (MR), MR stated she was assigned the manager of the day role on 6/1/25. MR stated she had received a call from LE who had asked if the facility had a missing resident, in which MR responded yes. MR stated LE requested MR go to scene and identify Resident 2. MR stated when she arrived at the scene, Resident 2 was sitting in the back of the LE vehicle while waiting to be transported to the acute hospital. MR stated Resident 2 was last seen walking freely throughout the facility and required supervision only when walking. MR stated the facility entrance alarm did not sound when Resident 2 eloped from the facility because there was no system in place to trigger an alarm and no one was monitoring the entrance door at that time . During a telephone interview on 6/6/25 at 1:20 p.m. with CNA 3, CNA 3 stated on 6/1/25, Resident 2 was observed walking around the facility freely. CNA 3 stated she was informed by LVN 2 that Resident 2 had eloped from the facility. CNA 3 stated the facility entrance door, and the back door of the dining room were the only doors in the facility that did not have an alarm system when opened. CNA 3 stated Resident 2 ' s elopement could have been prevented if the facility had an effective monitoring system in place that would have alerted staff that Resident 2 was exiting the facility. CNA 3 stated when Resident 2 eloped from the facility, there was a potential for heat exhaustion due to increased temperatures, potential for falls and injury due to the busy road. During a telephone interview on 6/6/25 at 1:37 p.m. with LVN 2, LVN 2 stated that on 6/1/25, LE contacted the facility to inform them Resident 2 had been located at a grocery store parking lot approximately half a mile (walking) from the facility. LVN 3 stated, Resident 2 was ambulatory (ability to walk independently) and had previous attempts of elopement. LVN 3 stated she had accompanied MR to identify Resident 1 at the scene. LVN 3 stated LE would not release Resident 2 back to the facility and transferred Resident 2 to the acute care hospital. LVN 3 stated when Resident 2 returned to the facility, she was placed on a 1 on 1, which was not implemented prior to the incident. LVN 3 stated Resident 2 required constant redirection, was a fast walker and would walk around the facility freely. LVN 3 stated if Resident 2 had specific monitoring interventions in place prior to 6/1/25, the elopement from the facility could have been prevented. LVN 3 stated Resident 2 was at risk for falls, injury heat exhaustion and being hit by a car when she eloped from the facility. During a review of reference titled, Map, the map indicated the distance from the facility to the grocery store was approximately half a mile walking distance that lasted approximately 11 minutes. During a review of the facility ' s policy and procedure (P&P) titled, Elopements and Wandering Residents, dated 12/19/2022, the P&P indicated, . This facility ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . wandering is random or repetitive locomotion that may be goal-directed . elopement occurs when a resident leaves the premises or a safe area without authorization . the facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner .

Feb 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 allegations of abuse according to the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, for one of three sampled Residents (Resident 1), when Resident 1 reported a resident-to-resident verbal altercation to licensed vocational nurse (LVN) 1 on 2/9/25 and LVN 1 failed to report the incident . This failure resulted in the incident of abuse being reported three days later causing Resident 1 distress when Resident 1 continued to encounter Resident 2 during smoking breaks and was not monitored or separated by the facility staff. This failure exposed Resident 1 to further verbal altercations and emotional distress. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for cerebral infarction (blood flow to the brain is blocked), attention deficit hyperactivity disorder (attention difficulty and impulsiveness), bipolar disorder (mood changes from sad to manic), anxiety (intense worry and fear), adult failure to thrive and history of suicidal behavior. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 1/23/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 2/12/25 at 12:17 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 2/9/25 Resident 1 had attempted to enter the dining room to watch television and was denied access from Resident 2. LVN 1 stated Resident 1 had reported on 2/9/25 that Resident 2 was yelling profanity and kicked Resident 1 out of the dining room. LVN 1 stated Resident 1 was upset and crying at the time of the incident. LVN 1 stated the incident was considered a resident-to-resident altercation and a form of abuse but was not reported. LVN 1 stated it was the facility process to document and report all resident altercations for their safety, monitoring and protection. LVN 1 stated the failure to report the incident resulted in Resident 1 being exposed to further altercations with Resident 2 and lack of monitoring from the facility staff. LVN 1 stated there was a potential for further distress for Resident 1. During an interview on 2/12/25 at 12:41 p.m. with Resident 1, Resident 1 recalled incident that occurred on 2/9/25 with Resident 2. Resident 1 stated he had entered the dining room to watch television with group of residents. Resident 1 stated Resident 2 began to yell at Resident 1 stating he could not be in there and needed to leave. Resident 1 stated Resident 2 was yelling out profanity and calling him a piece of shit while also insulting Resident 1's wife. Resident 1 stated he exited the dining room following the incident and reported the altercation to LVN 1. Resident 1 stated the incident made him feel like shit and he became angry with tears the day of the incident. Resident 1 stated since the incident occurred, he felt bothered by Resident 2's attempts to continue to get under my skin. Resident 1 stated he was around Resident 2 following the incident and felt uncomfortable every time Resident 1 saw Resident 2. Resident 1 stated he had to share a smoking break with Resident 2 today which made him feel uncomfortable. Resident 1 stated he attempted to separate himself from Resident 2 during the smoking break and proceeded to immediately leave the area once he was done smoking. Resident 1 stated when Resident 2 was around him anywhere in the facility, Resident 1 would leave and go back to his room or another area away from Resident 2. During an interview on 2/12/25 at 1:46 p.m. with the assistant director of nurses (ADON), the ADON stated the facility process was to document, report and monitor resident to resident altercations that occurred in the facility. The ADON stated the facility was not made aware that an incident had occurred on 2/9/25 between Resident 1 and Resident 2 in the dining room. The ADON stated LVN 1 had not reported the incident to the facility administration and had not completed required documentation. The ADON stated when the incident was not reported and documented, Resident 1 and Resident 2 had not received monitoring to prevent further altercations. The ADON stated the failure to report placed Resident 1 at risk for further verbal altercations with Resident 2. During a record review of Resident 1's Progress Note (PN), dated 2/12/25, the PN indicated, . Resident came to my office and stated another resident had verbally assaulted him and that the resident had called him names using foul language and that he was kicking him out of the dining hall and that he was saying things about his wife and at the time of the interview resident became tearful and started to cry, resident stated he is not a good person he always talks bad to staff and to other residents and he wished to not be around him any longer and he sated I don't like mean people and [Resident 2] is rude and disrespectful . During a record review of Resident 1's Progress Note, dated 2/13/25, the PN indicated, . resident to resident verbal altercation . residents continue to be separated in the facility and during scheduled smoke times . During a review of Resident 1's Progress Note, dated 2/13/25, the PN indicated, . [Resident 1] went on saying that [Resident 2] is often verbally mean and uses foul language at him. I asked [Resident 1] if he starts talking to [Resident 2] first, he responded no, that he tries to ignore him . [Resident 1] responded he will not allow someone to verbally abuse him or talk ill about his wife. [Resident 1] stated that [Resident 2] initiates the conversation every time . no episodes of tears or crying noted but [Resident 1] did seem emotionally upset while talking . During a telephone interview on 2/26/25 at 4:17 p.m. with certified nursing assistant (CNA) 2, CNA 2 stated that on 2/9/25, Resident 1 entered the dining room to attend a resident gathering. CNA 2 stated when Resident 1 entered the dining room, Resident 2 began yelling profanity and telling Resident 1 to leave the dining room. CNA 2 stated Resident 1 began to cry and left the dining room to head back to his room. CNA 2 stated Resident 1 was upset and refused to attend the resident gathering any further following the altercation. CNA 2 stated LVN 1 was present in the dining room when the incident happened. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 12/19/2022, the P&P indicated, .it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . willful means the individual must have acted deliberately . verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability . the facility will develop and implement written policies and procedures that . establish policies and procedures to investigate any such allegation and include training for new and existing staff on activities that constitute abuse . employee training . training topics . identifying what constitutes as abuse . recognizing signs of abuse . reporting process for abuse . the identification, ongoing assessment, care planning, for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . the facility will make efforts to ensure all residents are protected from physical and psychosocial harm . responding immediately to protect the alleged victim and integrity of the investigation . examining the alleged victim for any injury . increased supervision of alleged victim and residents . protection from retaliation . providing emotional support and counseling to the resident during and after the investigation . the facility will have written procedures that include reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified timeframes . immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .

Jan 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 observation, interview and record review, the facility failed to follow the policy and procedure, titled Abuse, Neglect and Exploitation to ensure residents were free from abuse for one of three sampled residents (Resident 1), when certified nursing assistant (CNA) 1 deliberately cut Resident 1's hair without permission and disregarding Resident 1's personal preference to grow and donate her hair to charity. This failure resulted in emotional distress causing unnecessary mental trauma evidence by Resident 1 feeling angry, sad, betrayed and expressing feelings of being cautious, scared and vigilant in the facility following the incident. Findings: During a review of Resident 1's admission Record (AR a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), communication deficit, major depressive disorder (condition manifested by persistent sadness, loss of interest), multiple sclerosis (condition causing nerve damage disrupting function between the brain and body), muscle weakness, contracture (tightening of muscles, tendons, ligaments and skin) of left and right ankle. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 10/17/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0- 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 -12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 1/30/2025 at 10:11 a.m. with Resident 1 in Resident 1's room, Resident 1 was observed lying in bed with hair observed in a ponytail. Resident 1 stated she had been growing her hair since admission in 2018 in order to donate it. Resident 1 stated that she shared her desire to grow her hair with all staff caring for her in the facility. Resident 1 stated that on 1/25/2025, CNA 2 discovered that Resident 1's hair was cut. Resident 1 stated her hair was at hip length prior to CNA 1 cutting her hair. Observation of Resident 1 visibly crying when positioning hair forward to show hair was now shoulder length. Resident 1 stated she felt betrayed, angry and sad following the cutting of her hair. Resident 1 stated since 1/25/2025, she was cautious and vigilant of who was providing care. Resident 1 further stated the incident had led to feeling scared of retaliation from CNA 1. During a review of Resident 1's Progress Note, dated 1/30/2025, the progress note indicated, . On January 25, 2025, at 6:00 p.m., this writer was called to [Resident 1] room. Two CNAs were assisting [Resident 1] to pull up in bed so she could eat her dinner. [CNA 2] stated [Resident 1], who cut your hair? [Resident 1] had a puzzled look and did not know what she was talking about. [CNA 2] pointed out that [Resident 1] hair was shorter than when she last saw it. This writer had no knowledge of [Resident 1] receiving a haircut as [Resident 1] preference was to keep her hair long. This writer had regularly provided care to [Resident 1] for many months and [Resident 1] had always denied any haircuts as she wanted to donate her hair to a charity. [Resident 1] stated that she was unaware her hair was cut and did not give anybody consent to cut her hair. [Resident 1] was observed to be visibly upset that her hair was cut without her consent. Upon observation, this writer observed that a minimum of seven inches was cut from [Resident 1] hair. After an amount of time, it was soon learned that [CNA 1] was the one who cut [Resident 1] hair. [CNA 3] witnessed the alleged incident . During an interview on 1/30/2025 at 11:19 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/25/2025, CNA 2 was heard asking Resident 1 if she had cut her hair. LVN 1 stated Resident 1's hair being cut was out of the ordinary because Resident 1 had requested to not cut her hair. LVN 1 stated she had observed Resident 1's hair braided but the hair tips indicated Resident 1's hair was recently cut. LVN 1 stated she asked Resident 1 if she had requested a haircut in which Resident 1 replied, No. LVN 1 stated Resident 1's hair was longer than hip length prior to the haircut and was now below the shoulder. LVN 1 stated she began investigating the occurrence and discovered CNA 3 had witnessed CNA 1 cutting Resident 1's hair in the shower. LVN 1 stated she felt sad for Resident 1 and felt CNA 1 had violated Resident 1's rights. LVN 1 stated for Resident 1, growing her hair was an important choice that was taken from her by CNA 1. During a review of Resident 1's Interdisciplinary Team (IDT) Note, dated 1/27/2025, the note indicated, . [CNA 2] pointed out that [Resident 1] hair was shorter than when she last saw it. [LVN 1] had no knowledge of [Resident 1] receiving a haircut as [Resident 1] preference is to keep her hair long. [LVN 1] has regularly provided care to [Resident 1] for many months and [Resident 1] has always denied any haircuts as she wanted to donate her hair to a charity. [Resident 1] stated that she was unaware her hair was cut and did not give anybody consent to cut her hair . [Resident 1] was spoken to when incident was discovered, and resident stated she was upset but not much can be done at this time just wished to no longer work with [CNA 1] . During an interview on 1/30/2025 at 11:50 a.m. with the social services director (SSD), the SSD stated she had met with Resident 1 following the incident on 1/25/2025. The SSD stated Resident 1 had expressed feelings of being violated and angry following the incident. The SSD stated Resident 1 made facility staff aware of her preference to grow her hair. The SSD stated Resident 1's choice should have been respected. During a review of Resident 1's Progress Note Social Services, dated 1/28/2025, the progress note indicated, . Visited with resident today, follow up (f/u) from hair cut incident. She told me she was still upset, feels violated, and does not want that CNA in her room . During a review of Resident 1's Progress Note Social Services, dated 1/29/2025, the progress note indicated, . Visited with resident today. She appeared less irritable regarding recent haircut. Did mention again, she does not want that CNA near her . During an interview on 1/30/2025 at 12:35 p.m. with CNA 2, CNA 2 stated she had observed Resident 1's hair was cut shorter. CNA 2 stated she asked Resident 1 if she had a recent haircut in which Resident responded, No. CNA 2 stated CNA 1 was caring for Resident 1 CNA 2 stated CNA 3 had reported observing CNA 1 cutting Resident 1's hair in the shower. CNA 2 stated she recalled Resident 1's hair had grown below her hip and was now at shoulder length. CNA 2 stated Resident 1 always informed staff of her hair and how she was growing it to donate it. CNA 2 stated it was important to respect Resident 1's right to personal preference due to the potential for emotional harm. During an interview on 1/30/2025 at 12:51 p.m. with the director of staff development (DSD), the DSD stated CNA 1 had been in serviced on abuse and resident rights. The DSD stated when CNA 1 cut Resident 1's hair, it was a form of emotional abuse and violation of Resident 1's rights. The DSD stated Resident 1's choice to grow her hair was known to the facility staff. The DSD stated it was important to respect and follow Resident 1's personal preference and beliefs because they were a representation of her wellbeing. The DSD stated Resident 1 had the potential to feel upset and experience depressed feelings. During an interview on 1/30/2025 at 1:19 a.m. with the assistant director of nursing (ADON), the ADON stated the facility identified the incident on 1/25/2025 when Resident 1's hair was cut by CNA 1, as a form of physical and emotional abuse. The ADON stated, Resident 1's personal preference for growing her hair should have been respected by all staff in the facility. The ADON stated, when Resident 1's hair was cut, there was risk for psychosocial harm. During a telephone interview on 1/31/2025 at 10:53 a.m. with CNA 3, CNA 3 stated she recalled CNA 1 cutting Resident 1's hair on one occasion prior to 1/25/2025. CNA 3 stated CNA 1 was observed cutting Resident 1's hair in the bathroom following Resident 1's scheduled shower. CNA 3 stated a shower bed was required to shower Resident 1. CNA 3 stated the shower bed allowed Resident 1's hair to hang freely at the edge. CNA 3 stated CNA 1 cut Resident 1's hair while CNA 3 was blow drying Resident 1's hair. CNA 3 stated she had questioned CNA 1 regarding the cutting of Resident 1's hair but CNA 1 assured CNA 3 It was ok she always cut her hair. CNA 3 stated she was not familiar with Resident 1 therefore she did not question CNA 1. CNA 3 stated after the shower, CNA 1 braided Resident 1's hair and continued with her job routine as usual without mentioning the haircut to Resident 1. Following the incident on 1/25/2025, CNA 3 stated CNA 1 had told her not to say anything about what she had seen when she cut Resident 1's hair in the shower on the previous occasion. CNA 3 stated prior to 1/25/2025, Resident 1's hair was at lower back length and after 1/25/2025 it was significantly shorter reaching below the shoulder in length. During a telephone interview on 1/31/2025 at 11:01 a.m. with CNA 1, CNA 1 stated she had worked in the facility for almost 2 years and had cared for Resident 1 at least every 2 months until 1/25/2025. CNA 1 stated she was familiar with Resident 1 and her preference to grow her hair. CNA 1 stated she had not cut Resident 1's hair on 1/25/2025 or any time before that date. CNA 3 stated she knew how much Resident 1 loved her hair and would not have cut her hair. CNA 1 stated that everyone in the facility wanted to cut Resident 1's hair because it was too much work to maintain it. CNA 1 stated that prior to 1/25/2025, Resident 1's hair length was to her lower back and on 1/25/2025 it was to her shoulder length. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 12/19/2022, the P&P indicated, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse . instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . willful means the individual must have acted deliberately . During a review of the facility's P&P titled, Resident Rights, dated 2022, the P&P indicated, . The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . the resident has the right to be informed of, and participate in, his or her treatment, including . the right to participate in establishing the expected goals and outcome of care, the type, amount, frequency and duration of care . the right to be informed, in advance, of changes to the plan of care. The right to be informed in advance, of the care to be furnished and the type of care giver or professional that will furnish care . the resident has the right to be treated with respect and dignity, including . the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including .the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

CONCERN (D) 📢 Someone Reported This

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

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

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 person-centered care plan that included measurable objectives and timeframes to meet psychosocial needs according to the policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of four sampled Residents (Resident 1), when Resident 1 ' s preference to grow her hair to donate to charity was not documented as part of the plan of care in the care plan. This failure resulted in psychosocial and emotional harm for Resident 1, when her hair was deliberately cut by certified nursing assistant (CNA) 1 and stated she was feeling betrayed, angry and sad. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for dysphagia (difficulty swallowing), communication deficit, major depressive disorder (condition manifested by persistent sadness, loss of interest), multiple sclerosis (condition causing nerve damage disrupting function between the brain and body), muscle weakness, contracture (tightening of muscles, tendons, ligaments and skin) of left and right ankle. During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 10/17/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 1/30/25 at 10:11 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 was observed lying in bed with hair observed in a ponytail. Resident 1 stated she had been growing her hair since admission in 2018 in order to donate it. Resident 1 stated that she shared her desire to grow her hair with all staff caring for her in the facility. Resident 1 stated that on 1/25/25, CNA 2 discovered that Resident 1 ' s hair was cut. Resident 1 stated her hair was at hip length prior to CNA 1 cutting her hair. Observation of Resident 1 visibly crying when positioning hair forward to show hair was now shoulder length. Resident 1 stated she felt betrayed, angry and sad following the cutting of her hair. During a concurrent interview and record review on 1/30/25 at 11:46 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s electronic medical record (EMR) for Care Plans were reviewed. The EMR indicated there was no care plan for Resident 1 ' s preference to grow her hair for donation to charity. LVN 1 stated that on 1/25/25, CNA 2 was heard asking Resident 1 if she had cut her hair. LVN 1 stated Resident 1 ' s hair being cut was out of the ordinary because Resident 1 had requested to not cut her hair. LVN 1 stated she had observed Resident 1 ' s hair braided but the hair tips indicated Resident 1 ' s hair was recently cut. LVN 1 stated she asked Resident 1 if she had requested a haircut in which Resident 1 replied, No. LVN 1 stated Resident 1 ' s hair was longer than hip length prior to the haircut and was now below the shoulder. LVN 1 stated she felt sad for Resident 1 and felt CNA 1 had violated Resident 1 ' s rights. LVN 1 stated for Resident 1, growing her hair was an important choice that was taken from her by CNA 1. LVN 1 stated it was important to document and care plan Resident 1 ' s personal preference to grow her hair to respect Resident 1 ' s decisions. LVN 1 stated it was important to document a personal preference to avoid situations such as the cutting of Resident 1 ' s hair and causing Resident 1 preventable anguish. During a concurrent interview and record review on 1/30/25 at 11:50 a.m. with the social services director (SSD), Resident 1 ' s EMR for Care Plans were reviewed. The EMR indicated there was no care plan for Resident 1 ' s personal preference to grow her hair for donation to charity. The SSD stated when Resident 1 voiced her personal preference it should have been care planned with interventions to include Resident 1 ' s desire to not have her hair cut. The SSD stated Resident 1 voiced her preference to all staff caring for her throughout the years. The SSD stated it was important to have a care plan to address Resident 1 ' s preferences to provide Resident 1 with proper care. During an interview on 1/30/25 at 12:19 p.m. with LVN 2, LVN 2 stated it was the facility process to document all residents personal preferences in the care plan. LVN 2 stated it was important to care plan preferences to plan Resident 1 ' s care accordingly. LVN 2 stated there was a potential for Resident 1 to become angry and upset when Resident 1 ' s personal preference was not documented in the care plan. During a concurrent interview and record review on 1/30/25 at 12:51 p.m. with the director of staff development (DSD), Resident 1 ' s EMR for Care Plans was reviewed. The EMR indicated there was no care plan for Resident 1 ' s personal preference to grow her hair for donation to charity. The DSD stated Resident 1 ' s preference to grow her hair should have been care planned and individualized for Resident 1 ' s plan of care. The DSD stated, Resident 1 ' s preference to grow her hair verbalized by Resident 1 to staff who provided care. During an interview on 1/30/25 at 1:19 p.m. with the director of nursing (DON), the DON stated it was the facility process to care plan all Resident ' s personal preferences with care. The DON stated, Resident 1 ' s preference to grow her hair and donate it to charity should have been care planned with interventions. The DON stated there was no excuse to not have completed a care plan for Resident 1 ' s hair growth. The DON stated, Resident 1 ' s preference should have been respected and had the potential to cause psychosocial harm. During a review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Each resident ' s comprehensive person-centered care plan is consistent with the resident ' s rights to participate in the development and implementation of his or her plan of care, including the right to . participate in establishing the expected goals and outcomes of care . The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being, including . services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . includes the resident ' s stated goals upon admission and desired outcomes . Care plan interventions are chosen only after 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 .

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to meet professional standards of quality for one of five sampled residents (Resident 1), when Resident 1 had an unwitnessed fall on 8/6/24 and the facility staff did not complete a change of condition assessment, skin assessment and post fall assessment. This failure resulted in incomplete documentation for Resident 1 and put Resident 1 at risk for falls and potential delay in care. Findings: During an observation on 8/16/24 at 9:58 a.m., Resident 1 was observed lying in bed with eyes closed. Resident was dressed, clean and groomed. During a review of Resident 1's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (disorder of the brain that slowly destroys memory and thinking skills), muscle weakness, altered mental status (changes in behavior, consciousness, mood or appearance) and unspecified dementia (loss of memory, language, problem solving skills and other thinking abilities). During a review of Resident 1's Minimum Data Set [MDS - a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 7/24/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 0 out of 15 (0- 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 -12 moderate cognitive impairment, 13- 15 cognitively intact) which indicated Resident 1 was severely cognitively impaired. During a concurrent interview and record review on 8/16/24 at 12:48 p.m. with LVN 1, Resident 1's Risk Management Assessment (RMA) dated 8/6/24, was reviewed. The RMA indicated, Resident 1 had an unwitnessed fall with no injuries and was found by facility staff lying on the floor outside the therapy room. LVN 1 stated there was no change of condition (COC) assessment, post fall assessment and skin assessment completed for Resident 1's fall. LVN 1 stated the facility process was for an unwitnessed fall to complete the COC assessment, post fall assessment and skin assessment to effectively monitor Resident 1. LVN 1 stated the proper documentation was important to recognize delayed injury and properly initiate Resident 1's plan of care. LVN 1 stated the documentation was the charge nurse's responsibility to complete after a resident fall. During a concurrent interview and record review on 8/16/24 at 12:56 p.m. with LVN 1, the facility's Post Fall Checklist Binder undated, was reviewed. The Post fall checklist indicated, . post fall checklist . Situation, Background, Assessment, and Recommendation (SBAR) Post fall & Change of Condition . LVN 1 stated the post fall binder provided a list of documentation to be completed by the charge nurse when there was a witnessed or unwitnessed fall. LVN 1 stated the post fall process binder was available to all nurses and always located at the nurse's station for reference. During an interview on 8/16/24 at 1:28 p.m. with LVN 2, LVN 2 stated the facility process for an unwitnessed fall was for the charge nurse to complete a change of condition assessment, skin assessment and all documentation listed in the post fall process binder. LVN 2 stated if the documentation was not completed after a fall, it places the resident at risk for unknown conditions and delays in care. During a concurrent interview and record review on 8/16/24 at 1:34 p.m. with the DON, Resident 1's Risk Management Assessment (RMA) dated 8/6/24, was reviewed. The RMA indicated Resident 1 had an unwitnessed fall with no injuries and was found by facility staff lying on the floor outside the therapy room. The DON stated there was no change of condition assessment completed for Resident 1's unwitnessed fall. The DON stated it was the expectation that the charge nurse on shift to have completed the COC assessment for Resident 1. The DON stated it was important for the COC to have been completed to know the root cause of Resident 1's fall and gather as much information for proper assessment and implementation to prevent further falls. During an interview on 8/16/24 at 2:06 p.m. with the administrator (ADM), the ADM stated it was the facility expectation for the nurses to follow the facility process for falls and complete a COC assessment. The ADM stated it was important to have all documentation completed to know what happened to Resident 1. During a review of the facility's policy and procedure (P&P) titled, Falls-Clinical Protocol dated 03/2018, the P&P indicated, . the nurse shall assess and document/report the following . change of condition or level of consciousness, precipitating factors, details on how fall occurred . the staff will evaluate and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly .

Aug 2024 13 deficiencies 2 IJ (1 facility-wide)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Pressure Ulcer Prevention (Tag F0686)

Someone could have died · This affected multiple residents

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Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure residents with pressure ulcers received treatment and services in accordance with professional standards of practice, to promote healing and prevent deterioration for 3 (Residents #15, #5, and #46) of 3 sampled residents reviewed for pressure ulcers. Specifically, the facility failed to: - Accurately and consistently assess and document the appearance, stage, and complete measurements of pressure ulcers at least weekly to facilitate the ability to promptly identify deterioration or track healing progress of pressure ulcers for Residents #15, #46, and #5. - Consult with the physician to obtain appropriate pressure ulcer treatment orders when nursing staff noted a decline or deterioration in Resident #15's pressure ulcers and when a new Stage III pressure ulcer was identified for Resident #15. - Obtain pressure ulcer treatment orders to cover all dates when pressure ulcer treatments were needed for Resident #5. - Ensure wound treatments were consistently provided and documented for Residents #15, #46, and #5. - Notify the Registered Dietitian (RD) to obtain nutritional recommendations to facilitate wound healing for Resident #15 and Resident #46. The failures resulted in delayed healing and deterioration of Resident #15's Stage III pressure ulcers to the right and left buttocks and had the likelihood to cause delayed healing, deterioration, or infection of pressure ulcers for Resident #46 and Resident #5. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 Pressure Ulcers at a scope and severity of K. The IJ began on 04/25/2024 when nursing staff noted a decline in the condition of Resident #15's pressure ulcers and failed to consistently assess the wounds, consult with the physician to obtain appropriate treatment orders, and consistently provide pressure ulcer treatments to promote wound healing. The Administrator and Interim Director of Nursing (IDON) were notified of the IJ on 08/03/2024 at 1:30 PM and were provided the IJ template at 1:43 PM. A removal plan was requested. The removal plan was accepted by the State Survey Agency (SSA) on 08/06/2024 at 3:50 PM. The IJ was removed on 08/06/2024 at 6:30 PM after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance remained at the lower scope and severity of isolated harm that was not immediate jeopardy for F686. Findings included: A facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised 04/2018, specified, Assessment and Recognition 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. The policy also indicated, Treatment/Management 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc. [et cetera]), and application of topical agents. The policy indicated, Monitoring 1. During resident visits, the physician will evaluate and document the progress of wound healing - especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. 1. An admission Record indicated the facility admitted Resident #15 on 07/28/2022. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus, obesity, and bilateral above the knee amputations. The admission Record revealed diagnoses of Stage III pressure ulcers to the left and right buttocks were added to the resident's list of diagnoses on 07/19/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had two Stage III pressure ulcers, one of which was present upon admission. The MDS also revealed Resident #15 had moisture-associated skin damage. Per the MDS, the resident had treatments for pressure ulcers that included a pressure reducing device for the bed, a nutrition or hydration intervention to manage skin problems, and pressure ulcer/injury care. Resident #15's care plan included a focus area revised 08/16/2023 that indicated the resident had a recurring Stage III pressure ulcer to the left buttock due to being bedfast, incontinent of bowel, obesity, edema, and a history of a previous ulcer. Interventions directed staff to provide nutritional and hydration support (initiated 02/01/2023); provide a pressure reduction/relieving mattress (initiated 02/01/2023); provide treatment as ordered (revised 05/01/2024); and turn and reposition the resident per schedule (revised 05/01/2024); however, the care plan revealed the resident was noncompliant with repositioning. Resident #15's care plan revealed no focus area for the Stage III pressure ulcer to the right buttock was added to the care plan until 08/03/2024 (during the survey). Interventions initiated 08/03/2024 directed staff to evaluate the need for a pain reliever prior to cleansing or dressing changes, provide treatment as ordered, and perform weekly wound assessments. Resident #15's care plan included a focus area, initiated 08/05/2022 and revised 07/31/2024, that indicated the resident was at risk for altered nutritional status and dehydration related to pressure injuries (ulcers). The care plan indicated on 08/05/2022, the dietitian documented a wound was present and nutritional estimates of protein, calories, and hydration had been made. An intervention initiated by the dietitian on 12/08/2022 directed staff to provide Prostat (protein supplement) daily. Resident #15's Progress Notes, dated 04/17/2024, revealed a Weight and Skin Review was documented by the RD. The notes revealed the RD reviewed Weekly Skin Reviews, dated 04/11/2024, that revealed the resident had a Stage III pressure ulcer to the left buttock that measured 6.3 centimeters (cm) in length by (x) 0.6 cm in width x 0.1 cm in depth and a Stage III pressure ulcer to the right buttock that measured 1.7 cm in length x 0.5 cm in width x 0.1 cm in depth. The notes revealed the resident was receiving ProMod (protein supplement) once per day and ascorbic acid (vitamin C supplement). Per the notes, the RD recommended adding zinc sulfate (zinc supplement) for 14 days to promote wound healing. The notes revealed the goal was for skin improvement by the next review. There was no documented evidence the RD assessed Resident #15's nutritional status again until 07/31/2024, after the survey was initiated. Resident #15's Order Recap Report, printed 08/02/2024, revealed physician orders were initiated on 03/28/2024 to clean the recurrent Stage III pressure ulcer to the left superior buttock and the recurring Stage III pressure ulcer to the right buttock with normal saline, pat the area dry, apply Calmoseptine (a moisture barrier/skin protectant) and Vaseline/A&D Ointment (treats and prevents skin irritation) to the wound bed, and cover the area with a non-adherent dressing every shift for 21 days. The report revealed that order's end date was 04/04/2024, after which the physician ordered the same treatment again, beginning on 04/04/2024 and ending on 04/11/2024. The same order was repeated beginning 04/11/2024 and ending 04/18/2024. The same treatment order was repeated beginning on 04/18/2024 and ending 04/25/2024. The same treatment order was repeated beginning 04/25/2024 and ending 05/16/2024. The Order Recap Report contained no evidence the resident had a physician's order to treat a pressure ulcer to the left inferior buttock. Weekly Wound Reviews completed in April 2024 for Resident #15's left buttock pressure ulcer revealed the following: - The Weekly Wound Review, dated 04/04/2024, indicated Resident #15's left buttock pressure ulcer was a Stage III wound measuring 6.3 cm in length x 0.6 cm in width x 0.1 cm in depth. The review indicated the wound base was comprised of 90% epithelial tissue and 10% red granulation tissue. - The Weekly Wound Review, dated 04/18/2024, indicated Resident #15's left buttock pressure ulcer was a Stage III wound. The length had decreased to 3.2 cm; however, the width had increased to 1.7 cm. The depth remained 0.1 cm. The review indicated the wound base was comprised of 50% pink epithelial tissue (decreased from 90%) and 50% red granulation tissue (increased from 10%). - The Weekly Wound Review dated 04/25/2024 indicated Resident #15's left buttock pressure ulcer was a Stage III wound that measured 3.0 cm in length. The width of the wound had increased to 2.4 cm. The depth remained 0.1 cm. The review revealed the wound base was comprised of 75% pink epithelial tissue and 25% red granulation tissue. The review indicated Calmoseptine cream was unavailable for three weeks and the pressure ulcer declined in that time. The section of the Weekly Wound Review form designated for information regarding physician notification was not completed to indicate the physician was informed of the Calmoseptine being unavailable or of a decline in the resident's wound. The review was signed as completed by Licensed Vocational Nurse (LVN) #17. The surveyor attempted to contact LVN #17 for a telephone interview on 08/03/2024 at 11:18 AM and 08/05/2024 at 3:21 PM and left two voice mail messages requesting a return call. LVN #17 did not return the surveyor's call as of the survey exit date (08/07/2024). Resident #15's April 2024 Treatment Administration Record (TAR) revealed no documented evidence the pressure ulcer treatment for the left buttock pressure ulcer was provided as scheduled on eight occasions during the month, on 04/03/2024 night (PM) shift, 04/04/2024 day (AM) shift, 04/05/2024 AM shift, 04/11/2024 AM shift, 04/18/2024 AM shift, 04/25/2024 AM shift, 04/29/2024 AM shift and 04/30/2024 PM shift. According to the TAR, staff documented the pressure ulcer treatment, which included Calmoseptine, was provided all other days as scheduled, and there was no indication the Calmoseptine was not available. Weekly Wound Reviews completed in April 2024 for Resident #15's right buttock pressure ulcer revealed the following: - The Weekly Wound Review dated 04/04/2024 indicated the right buttock pressure ulcer was a Stage III wound that measured 1.7 cm in length x 0.5 cm in width x 0.1 cm in depth. The review indicated the wound bed was comprised of 100% granulation tissue. - The Weekly Wound Review dated 04/25/2024 indicated the right buttock pressure ulcer was a Stage III wound that measured 6.1 cm in length x 2.5 cm in width x 0.2 cm in depth. The review revealed the wound base was comprised of 75% epithelial tissue and 25% granulation tissue. The review also indicated the Calmoseptine cream was unavailable for three weeks and that the pressure ulcer had declined in that time. The section of the review form designated for information regarding physician notification was not completed to indicate the physician was informed of the Calmoseptine being unavailable or of a decline in the resident's wound. The review was signed as completed by LVN #17. The surveyor attempted to contact LVN #17 for a telephone interview on 08/03/2024 at 11:18 AM and 08/05/2024 at 3:21 PM and left two voice mail messages requesting a return call. LVN #17 did not return the surveyor's call as of the survey exit date (08/07/2024). Resident #15's April 2024 TAR revealed no documented evidence the right buttock pressure ulcer treatment was provided as scheduled on eight occasions during the month, on 04/03/2024 night (PM) shift, 04/04/2024 day (AM) shift, 04/05/2024 AM shift, 04/11/2024 AM shift, 04/18/2024 AM shift, 04/25/2024 AM shift, 04/29/2024 AM shift and 04/30/2024 PM shift. According to the TAR, staff documented the treatment, which included Calmoseptine, was provided all other days and there was no indication Calmoseptine was not available. After the Weekly Wound Reviews dated 04/25/2024 for the left superior buttock and right buttock pressure ulcers, there was no further documentation of assessments of Resident #15's pressure ulcers until 05/23/2024, approximately one month without a documented assessment. Weekly Pressure Injury/Ulcer Progress Reports for May 2024 indicated the following regarding a newly identified Stage III pressure ulcer to Resident #15's left inferior buttock area: - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated Resident #15 had developed a new a Stage III pressure ulcer to the left inferior buttock that measured 1 cm in length x 1 cm in width. The depth measurement was left blank. The report revealed the wound had 100% epithelialization. The report indicated the treatment being provided was the same as the other pressure ulcers, which included cleaning the wound with normal saline, patting the area dry, applying Calmoseptine and Vaseline/A&D Ointment, and covering the area with a non-adherent dressing. The report revealed the physician notification portion of the form was not completed and there was no documented evidence the facility notified the physician of a new pressure ulcer to the left inferior buttock. - According to a Weekly Pressure Injury/Ulcer Progress Report dated 05/30/2024, the Stage III pressure ulcer to the left inferior buttock measured 1.1 cm length by 1 cm width, with no depth documented. The report indicated the wound was red but provided no other information about the appearance of the wound. The report indicated the treatment with Calmoseptine /Vaseline continued. Weekly Pressure Injury/Ulcer Progress Reports for May 2024 revealed the following regarding the Stage III pressure ulcer to Resident #15's left superior buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated the Stage III pressure ulcer to the left superior buttock measured 5.5 cm in length x 2.9 cm in width, with no depth measurement provided. The wound had increased in length and width since the most recent documented assessment on 04/25/2024, yet the report indicated the wound had 100% epithelialization. The treatment was to clean the wound with normal saline, pat dry, apply Calmoseptine/Vaseline, and cover with a non-adherent dressing. The report revealed the physician notification portion of the form was not completed and there was no documented evidence the resident's physician was notified of the increase in size of the pressure ulcer to the left superior buttock. - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/30/2024, indicated the pressure ulcer to Resident #15's left superior buttock measured 5.5 cm in length x 2.7 cm in width, with no depth measurement recorded. The report indicated the wound was red and had no undermining/tunneling; however, there was no other documentation regarding the appearance or stage of the wound. Weekly Pressure Injury/Ulcer Progress Reports for May 2024 revealed the following regarding the pressure ulcer to Resident #15's right buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated Resident #15 had a Stage III pressure ulcer to the right buttock that measured 3 cm in length x 0.5 cm in width, with no depth measurement provided. The report revealed the wound was pink and had 100% epithelialization with no drainage/odor or pain. The treatment was to clean the wound with normal saline, pat dry, apply Calmoseptine/Vaseline, and cover with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 05/30/2024, indicated Resident #15 had a Stage III pressure ulcer to the right buttock that measured 3.1 cm in length x 0.8 cm in width, with no depth measurement provided. The report indicated the wound was red but provided no other information about the appearance or stage of the wound. Resident #15's Order Recap Report revealed treatment orders to the left superior buttock and right buttock Stage III pressure ulcers with Calmoseptine and Vaseline/A&D ointment ended on 05/16/2024, and there were no further orders to treat the left superior and right buttock pressure ulcers until 05/20/2024 when an order was written to clean the pressure ulcers with warm water, dry the area, apply Calmoseptine and Vaseline ointment, and cover the area with a non-adherent dressing every (day and night shift). Resident #15's May 2024 TAR revealed no documented evidence treatment was provided to the pressure ulcer to the left inferior buttock in May 2024. The TAR revealed no documented evidence treatment was provided to the left superior or right buttock pressure ulcers on 05/04/2024 during the PM/night shift. Further review of the TAR revealed no treatment orders for the pressure ulcers to the right, left inferior, or left superior buttocks from the evening/night shift on 05/16/2024 until the evening/night shift on 05/20/2024. Consequently, there was no documented evidence a treatment was provided to the pressure ulcers on those dates. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding a newly identified pressure ulcer to Resident #15's left sub-inferior buttock: - A Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024, indicated Resident #15 had developed a new pressure ulcer to the left sub-inferior buttock that measured 0.4 cm in length x 0.5 cm in width, with no depth measurement provided. The report indicated the wound was red, had no drainage/odor, no pain, and no tunneling/undermining. No further information was documented regarding the type of tissue present in the wound bed, the appearance, or the stage of the wound. The report revealed the treatment being provided was to clean the wound with normal saline, pat the area dry, apply Medi-honey (an agent used for healing and removal of dead tissue), and cover the area with a non-adherent dressing. The physician notification portion of the form was not completed, and Resident #15's health record revealed no documented evidence the resident's physician was notified the resident had developed a new pressure ulcer to the left sub-inferior buttock. - A Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, indicated the pressure ulcer to Resident #15's left sub-inferior buttock had increased in size to 1.1 cm in length x 0.5 cm in width, with no depth measurement provided. The treatment information on the report did not reference the prior instructions to apply Medi-Honey to the wound; instead, the report indicated the wound was being treated by cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering with a non-adherent dressing. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding the pressure ulcer to Resident #15's left superior buttock area: - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024 revealed the left superior buttock pressure ulcer measured 4 cm in length x 2.4 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, with no drainage/odor, pain, or undermining. The report did not indicate the stage or any other description of the wound. The report indicated the treatment was to clean with normal saline, pat dry, apply Medi-Honey, and cover with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024 for the pressure ulcer to the left superior buttock, revealed the wound measured 3.5 cm in length x 2 cm in width, with no depth measurement provided. The report indicated the pressure ulcer tissue was red and necrotic, and the wound had no drainage/odor, no pain, and no tunneling/undermining. There was no other documentation regarding the appearance or stage of the wound. The report did not reference the previous instructions to apply Medi-Honey to the wound; instead, the report indicated the treatment consisted of cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering the pressure ulcer with a non-adherent dressing. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding the pressure ulcer to Resident #15's left inferior buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024, revealed the pressure ulcer to the left inferior buttock measured 1.3 cm in length x 1 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wound had no drainage/odor, pain, or tunneling/undermining. The report indicated the wound treatment consisted of cleaning with normal saline, patting dry, applying Medi-Honey, and covering with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, revealed the pressure ulcer to Resident #15's left inferior buttock measured 2 cm in length x 1 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wound had no drainage/odor, pain, or tunneling/undermining. The report did not reference the previous instructions to apply Medi-Honey to the wound; instead, the report indicated the treatment consisted of cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering the pressure ulcer with a non-adherent dressing. Weekly Pressure Injury/Ulcer Progress Reports for June 2024 revealed the following regarding the pressure ulcer to Resident #15's right buttock: - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024, revealed the pressure ulcer to the right buttock measured 1.9 cm in length x 0.6 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wound had no drainage/odor, pain, or tunneling/undermining. The report indicated the wound treatment consisted of cleaning with normal saline, applying Medi-Honey, and covering with a non-adherent dressing. - The Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, revealed the pressure ulcer to the right buttock measured 1.3 cm in length x 0.4 cm in width, with no depth measurement provided. The report indicated the pressure ulcer tissue was red and necrotic, and the wound had no drainage/odor, no pain, and no tunneling/undermining. There was no further documentation regarding the appearance or stage of the wound. The report did not reference the previous instructions to apply Medi-Honey to the wound; instead, the report indicated the treatment consisted of cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering the pressure ulcer with a non-adherent dressing. Resident #15's Weekly Pressure Injury/Ulcer Progress Report, dated 06/13/2024, indicated the pressure ulcer to the left inferior buttock measured 2 cm in length x 1 cm in width, with no depth measurement given. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/20/2024, indicated Resident #15 had multiple wounds to the left buttock with a total measurement of 9.3 cm in length x 2.2 cm in width, with no depth measurement provided. The report indicated the wound tissue was red and necrotic, and the wounds had no drainage/odor, no pain, and no tunneling/undermining. No other information was provided regarding the appearance or stage of the wound. The report revealed the pressure ulcers continued to be treated by cleaning with normal saline, patting the area dry, applying Calmoseptine, and covering with a non-adherent dressing. The physician notification portion of the report was not completed, and there was no documented evidence the physician was notified that the left buttock now had multiple wounds with an overall increase in size. Weekly Pressure Injury/Ulcer Progress Reports, dated 06/20/2024, indicated Resident #15 had a pressure ulcer to the right outer buttock that measured 0.6 cm in length by 0.5 cm in width (no depth measurement provided) and a pressure ulcer to the right inner buttock that measured 1 cm in length x 0.4 cm in width (no depth measurement provided). The reports indicated both pressure ulcers were red and necrotic with no drainage/odor or tunnelling/undermining. The reports contained no other description of the appearance or stage of the wounds. The reports revealed both pressure ulcers were being treated by cleaning with normal saline, patting dry, applying Calmoseptine, and covering with a non-adherent dressing. The physician notification sections of the reports were not completed, and there was no documented evidence the physician was notified of the development of an additional pressure ulcer to the right buttock. Resident #15's Order Recap Report revealed an order started on 06/20/2024 to treat the recurring Stage III pressure injury to the right buttock. The order did not specify whether the treatment order was for the right inner or outer buttock. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/27/2024, indicated Resident #15 the multiple open areas to site on the left buttock. The report did not include individual measurements for each wound or open area and indicated an overall measurement of 10 cm length by 7 cm width, with no depth measurement provided. This indicated an increase in the length and width of the pressure ulcers. The report indicated the wound was red and necrotic, had no drainage/odor, no pain, and no tunneling/undermining, but provided no other information about the appearance or stage of the wounds. The report revealed the treatment to the pressure ulcer continued to be cleaning the area with normal saline, patting the area dry, and applying Calmoseptine. The report indicated the treatment now included applying a non-adherent foam dressing. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/27/2024, indicated Resident #15 now had multiple wounds to the right buttock; however, the report did not include individual measurements for each wound. The report indicated a measurement of 2.5 cm length by 1.9 cm width, with no depth measurement provided. The report indicated the wound was red and necrotic, with no drainage or odor, no pain, and no tunneling, but no other information about the appearance of the wound, including the stage. The report revealed the treatment to the pressure ulcer to the right buttocks continued to be cleaning the area with normal saline, patting the area dry, and applying Calmoseptine. The report indicated the treatment now included applying a non-adherent foam dressing. Resident #15's June 2024 TAR revealed the following: - Treatment instructions for the left buttock healing STG [stage] 3 pressure ulcer to the left buttock (specific location on buttock not documented) indicated the wound was to be cleaned with warm water and dried, then Calmoseptine and Vaseline ointment were to be applied and the wound was to be covered with a non-adherent dressing every shift. The TAR indicated this treatment started on 06/01/2024 and continued through the day shift on 06/06/2024. No treatment was documented as having been provided on the night shift on 06/06/2024, and the next treatment protocol was not initiated for the left buttock until the night shift on 06/07/2024. - Treatment instructions for the left buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, the Medi-Honey and a non-adherent dressing were to be applied every day and night shift for 21 days. The TAR indicated this treatment was initiated on the night shift on 06/07/2024 and continued through the night shift on 06/12/2024. The treatment scheduled on the day shift on 06/13/2024 was not initialed by a nurse as having been provided. - Treatment instructions for the left buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adherent dressing were to be applied one time daily for 21 days. The TAR indicated this treatment started on 06/13/2024 and continued through 06/26/2024. There was no documentation any treatment was provided to the left buttock pressure ulcer on 06/27/2024, and the next treatment protocol was not initiated until 06/28/2024. - Treatment instructions for the left buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adhesive foam dressing were to be applied one time daily for 21 days. The TAR indicated this treatment started on 06/28/2024 and continued through the end of the month. - Treatment instructions for the right buttock healing STG [stage] 3 pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with warm water and dried, then Calmoseptine and Vaseline ointment were to be applied, and the wound was to be covered with a non-adherent dressing every day and night shift. The TAR indicated this treatment was provided twice daily beginning 06/01/2024 and continuing through the day shift on 06/06/2024. - Treatment instructions for the right buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Medi-Honey and a non-adherent dressing were to be applied every day and night shift for 21 days. The TAR indicated this treatment was provided twice daily beginning with the night shift on 06/07/2024 and continuing through the evening shift on 06/12/2024. The scheduled treatment for the day shift on 06/13/2024 was not initialed by a nurse as having been provided, and a new treatment protocol was initiated for wound treatments once daily on 06/13/2024. - Treatment instructions for the right buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adherent dressing were to be applied once daily. The TAR indicated this treatment was provided daily from 06/13/2024 through 06/26/2024. No treatment was initialed as provided on 06/27/2024, and the next treatment protocol was not initialed as having been initiated until 06/28/2024. - Treatment instructions for the right buttock pressure ulcer (specific location on buttock not documented) indicated the wound was to be cleaned with normal saline and patted dry, then Calmoseptine and a non-adherent foam dressing were to be applied once daily for 21 days. The TAR indicated this treatment was provided daily beginning on 06/28/2024 and continued through the end of the month. The Order Recap Record revealed orders to treat the pressure ulcers daily with Calmoseptine were discontinued on 06/27/2024, and another order for treatment was dated as ordered 06/27/2024; however, the Order Recap Record indicated the new treatment was not started u[TRUNCATED]

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19) to staff and residents. Specifically, the facility failed to: 1. Ensure timely COVID-19 testing of symptomatic staff and residents and the implementation of COVID-19 testing during an outbreak, 2. Ensure staff were wearing proper Personal Protective Equipment (PPE), 3. Ensure signage was posted of proper PPE for rooms with positive COVID-19 residents, and 4. Ensure staff were fit tested for N-95 respirator masks. The failed practices had the potential to affect all residents that resided in the facility. It was determined the facility's noncompliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 Infection Control at a scope and severity of L. The IJ began on [DATE] when the Maintenance Director worked in the facility with symptoms of COVID-19. The Maintenance Director was not immediately tested for COVID-19, but the next day, on [DATE], tested positive for COVID-19. At that time, COVID-19 outbreak testing was not initiated for facility residents and staff. On [DATE], while symptomatic, Nursing Assistant (NA) #1 was asked to continue working while waiting for additional staff. During this time, NA #1 cared for Resident #51. On [DATE] NA #1 tested herself at home for COVID-19, and the result was positive. On [DATE], Resident #51 was sent to the hospital due to COVID-19. As of [DATE], 32 residents and 12 staff members had tested positive for COVID-19. On [DATE] at 5:51 PM, the Administrator and Interim Director of Nursing (IDON) were notified of the IJ and provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 5:05 PM. The IJ was removed on [DATE] at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F880 remained at the lower scope and severity of widespread, with actual harm that was not immediate jeopardy for F880. In addition, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 (Resident #5, #9, and #60) of 3 residents reviewed for EBP. Findings included: 1. An undated facility policy titled, COVID-19, revealed the section titled 2. Monitoring Signs and Symptoms, indicated, b. These symptoms may appear 2-14 days after exposure (based on incubation period of SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2] virus): i. Fever ii. Cough iii. Shortness of breath or difficulty breathing iv. Myalgia v. Chills or repeated shaking with chills vi. Headache vii. Sore throat viii. Runny nose ix. Loss of taste or smell x. Nausea/vomiting xi. Diarrhea c. Emergency warning signs include: i. Trouble breathing ii. Persistent pain or pressure in the chest iii. New confusion or inability to arouse iv. Bluish lips or face. The policy revealed the section titled 3. Resident Assessment, indicated, a. Criteria to Guide Evaluation of Persons Under Investigation (PUI) for COVID-19. The policy revealed the section titled Clinical Criteria, indicated, At least one of the following symptoms: - cough - shortness of breath - difficulty breathing. The policy revealed the section titled 4. Staff and Visitor Screening if Community Wide COVID-19 Illness, indicated, b. If a staff member develops signs & [and] symptoms of a respiratory infection during work, the staff member needs to: i. immediately stop work & put on a facemask ii. Inform the Infection Preventionist of any individuals, equipment or locations the person came in contact 1. Contact & follow local health department recommendations for next steps (e.g. [exempli gratia; for example], testing, locations for treatment). An email from the Department of Public Health, dated [DATE], sent to the facility in response to the facility's report of COIVD-19 positive staff members revealed the following instructions, A single new case of SARS-CoV-2 infection in any HCP [health care provider] or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using broad-based approach regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed the Maintenance Director had symptoms starting on [DATE] including fever, myalgia, sore throat, upset stomach, and cramping. The list revealed the Maintenance Director tested positive for COVID-19 on [DATE]. On [DATE] at 1:07 PM, the Infection Preventionist (IP) stated the Maintenance Director became symptomatic during a shift, tested positive for COVID-19, and went home. The IP stated the Maintenance Director was at the facility for a few hours and due to him not feeling well he wore a mask while he was at the facility. The IP stated the Maintenance Director asked to be tested sometime into his shift, and he tested positive for COVID-19. The IP stated staff should stay home if they are not feeling well. The IP stated the Maintenance Director was at the facility before she came in to work, and the Maintenance Director should have requested a test earlier if he was not feeling well. On [DATE] at 2:52 PM, the IP stated the Maintenance Director had worked and fixed a window on [DATE]. On [DATE] at 3:57 PM, the Maintenance Director stated he worked at the facility every day. The Maintenance Director stated on [DATE] he had a sore throat, headache, low energy, and fever and sweats at night. The Maintenance Director stated on [DATE] he had started the day and did not feel well, and that morning he had done some general things inside and outside the building. The Maintenance Director stated he told his boss he was not feeling well, and the Infection Preventionist (IP) tested him. The Maintenance Director stated he tested positive, and he went home. A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed Nursing Assistant (NA) #1 had symptoms starting on [DATE] including cough, myalgia, chills, and headache. The list revealed NA #1 tested positive for COVID-19 on [DATE]. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated NA #1 tested positive for COVID-19 at home. On [DATE] at 1:07 PM, the IP stated NA #1 became symptomatic early in the morning, worked four hours, and was sent home. The IP stated NA #1 tested at home and sent a picture of the test from home. The IP stated she did not test NA #1 because NA #1 just said she was not feeling well. The IP stated it seemed like an isolated case, there were no other cases, and no one else had symptoms. On [DATE] at 9:17 AM, NA #1 stated she picked up a shift to work on [DATE]. NA #1 stated she started feeling weak with chills around 7:30 AM, and she told the scheduler. NA #1 stated the scheduler asked her to stay until 10:00 AM when other staff would be there. NA #1 stated she still felt bad on Saturday ([DATE]), so she tested herself and was positive. On [DATE] at 9:06 AM, NA #1 stated she had helped with Resident #51 on [DATE]. NA #1 stated Resident #51 was constantly trying to go out the doors, and the alarms would go off. NA #1 stated Resident #51 usually had one-to-one supervision. NA #1 stated no one was assigned to do one-to-one supervision with the resident that morning, so she was helping to keep Resident #51 from exiting. An admission Record revealed the facility admitted Resident #51 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease and Alzheimer's disease. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #51 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problem per a staff assessment of mental status (SAMS). A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed Resident #51 had symptoms on [DATE] including cough, myalgia, fatigue, and mucous. The list revealed Resident #51 tested positive for COVID-19 on [DATE]. A late entry nursing progress note, dated [DATE] at 10:00 AM, revealed Resident #51 had altered level of consciousness, weakness, cough, and behavioral symptoms. The note revealed Resident #51 was wandering throughout the building sneezing and coughing. The note revealed hospice recommended sending Resident #51 out for further evaluation. A nursing progress note, dated [DATE] at 11:38 AM, revealed Resident #51 tested positive for COVID-19 and was experiencing cough, congestion, blowing mucus in their hands, and spitting on the floor. The note revealed an ambulance was called to transport Resident #51 to a medical center. On [DATE] at 4:22 PM, the Infection Preventionist (IP) stated Resident #51 was not tested for COVID-19 on [DATE] because she thought it was just a cold. The IP stated Resident #51 was tested on [DATE]. On [DATE] at 1:43 PM, Licensed Vocational Nurse (LVN) #2 stated Resident #51 wandered the halls. LVN #2 stated the morning Resident #51 was sent to the hospital the resident was coughing and sneezing phlegm. On [DATE] at 1:53 PM, LVN #3 stated on [DATE] Resident #51 slept most of the day. LVN #3 stated Resident #51 had days where the resident slept most of the day. LVN #3 stated the morning Resident #51 was sent out to the hospital the resident had nasal secretions, throat clearing, and was not their normal self. Registered Nurse (RN) #12, a hospice nurse, was interviewed on [DATE] at 8:36 AM about her visit with Resident #51 on [DATE]. RN #12 stated Resident #51 was lying down, seemed lethargic, and a family member was concerned Resident #51was not waking up. RN #12 stated Resident #51's roommate stated Resident #51 had been lying down since yesterday. RN #12 stated Resident #51 was coughing, but the cough was not a concerning cough for her. RN #12 stated Resident #51's lungs had rales (abnormal lung sounds). RN #12 stated she spoke to the nurse on the floor who stated Resident #51's usual behavior was sleep for long periods. RN #12 stated she told the floor nurse about the cough and rales for monitoring. RN #12 stated she was not aware Resident #51 was exposed to COVID-19 when a staff member tested positive, and that would have changed her decision to treat the resident. RN #12 stated she would have done a COVID-19 test and maybe even have started Resident #51 on an antibiotic, if the resident had tested COVID-19 positive. A handwritten COVID-19 testing log, dated [DATE], revealed staff and resident testing for COVID-19 began after Resident #51 tested positive for COVID-19. A handwritten COVID-19 testing log, dated [DATE], revealed 103 staff and residents were tested for COVID-19. A handwritten testing log, dated [DATE], revealed 92 staff and residents were tested for COVID-19. A handwritten testing log, dated [DATE], revealed four staff and residents were tested for COVID-19. On [DATE] at 8:30 AM, the IP stated COVID-19 started with the Maintenance Director being symptomatic on [DATE]. The IP stated that since there was only one staff member who tested positive, it was an isolated case, and she did not implement testing. The IP stated, on [DATE], another staff member tested positive, and she did not test any other staff or residents. The IP stated she did not start testing all staff and residents until Resident #51 tested positive on [DATE]. The IP stated two other residents tested positive on [DATE], and all staff and residents were tested. The IP stated all staff and residents were tested again on [DATE]. The IP stated on [DATE] she tested symptomatic staff and residents. On [DATE] at 11:51 AM, during a follow up interview, the IP stated she tested symptomatic residents and staff only on [DATE] due to testing supplies being expired. The IP stated she did not want to use outdated testing supplies. On [DATE] at 1:07 PM, the IP stated there were not many stores locally from which to get testing supplies. The IP stated with the amount they needed there was nowhere to get the supplies, and they would have emptied out the drug stores as there was only one big pharmacy in the area. The IP stated she started outbreak testing for COVID-19 if there were three or more cases as that was considered an outbreak. On [DATE] at 1:55 PM, the Interim Director of Nursing (IDON) stated outbreak investigation and testing would start with three or more staff or residents positive for COVID-19. The IDON stated if the facility was in outbreak, every resident and staff should be tested on day one, day three, and day five. The IDON stated the facility was currently in outbreak as there was one COVID-19 positive resident on each hall for a total of three residents. The IDON stated if staff were not feeling well prior to work they would stay outside and test prior to working. The IDON stated she was not aware there were no testing supplies for the fifth day of testing. The IDON stated she would have expected the IP nurse to contact her for guidance upon finding outdated testing supplies. The IDON stated she would have expected the IP to look up the information on the company website that supplied the equipment to find the true expiration date, and it had been her understanding that testing supplies could be used beyond the expiration date. On [DATE] at 2:21 PM, the Administrator stated testing should be done per CDPH's (California Department of Public Health) guidance. The Administrator stated an outbreak was considered three or more positives, and the testing schedule would be day one, day three, and day five during the outbreak. The Administrator stated all the residents and staff would be tested. The Administrator stated he was unaware there were no testing supplies available for the fifth day of testing, [DATE]. The Administrator stated there was a sister facility with which they could share supplies, and he was asked to bring testing supplies on [DATE]. On [DATE] at 5:16 PM, the IP stated she tested staff and residents if they showed enough symptoms of COVID-19 like a sore throat, fever, no taste, and diarrhea, for those symptoms that would signal COVID-19, or if someone told her they needed to be tested. The IP stated she would test if there were different signs than just a cold. On [DATE] at 11:40 AM, the IDON stated if someone had new signs or symptoms testing would be initiated immediately. 2. An undated facility policy titled, COVID-19, indicated, 7. PPE [personal protective equipment] a. Gloves i. Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. The policy revealed, b. Gowns i. Put on a clean isolation gown upon entry into the patient room or area. The policy revealed, c. Respiratory Protection i. Use respiratory protection (i.e. a respirator) that is at least as protective as a fit-tested NIOSH [National Institute for Occupational Safety and Health]-certified disposable N95 filtering facepiece respirator before entry into the patient room or care area. The policy revealed, d. Eye Protection i. put on eye protection (e.g., goggles, a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area. An admission Record revealed the facility admitted Resident #21 on [DATE]. According to the admission Record, the resident had a medical history that included diagnosis of mild persistent asthma with acute exacerbation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A late entry nursing Progress Note, dated [DATE], indicated Resident #21 had a change of condition and tested positive for COVID-19 with signs and symptoms of being tired, weak, increased confusion, and drowsy. An admission Record revealed the facility admitted Resident #22 on [DATE]. According to the admission Record, the resident had a medical history that included diagnoses of encephalopathy and muscle weakness. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A nursing progress note, dated [DATE] at 5:52 PM, revealed Resident #22 tested positive for COVID-19 with signs and symptoms of feeling weak and a of temperature of 101.1 F (degrees Fahrenheit). An observation of Resident #21's and Resident #22's room, on [DATE] at 10:08 AM, revealed signage on the wall by the entry that indicated staff should wash their hands and make sure their eyes and nose were covered prior to entry. The observation revealed enhanced barrier precaution (EBP) signage on the door of the room requiring staff to wash their hands and wear gown and gloves. The observation revealed Housekeeper (HK) #4 inside the room replacing trash can liners, cleaning the bathroom, and mopping the floors. The observation revealed HK #4 had an N-95 mask and gloves on. During the observation HK #4 exited Resident #21's and Resident #22's room, without removing her gloves in the room, to get cleaning supplies from the housekeeping cart. The observation revealed HK #4 taking her gloves off and placing them in the trash can on her cleaning cart. At the time of the observation, HK #4 stated staff were required to wear a mask and gloves inside the room where Resident #21 and Resident #22 resided. HK #4 stated staff were only required to wear a gown if they were providing care to the resident. HK #4 stated PPE should be taken off once staff exited the room at the door and placed in a bag and taken to the storage room. During an observation and interview on [DATE] at 10:19 AM, HK #5 was observed to go into Resident #21's and Resident #22's room donning an N-95 mask. At the time of the observation, HK #5 stated the signage on the wall meant that staff were supposed to wear more PPE when inside the room. HK #5 stated, since the residents had COVID-19, staff should wear additional PPE including a facemask, gloves, and a gown when entering the room. HK #5 stated he should have had additional PPE on when entering the room. An observation and interview on [DATE] at 8:12 AM, revealed Licensed Vocational Nurse (LVN) #6 donning an N-95 mask and gloves in Resident #21's room while taking the resident's blood pressure reading. LVN #6 stated he should wear the mask and the gloves while in Resident #21's room, but he was not required to wear a face shield or a gown. After observing the signage at the door, LVN #6 stated he missed seeing the sign that said to cover the eyes, nose, and mouth. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated PPE required to enter an isolation room was a gown, gloves, goggles, and an N-95 mask. On [DATE] at 1:55 PM, the Interim Director of Nursing (IDON) stated staff going into COVID-19 positive rooms should don PPE prior to entering the room including a gown, gloves, an N-95 mask, and a face shield. On [DATE] at 2:21 PM, the Administrator stated staff should use the proper PPE including a gown, face shield, gloves, and a mask, and the N-95 mask was preferred. The Administrator stated staff should put PPE on at the entry of the room and should take the PPE off inside the room. 3. A LTC [Long Term Care] Respiratory Surveillance Line List, dated [DATE], revealed Resident #21 tested positive for COVID-19 on [DATE], Resident #22 tested positive for COVID-19 on [DATE], Resident #24 tested positive for COVID-19 on [DATE], Resident #29 tested positive for COVID-19 on [DATE], Resident #47 tested positive for COVID-19 on [DATE], Resident #37 tested positive for COVID-19 on [DATE], and Resident #56 tested positive for COVID-19 on [DATE]. An observation on [DATE] at 9:12 AM of Resident #47's room revealed the room had no signage or personal protective equipment (PPE) bins outside the room. Resident #47's room should have had signage to ensure staff wore proper PPE inside the room of a resident with COVID-19. An observation on [DATE] at 10:08 AM of Resident #21's and Resident #22's room revealed signage on the door that indicated droplet precautions and to fully cover the eyes, nose, and mouth before room entry. The observation revealed enhanced barrier precaution (EBP) signage on the door that indicated staff must clean their hands and gown and glove only during certain care. An observation on [DATE] at 10:18 AM of Resident #37's and Resident #56's room revealed the room had signage indicating droplet precautions, but there was no signage to ensure staff wore a gown and gloves. An observation on [DATE] at 11:18 AM of Resident 24's room revealed the room had droplet precaution signage on the wall in the hallway by the door that indicated everyone must fully cover their eyes, nose, and mouth before room entry and to remove face protection before room exit. There was no signage observed to indicate staff should be in full PPE including a gown, gloves, an N-95 mask, and a face shield to enter the Resident #37's room. An observation on [DATE] at 11:25 AM of Resident #29's room revealed the door open and signage on the door requiring eyes and nose to be covered. There was no signage observed to indicate staff should be in full PPE including a gown, gloves, an N-95 mask, and a face shield prior to entering the room. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated COVID-19 positive residents were in isolation with signage outside their doors indicating proper PPE. The IP stated staff were required to wear proper PPE to enter an isolation room which was a gown, gloves, goggles, and an N-95 mask. On [DATE] at 11:02 AM, the Director of Staff Development (DSD) stated the proper signage for COVID-19 isolation rooms was droplet and contact precaution signs. 4. A facility policy titled, Personal Protective Equipment - Contingency and Crisis Use of N-95 Respirators (COVID-19 Outbreak), revised 09/2021, revealed the section titled Objective indicated To prevent transmission of infectious agents through the inhalation of airborne particles or droplet nuclei. The policy revealed, 1. When N95 filtering facepiece respirators (FFR) are available and there is not an anticipated shortage, the facility operates under conventional capacity measures, including: The policy revealed, f. adopting just in time fit testing if feasible. On [DATE] at 8:12 AM, Licensed Vocational Nurse (LVN) #6 was observed donning an N-95 mask and gloves while taking a blood pressure reading for Resident #21 who was COVID-19 positive. LVN #6 stated he had not been fit tested for the N-95 mask. On [DATE] at 8:30 AM, the Infection Preventionist (IP) stated staff were required to wear a gown, gloves, goggles, and an N-95 mask inside rooms with positive COVID-19 residents. The IP stated not all staff had been fit tested for the N-95 masks. On [DATE] at 2:21 PM, the Administrator stated staff should use the proper PPE including gown, face shield, gloves, and a mask. The Administrator stated using an N-95 mask was preferable. The Administrator stated not all staff were fit tested for N-95 masks. On [DATE] at 5:06 PM, a Removal Plan was submitted by the facility and the accepted by the state survey agency. It read as follows: Magestic Mountain Care Center 1. How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken; 3. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur; 4. How the facility plans to monitor its performance to make sure that solutions are sustained; Version 7, F880 01.1 Failed to Provide Testing Residents who were found to be COVID-19 Positive had their physician notified, obtained appropriate orders to treat their symptoms, and were placed on alert monitoring. On [DATE] the Infection Preventionist (IP) and designee initiated COVID-19 testing for all 53 Resident in house and staff members. 01.2 All Residents had the potential to be affected by the deficient finding. All Residents and staff will be tested on the first day, third day, and fifth day. If there are new cases, the testing will continue every three to seven days until there are no new cases for fourteen days. On [DATE], 3 new COVID-positive Residents were identified and placed on close monitoring by following COVID 19 protocol and monitoring for any change of condition pertaining to COVID 19. Resident identifier #215 Resident identifier #33 Resident identifier #53 On [DATE] one additional employee tested positive for COVID-19 and was removed from the schedule. 01.3 On [DATE] the Interim Director of Nursing (DON) reeducated the IP and staff with an in-service on the following: - COVID-19 testing guidelines and the importance of compliance with testing and ensuring adequate supplies of testing kits to prevent the spread of COVID 19. -Donning and doffing with proper personal protective equipment (PPE) - N-95 fit-testing protocols. Any staff not on duty at the time of the in-service will be educated by the IP or Designee prior to the start of their next shift. The IP/Designee will post a schedule of staff required to COVID 19 test at least one day prior to the testing date. The staff posting will be next to the time clock. This will also be followed up with a group text message. Any staff reporting back on duty will need to be tested for COVID-19 prior to the beginning of their next shift. On [DATE] the DON and designee educated the staff with an in-service about the signs and symptoms of COVID-19. If staff identifies any symptoms from residents or themselves, they must report it to the IP or designee as soon as possible. Any reported symptoms from residents or staff must result in the immediate administration of a COVID test. 01.4. The IP/Designee will report the COVID-19 testing results at the next daily stand-up meeting. They will then follow-up the announcement with the appropriate corrective action. The DON will audit the IP/Designee testing process on day one, day three, and day five to ensure that the residents and staff were tested for COVID-19. Any deficiencies will be corrected immediately, and the Administrator will be notified. The Administrator will review the plan of correction and submit all findings of non-compliance to the Quality Assessment and Assurance (QAA) committee. The QAA Committee shall review and monitor the effectiveness of this Plan of Correction monthly through [DATE]. The identified deficient practice was the IP's failure to adhere to the protocol of testing residents and staff on day one, day three, and day five. The deficient practice has been corrected subsequent to the findings. 2.1 Proper PPE On [DATE] an IP from one of our sister facilities provided an in-service training to 40 out of 84 active staff on the following: - The guidelines for COVID-19 testing and the importance of compliance, including ensuring the adequacy of testing kit supplies to prevent the spread of COVID-19. -Donning and doffing with proper PPEs -[DATE] the IP from sister facilities initiated the skills competency validation for staff, ensuring the proper donning and doffing of PPE. -N-95 fit testing protocols. Any staff out on leave of absence (LOA) will be educated by the IP or designee prior to the start of their next shift. The IP or designee will provide an in-service to the remaining staff that were not in-serviced on [DATE]. The Administrator/DON will verify that the remainder of the staff are educated with an in-service training. 2.2 All Residents had the potential to be affected by the found deficiencies. All Residents and staff will be tested on the first day, third day, and fifth day. If there are new cases, the testing will continue every three to seven days until there are no new cases for 14 days. The DON/Designee shall conduct random observations of at least three staff members each week to validate proper donning and doffing of appropriate PPE for four weeks or until substantial compliance is achieved. Annual competency-tests for doffing and donning are to be completed by all staff. On [DATE], three additional residents tested positive for COVID-19 and were placed on close monitoring for any change of condition. Resident identifier #215 Resident identifier #33 Resident identifier #53 On [DATE] one additional employee tested positive for COVID-19 and was removed from the schedule. On [DATE], the IP from our sister facility initiated the skills competency validation for all active staff, ensuring the proper donning and doffing of PPE. On [DATE], the IP from our sister facility will complete the skills competency validation for all active staff, ensuring the proper donning and doffing of PPE. 2.3 On [DATE] the DON in-serviced and reeducated the IP on the following: - COVID-19 testing guidelines, emphasizing the importance of compliance and ensuring adequate supplies of testing kits to prevent the spread of COVID-19. -Donning and doffing with proper PPEs -N-95 fit testing protocols. The IP/Designee will complete a skills competency validation for newly hired staff on the proper donning and doffing of appropriate PPE during orientation. On [DATE], the IP from our sister facility initiated skills competency validation for staff on the proper donning and doffing of PPE. 2.4 The DON/Designee will conduct random observations of at least three staff members per week to validate proper donning and doffing of appropriate PPE for four weeks or until substantial compliance is achieved. Any findings will be corrected immediately, and the administrator will be notified. The administrator[TRUNCATED]

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview, record review, and facility policy review, the facility failed to notify the physician when new pressure ulcers were identified and when nursing staff noted increased wound measurements or a decline in the condition of pressure ulcers for 2 (Resident #15 and Resident #46) of 4 sampled residents reviewed for pressure ulcers. Findings included: A facility policy titled, Change in a Resident's Condition or Status, revised in 02/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g. [for example], changes in level of care, billing/payments, resident rights, etc. [et cetera]). The policy also indicated the nurse was to notify the resident's attending physician or physician on call when there was a, d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. 1. An admission Record indicated the facility admitted Resident #15 on 07/28/2022. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus, obesity, and bilateral above the knee amputations. The admission Record revealed diagnoses of Stage III pressure ulcers to the left and right buttocks were added to the resident's list of diagnoses on 07/19/2024. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/08/2024, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had two Stage III pressure ulcers, one of which was present upon admission. The MDS also revealed Resident #15 had moisture-associated skin damage. Per the MDS, the resident had treatments for pressure ulcers that included a pressure reducing device for the bed, a nutrition or hydration intervention to manage skin problems, and pressure ulcer/injury care. Resident #15's care plan included a focus area, initiated on 03/18/2023 and revised on 08/16/2023, that indicated the resident had a recurring Stage III pressure ulcer to the left buttock. A care plan focused area, initiated on 08/03/2024, indicated the resident also had a Stage III pressure ulcer to the right buttock. Resident #15's Order Recap [recapitulation] Report revealed physician orders started on 04/18/2024 to clean the left superior buttock recurrent Stage III pressure ulcer and the right buttock recurring Stage III pressure ulcer with normal saline, pat the areas dry, apply Calmoseptine (a moisture barrier/skin protectant) and Vaseline/A&D Ointment (treats and prevents skin irritations) to the wound beds, and cover the areas with a non-adherent dressing every shift for 21 days. Per the Order Recap Report, these orders were discontinued on 04/25/2024, and the same treatments were ordered again on 04/25/2024 and remained in effect until 05/16/2024. Weekly Wound Reviews for April 2024 revealed the following regarding the pressure ulcer to Resident #15's left buttock: - A Weekly Wound Review, dated 04/04/2024, indicated Resident #15's left buttock pressure ulcer was a Stage III wound measuring 6.3 cm in length x 0.6 cm in width x 0.1 cm in depth. The review indicated the wound base was comprised of 90% epithelial tissue and 10% red granulation tissue. - A Weekly Wound Review, dated 04/18/2024, indicated Resident #15's left buttock pressure ulcer was a Stage III wound. The length had decreased to 3.2 cm; however, the width had increased to 1.7 cm. The depth remained 0.1 cm. The review indicated the wound base was comprised of 50% pink epithelial tissue (decreased from 90%) and 50% red granulation tissue (increased from 10%). There was no documentation the physician was notified of the 40% loss of epithelialization. - A Weekly Wound Review dated 04/25/2024 indicated Resident #15's left buttock pressure ulcer was a Stage III wound that measured 3.0 cm in length. The width of the wound had increased to 2.4 cm. The depth remained 0.1 cm. The review revealed the wound base was comprised of 75% pink epithelial tissue and 25% red granulation tissue. The review indicated Calmoseptine cream was unavailable for three weeks and the pressure ulcer declined in that time. The section of the Weekly Wound Review form designated for information regarding physician notification was not completed to indicate the physician was informed of the Calmoseptine being unavailable or of a decline in the resident's wound. The review was signed as completed by Licensed Vocational Nurse (LVN) #17. Weekly Wound Reviews for April 2024 revealed the following regarding the pressure ulcer to Resident #15's right buttock: - A Weekly Wound Review dated 04/04/2024 indicated the right buttock pressure ulcer was a Stage III wound that measured 1.7 cm in length x 0.5 cm in width x 0.1 cm in depth. The review indicated the wound bed was comprised of 100% granulation tissue. - A Weekly Wound Review dated 04/25/2024 indicated the right buttock pressure ulcer was a Stage III wound that measured 6.1 cm in length x 2.5 cm in width x 0.2 cm in depth. The review revealed the wound base was comprised of 75% epithelial tissue and 25% granulation tissue. The review also indicated the Calmoseptine cream was unavailable for three weeks and that the pressure ulcer had declined in that time. The section of the review form designated for information regarding physician notification was not completed to indicate the physician was informed of the Calmoseptine being unavailable or of a decline in the resident's wound. The review was signed as completed by LVN #17. Resident #15's April 2024 Treatment Administration Record (TAR) revealed nursing staff documented the wound treatments to the left and right buttock pressure ulcers, which included application of Calmoseptine, were provided as scheduled, with the exception of eight occasions during the month of April 2024. There was no documentation the Calmoseptine was not available. The surveyor attempted to contact LVN #17 for a telephone interview to clarify the discrepancy regarding the availability of Calmoseptine on 08/03/2024 at 11:18 AM and 08/05/2024 at 3:21 PM. The surveyor left two voice mail messages requesting a return call. LVN #17 did not return the surveyor's call as of the survey exit date (08/07/2024). A Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated Resident #15 had developed a new a Stage III pressure ulcer to the left inferior buttock that measured 1 cm in length x 1 cm in width. The report revealed the physician notification portion of the form was not completed and there was no documented evidence the facility notified the physician of a new pressure ulcer to the left inferior buttock. A Weekly Pressure Injury/Ulcer Progress Report, dated 05/23/2024, indicated the Stage III pressure ulcer to the left superior buttock measured 5.5 cm in length x 2.9 cm in width, with no depth measurement provided. The wound had increased in length and width since the most recent documented assessment on 04/25/2024. The report revealed the physician notification portion of the form was not completed and there was no documented evidence the resident's physician was notified of the increase in size of the pressure ulcer to the left superior buttock. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/06/2024, indicated Resident #15 had developed a new pressure ulcer to the left sub-inferior buttock that measured 0.4 cm in length x 0.5 cm in width, with no depth measurement provided. The physician notification portion of the form was not completed, and Resident #15's health record revealed no documented evidence the resident's physician was notified the resident had developed a new pressure ulcer to the left sub-inferior buttock. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/20/2024, indicated Resident #15 had multiple wounds to the left buttock with a total measurement of 9.3 cm in length x 2.2 cm in width, with no depth measurement provided. The physician notification portion of the report was not completed, and there was no documented evidence the physician was notified that the left buttock now had multiple wounds with an overall increase in size. Weekly Pressure Injury/Ulcer Progress Reports, dated 06/20/2024, indicated Resident #15 had a pressure ulcer to the right outer buttock that measured 0.6 cm in length by 0.5 cm in width (no depth measurement provided) and a pressure ulcer to the right inner buttock that measured 1 cm in length x 0.4 cm in width (no depth measurement provided). The physician notification sections of the reports were not completed, and there was no documented evidence the physician was notified of the development of an additional pressure ulcer to the right buttock. A Weekly Pressure Injury/Ulcer Progress Report, dated 06/27/2024, indicated Resident #15 now had multiple wounds to the right buttock; however, the report did not include individual measurements for each wound. The report indicated a measurement of 2.5 cm length by 1.9 cm width, with no depth measurement provided. A Weekly Pressure Injury/Ulcer Progress Report, dated 07/11/2024, indicated Resident #15 had a pressure wound to the right buttock that measured 3 cm length by 2 cm width, with no depth measurement provided. (This indicated the size had increased from the 06/27/2024 measurements of 2.5 cm length by 1.9 cm width). The physician notification portion of the report was left blank, and there was no documented evidence the physician was notified that the pressure ulcer size had increased. The report was signed as completed by LVN #11. A Weekly Pressure Injury/Ulcer Progress Report, dated 07/11/2024, indicated the site of the pressure ulcer was L [left] buttock. No specific location on the buttock was noted. The measurements indicated the pressure ulcer was 12.5 cm length x 7 cm width. No depth measurement was provided. The section of the form designated for documentation of physician notification was left blank, and there was no documentation the physician was consulted regarding the increased size of the wound to determine if a change in treatment was needed. The report was signed as completed by LVN #11. Weekly Pressure Injury/Ulcer Progress Reports dated 08/01/2024 indicated Resident #15 continued to have pressure ulcers requiring treatment to the left and right buttocks. During an interview on 08/06/2024 at 8:36 AM, LVN #11 stated if a resident's pressure ulcer worsened, she notified a Registered Nurse (RN) or continued the same treatment. She stated she occasionally contacted the physician to get treatment orders but did not contact the physician every time a wound changed. LVN #11 stated she was not aware of whether Resident #15's physician had ever been seen the resident's pressure ulcers and was not sure the physician was ever notified of the pressure ulcers. During a telephone interview on 08/07/2024 at 3:31 PM, Physician #15 stated he knew that Resident #15 had a history of pressure ulcers but thought they were healed. He stated he was not aware that the resident currently had wounds and was not notified when the wounds were worsening. Physician #15 also stated that he had not seen the resident's pressure ulcers during the last three to four visits. He stated he thought that the facility had a wound team, including a wound physician that was visiting the facility weekly to manage residents' wounds and was not aware that they had stopped coming in February 2024. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated the physician should be notified of any change in a pressure ulcer and the notification should be documented in a progress note in the resident's medical record. During an interview on 08/06/2024 at 11:37 AM, the Administrator stated the physician should be notified any time there was a change to a pressure ulcer, and the notification should be documented in the resident's electronic health record. 2. An admission Record indicated the facility admitted Resident #46 on 08/28/2023 and readmitted the resident on 07/18/2024 after a hospital stay from 07/10/2024 to 07/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of a fracture of the second cervical vertebra, type 2 diabetes, intervertebral disc displacement of the thoracic region, Stage II pressure ulcer of the right buttock, anterior spinal artery compression syndrome of the lumbar region, paraplegia, central cord syndrome of the cervical spinal cord, acute myelomonocytic leukemia, dementia, and cervical region spinal stenosis. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS indicated the resident was not at risk for developing pressure ulcers and did not have an unhealed pressure ulcer. A Weekly Wound Review dated 04/04/2024 indicated Resident #46 had a Stage III pressure ulcer to the coccyx that measured 1.5 centimeters (cm) in length by (x) 3.9 cm in width x 0.1 cm in depth. The review revealed the wound base was comprised of 75% red epithelial (newly healed) tissue and 25% red granulation (healing) tissue. A Weekly Wound Review dated 04/18/2024 indicated the Stage III pressure ulcer to Resident #46's coccyx measured 1.0 cm in length x 0.7 cm in width x 0.1 cm in depth. The wound measurements had decreased, but the review indicated the wound bed no longer had any epithelial tissue and was now comprised of 100% granulation tissue, which represented a deterioration in the wound status. The physician notification section of the review form was left blank, and there was no evidence the physician was notified of the change in wound status. The review was signed as completed by Licensed Vocational Nurse (LVN) #17. During an interview on 08/06/2024 at 8:36 AM, LVN #11 stated she had been doing the wound measurements since May 2024. She stated she was not trained to do this and, I do not know what I am doing with staging or documenting wounds. She stated if a wound got worse, she would let the Registered Nurse (RN) know or just continue the same treatment. She stated that occasionally, she would contact the physician to get treatment orders. She stated she did not contact the physician with changes every time, just once in a while. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated the physician should be notified of any change to a wound for treatment changes and nutritional support. She stated the notification should be documented in a progress note in the medical record. During an interview on 08/06/2024 at 11:37 AM, the Administrator stated the physician should be notified any time there was a change to a wound, and this should be documented in the resident's electronic health record.

CONCERN (D)

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

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected 1 resident

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Based on interview, record review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete Minimum Data Set (MDS) assessments timely for 1 (Resident #21) of 20 sampled residents' whose electronic medical records were reviewed. Findings included: On 08/06/2024 at 12:32 PM, the Director of Clinical Operations (DCO) stated the facility used the RAI manual as their policy for MDS assessments. The CMS Long-Term Care Facility RAI 3.0 User's Manual, dated 10/2023, revealed, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. Per the manual The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. The manual specified, -The ARD must be within 92 days after the ARD of the previous OBRA assessment (Quarterly, Admission, SCSA [Significant Change in Status Assessment], SCPA [Significant Correction to Prior Comprehensive Assessment], SCQA [Significant Correction to Prior Quarterly Assessment), or Annual assessment + 92 calendar days). -The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). An admission Record indicated the facility admitted Resident #21 on 01/13/2024. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, muscle weakness, and abdominal aortic aneurysm. Resident #21's most recent Minimum Data Set (MDS) was a quarterly assessment with an ARD of 04/21/2024, indicating their next assessment was to have an ARD no later than 07/22/2024. Resident #21's electronic medical record (EMR) revealed a quarterly MDS, with an ARD of 07/22/2024, was In Progress. The EMR flagged this MDS as 1 [one] day overdue. On 08/06/2024 at 10:52 AM, the MDS Director stated Resident #21's MDS was not completed on time. She stated she was new to the position and was learning. She also stated time management was another reason it was not completed. On 08/06/2024 at 11:08 AM, the Interim Director of Nursing (IDON) stated MDS assessments should be completed according to the allotted timeframes, and they should be submitted timely. On 08/06/2024 at 11:57 AM, the Administrator stated the MDS Consultant was supposed to monitor for the completion of the MDS assessments.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a Minimum Data Set (MDS) assessment accurately reflected the presence of a serious mental illness per the state Level II Preadmission Screening and Resident Review (PASRR) process for 1 (Resident #15) of 4 residents reviewed for PASRR requirements. Findings included: On 08/06/2024 at 12:32 PM, the Director of Clinical Operations (DCO) stated the facility used the RAI manual as their policy for MDS assessments. The CMS Long-Term Care Facility RAI 3.0 User's Manual, dated 10/2023, indicated A1500: Preadmission Screening and Resident Review (PASRR) included Coding Instructions that specified, -Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. An admission Record indicated the facility admitted Resident #15 on 07/28/2022. According to the admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia and anxiety disorder. Resident #15's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 07/28/2022, indicated the Level I screening was positive due to suspected mental illness, and a Level II was required. Resident #15's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 08/16/2022, indicated the resident required nursing facility services due to a medical or mental health condition, and specialized services were recommended. An annual MDS, with an Assessment Reference Date (ARD) of 08/10/2023, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an active diagnosis of schizophrenia; however, A1500 was coded as 0, which indicated the resident was not considered by the state Level II PASRR process to have as serious mental illness and/or intellectual disability or related condition. During an interview on 08/05/2024 at 3:24 PM, the MDS Director stated MDS assessments needed to be accurate to ensure they captured the proper care for the resident and for billing purposes. She stated she was responsible for ensuring the MDS assessments were accurate. She stated she utilized information obtained through record review and through interviews to code the MDS assessments. The MDS Director stated if a resident had a Level II PASRR, it should be coded on the MDS. The MDS Director stated Resident #15 did have a Level II PASRR and confirmed it was not coded correctly on their annual MDS. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated MDS assessments needed to be accurate because it was a document that reflected the residents' status and should be correct. She stated the accuracy of MDS assessments was the responsibility of MDS staff. The IDON stated if a resident had a Level II PASRR, then it should be coded on the MDS. She stated Resident #15 did have a Level II PASRR and confirmed that it was not coded correctly on their MDS. During an interview on 08/06/2024 at 11:37 AM, the Administrator stated the MDS Consultant and the MDS staff were responsible for ensuring MDS assessments were accurate. The Administrator stated Resident #15's MDS should have been coded to reflect their Level II PASRR findings.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on interview, record review, and facility document review, the facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) assessment for 1 (Resident #40) of 2 residents reviewed for PASRR. Findings included: A California Department of Health Care Services PASRR Information Notice titled, When to initiate a Preadmission Screening and Resident Review (PASRR) Reconsideration Request or Resident Review, dated 04/02/2024, indicated, If the Level I Screening indicates suspected SMI [Serious Mental Illness] and/or ID [Intellectual Disabilities]/DD [Developmental Disabilities]/RC [Related Conditions], the individual must be referred for further evaluation (Level II Evaluation). The goal of the Level II Evaluation and subsequent Determination process is to ensure appropriate placement of individuals in the least restrictive setting that best meets their needs and identify the need for specialized services (PASRR Determination). The notice also indicated, SNFs [skilled nursing facilities] must initiate a Resident Review by completing a Level I Screening when the following occurs: Within 72 hours of identifying a significant change in condition relating to the individual's SMI and/or ID/DD/RC. An admission Record revealed the facility admitted Resident #40 on 11/29/2021. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia and mixed anxiety disorders. A Psychologist Consultation/Follow Up form, dated 09/14/2022, revealed Resident #40 had initial complaints or symptoms of delusions, agitation or inappropriate behaviors, and treatment and compliance issues. The form revealed Resident #40 was given diagnoses of Dementia with Bx [behaviors], and Schizoaffective D/O [disorder]. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2024, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had diagnoses of anxiety disorder and schizophrenia. Resident #40's medical record revealed an additional Level I PASRR had not been resubmitted after receiving the new diagnosis of schizoaffective disorder. During an interview on 08/01/2024 at 1:40 PM, the Social Services Director (SSD) stated she was unaware she was supposed to do a new PASRR with a new qualifying diagnosis. The SSD stated the prior company that owned the facility had not required her to do a new PASRR for new diagnoses. The SSD stated she had been doing two jobs, medical records and social services, and things had started to fall behind during that time span and were not completed like they should have been. During an interview on 08/06/2024 at 10:29 AM, the Interim Director of Nursing (IDON) stated it was her expectation, for the PASRR process, that the assessments were to be filled out correctly and submitted timely. During an interview on 08/06/2024 at 11:31 AM, the Administrator stated his expectation was for the PASRR to be followed through with and completed as they were needed.

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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Based on interview, record review, facility document review, and review of a memorandum from the California Department of Health Care Services, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I screening was resubmitted for 1 (Resident #39) of 4 residents reviewed for PASRR. Specifically, the facility failed to resubmit a Level I screening to re-open their case when a Level II evaluation could not be completed due to the resident being hospitalized . Findings included: A memorandum from the California Department of Health Care Services, dated 04/02/2024, revealed, Subject: When to initiate a Preadmission Screening and Resident Review (PASRR) Reconsideration Request or Resident Review. The memorandum specified, PASRR cases closed as 'Attempt' or 'Unavailable' due to the SNF [skilled nursing facility] not providing the required documentation to the Level II Contractor timely (within 24 hours of a positive Level I Screening) or the unavailability of an individual during the scheduled Level II Evaluation are not considered completed. 'Attempt' and 'Unavailable' Letters issued in the PASRR Online System due to reasons stated above are not valid documentation for TAR [Treatment Authorization Request] approval because the PASRR process was not completed. Therefore, for cases closed as 'Attempt' or 'Unavailable' due to such reasons, the SNFs are required to submit a new Level I Screening to commence the PASRR process again and ensure successful completion. An admission Record indicated the facility admitted Resident #39 on 04/17/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia and unspecified psychosis. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #39 re-entered the facility in 04/29/2024 from a short-term general hospital. Resident #39's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 04/24/2024, indicated the resident had a serious diagnosed mental disorder, specifically schizophrenia, and received psychotropic medications for mental illness. Resident #39's PASRR Level I Screening was positive due to suspected mental illness. A letter from the Department of Health Care Services, Special Programs Branch, PASRR Section, dated 04/24/2024, indicated a Level II mental health evaluation was required. A letter from the Department of Health Care Services, Special Programs Branch, PASRR Section, dated 04/25/2024, indicated a Level II Mental Health Evaluation was not scheduled due to Resident #39 being transferred temporarily to an acute care hospital for treatment. The letter indicated the case was closed and a new Level I screening would need to be submitted to reopen the case. During an interview on 08/04/2024 at 12:50 PM, the Social Service Director (SSD) stated when a resident was readmitted from the hospital, a new PASRR needed to be done. She stated Resident #39's Level I screening should have been completed when the resident was readmitted from the hospital. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated Resident #39's Level I screening should have been resubmitted when the resident was readmitted to the facility. During an interview on 08/06/2024 at 11:31 AM, the Administrator stated he expected the facility to follow through with PASRRs as needed.

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, record review, and facility policy review, the facility failed to ensure the care plan was updated with fall interventions for 1 (Resident #39) of 4 residents reviewed for accidents. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised in 03/2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated, 9. Care plan interventions are chosen only after 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. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met. An admission Record indicated the facility admitted Resident #39 on 04/17/2024. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, rheumatoid arthritis, muscle weakness, and a history of falling. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one fall without injury and one fall with major injury since the previous assessment. Resident #39's care plan included a focus area initiated 04/21/2024 and revised 07/19/2024, that indicated the resident was at risk for falls related to generalized weakness, gait/balance problems, being unaware of safety needs, severe cognitive impairment, confusion, history of falling, history of non-compliance with using the call light or asking for help to get in and out of bed without assistance, a history of dangling their feet off the bed, and indicated that the resident strived for independence. Interventions directed staff to anticipate and meet the resident's needs (initiated 04/21/2021), keep the call light within reach at all times (initiated 04/21/2024), follow the facility fall protocol (initiated 04/21/2024), and provide therapy intervention as needed (initiated 07/19/2024). Resident #39's care plan included a focus area initiated 04/23/2024, that indicated the resident was at risk for injuries due to a recent fall incident related to balance problems and poor safety awareness. Interventions directed staff to have a certified nurse aide (CNA) complete visual checks of the resident every 15 minutes (initiated 04/23/2024 and revised 05/01/2024), when the resident becomes restless, assist to wheelchair and encourage to go out to the lobby area to watch television (initiated 04/23/2024 and revised 05/01/2024), invite to daily in house activities of preference and encourage participation (initiated 04/23/2024), and monitor for side effects from medications, labs, and appetite as cause for falls (initiated 04/23/2024). Resident #39's Progress Notes revealed an IDT [Interdisciplinary Team] Event Review note, dated 05/13/2024 at 4:11 PM, that indicated Resident #39 had a witnessed fall on 05/12/2024 at 4:00 PM. The review indicated the resident's roommate called for assistance because the resident was on the floor next to the bed. The note indicated that per interview with the roommate, Resident #39 was trying to get up multiple times without assistance and was trying to self-transfer to a wheelchair without assistance and fell. The review indicated the Root Cause Analysis for event revealed the resident had impulsive behavior, non-compliance with asking for help, and had a history of falls and restlessness. The review indicated the IDT recommended to check the resident every two hours, place the resident in the wheelchair in the morning after breakfast and place in front of the nursing station, continue the bed in the lowest position when in bed, and re-educate the resident on the importance of asking for assistance. Resident #39's care plan revealed it was not updated with the 05/12/2024 fall or interventions that were to be put into place. Resident #39's Progress Notes revealed an Event Initial Note, dated 06/29/2024 at 9:00 PM, that indicated Resident #39 had a witnessed fall on 06/29/2024 at 7:15 PM. Per the note, the resident had a fall out of bed on their head that was witnessed by a CNA, who was assisting another resident. The note indicated the CNA emphasized that the resident's head had a hard impact with the ground. Per the note, the resident sustained a 2 centimeter (cm) long by 2 cm wide raised area to the left front side of the forehead and a 10.5 cm long by 0.5 cm wide abrasion/bruising to the mid to lower back. The note indicated interventions to prevent the event from happening again were to complete frequent rounding, encourage the resident to use their call light and keep the bed in the lowest position. Resident #39's Progress Notes revealed an IDT note, dated 07/01/2024 at 10:40 AM that indicated the IDT met to discuss Resident #39's witnessed fall on 06/29/2024. The note indicated the CNA was doing their room rounds and found the resident in their bed trying to get out of the bed, and the resident fell on the floor. The note indicated the resident sustained a skin tear and skin discoloration and was sent out to the hospital for further evaluation. The note indicated the resident was sent back to the facility with no new orders. The note indicated the resident was a high risk for falls due to a history of falls, impulsive behavior, and forgetfulness. The note indicated the IDT recommended staff make sure the resident was in the lowest position when in bed. Resident #39's care plan revealed it was not updated with the 06/29/2024 fall or interventions that were to be put into place following the fall. During an interview on 08/05/2024 at 3:24 PM, the MDS Director stated she was responsible for updating the care plan with any changes, including new fall interventions. She stated she was unsure why the interventions were not added to Resident #39's care plan after their falls. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated the DON and MDS Director were responsible for putting fall interventions on the care plan. She stated if she was not the person that updated the care plan, then she would review the care plan to ensure that the interventions were on the care plan. The IDON stated the interventions mentioned in the IDT notes after Resident #39's falls should have been put on the care plan and the care plan should have been updated to reflect the actual interventions being used. During an interview on 08/06/2024 at 11:37 AM, the Administrator stated the care plan should be updated with fall interventions during the IDT review by the MDS nurse.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to ensure an environment free of accidents and hazards for 1 (Resident #39) of 4 residents reviewed for accidents. Specifically, the facility failed to prevent repeat falls for Resident #39. Findings included: A facility policy titled, Falls and Fall Risk, Managing, revised 03/2018, specified, 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. The policy revealed the section titled Resident-Centered Approaches to Managing Falls and Fall Risk included 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls and 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The policy revealed the section titled Monitoring Subsequent Falls and Fall Risk included 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling and 4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. An admission Record indicated the facility admitted Resident #39 on 04/17/2024. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, rheumatoid arthritis, muscle weakness, and a history of falling. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one fall without injury and one fall with major injury since the previous assessment. Resident #39's care plan included a focus area initiated 04/21/2024 and revised 07/19/2024, that indicated the resident was at risk for falls related to generalized weakness, gait/balance problems, being unaware of safety needs, severe cognitive impairment, confusion, history of falling, history of non-compliance with using the call light or asking for help to get in and out of bed without assistance, a history of dangling their feet off the bed, and indicated that the resident strived for independence. Interventions directed staff to anticipate and meet the resident's needs (initiated 04/21/2021), keep the call light within reach at all times (initiated 04/21/2024), follow the facility fall protocol (initiated 04/21/2024), and provide therapy intervention as needed (initiated 07/19/2024). Resident #39's care plan included a focus area initiated 04/23/2024, that indicated the resident was at risk for injuries due to a recent fall incident related to balance problems and poor safety awareness. Interventions directed staff to have a certified nursing aide (CNA) complete visual checks of the resident every 15 minutes (initiated 04/23/2024 and revised 05/01/2024); when the resident becomes restless, assist to wheelchair and encourage to go out to the lobby area to watch television (initiated 04/23/2024 and revised 05/01/2024); invite to daily in house activities of preference and encourage participation (initiated 04/23/2024); and monitor for side effects from medications, labs, and appetite as cause for falls (initiated 04/23/2024). Resident #39's Progress Notes revealed an Event Initial Note, dated 05/12/2024 at 4:00 PM, that indicated Resident #39 had a witnessed fall. The note indicated the resident was found lying on the floor in their room and the roommate stated the resident attempted to get out of bed by themself and fell. The note indicated the resident sustained a 1.5 centimeter (cm) long by 1.5 cm wide skin tear to the right wrist. Resident #39's Progress Notes revealed an Event follow up note, dated 05/13/2024 at 3:22 AM, that indicated Resident #39 had no delayed injuries from the fall. The note indicated interventions to reduce risk of reoccurrence included to remind the resident to call for help and wait for assistance, keep a call light in reach, and keep the resident's bed in the lower position. Resident #39's Progress Notes revealed an Event follow up note, dated 05/13/2024 at 2:32 PM, that indicated the resident was unable to remember to call for assistance. Resident #39's Progress Notes revealed an IDT [Interdisciplinary Team] Event Review note, dated 05/13/2024 at 4:11 PM, that indicated Resident #39 had a witnessed fall on 05/12/2024 at 4:00 PM. The review indicated the resident's roommate called for assistance because the resident was on the floor next to the bed. The note indicated that per interview with the roommate, Resident #39 was trying to get up multiple times without assistance and was trying to self-transfer to a wheelchair without assistance and fell. The review indicated the Root Cause Analysis for event revealed the resident had impulsive behavior and non-compliance with asking for help and had a history of falls and restlessness. The review indicated the IDT recommended to check the resident every two hours, place the resident in the wheelchair in the morning after breakfast and place in front of the nursing station, continue the bed in the lowest position when in bed, and re-educate the resident on the importance of asking for assistance. Resident #39's Progress Notes revealed an Event follow up note, dated 05/14/2024 at 5:04 PM, indicated the resident was cognitively impaired and unable to remember to ask for assistance. Resident #39's Progress Notes revealed an Event Initial Note, dated 06/29/2024 at 9:00 PM, completed by Licensed Vocational Nurse (LVN) #2, that indicated Resident #39 had a witnessed fall on 06/29/2024 at 7:15 AM. Per the note, the resident had a fall out of bed on their head that was witnessed by a CNA, who was assisting another resident. The note indicated the CNA emphasized that the resident's head had a hard impact with the ground. Per the note, the resident was complaining of a pain level of 10 out of 10 (on a scale of 0 to 10 with 10 being the worst pain), sustained a 2 cm long by 2 cm wide raised area to the left front side of the forehead and a 10.5 cm long by 0.5 cm wide abrasion/bruising to the mid to lower back. The note indicated interventions to prevent the event from happening again were to complete frequent rounding, encourage the resident to use their call light and keep the bed in the lowest position. Resident #39's Progress Notes revealed a Progress Note, dated 06/30/2024 at 7:15 AM, that indicated a physician was notified of Resident #39's fall on 06/29/2024. The note indicated that the physician gave orders to send the resident out to the hospital for further evaluation. The note indicated that the resident was sent to the hospital on [DATE] at 7:45 PM via ambulance. The note indicated the resident returned from the hospital with no new orders and no abnormal findings. Resident #39's Progress Notes revealed an IDT progress note, dated 07/01/2024 at 10:40 AM, that indicated the IDT met to discuss Resident #39's witnessed fall on 06/29/2024. The note indicated that a CNA found the resident when completing rounds trying to get out of bed, and the resident fell on the floor. The note indicated the resident sustained a skin tear and skin discoloration and was sent out to the hospital for further evaluation. The note indicated the resident was sent back to the facility with no new orders. The note indicated the resident was a high risk for falls due to a history of falls, impulsive behavior, and forgetfulness. The note indicated the IDT recommended staff to make sure that the resident's bed was in the lowest position when the resident was in bed. During a phone interview on 08/02/2024 at 6:46 AM, CNA #16 stated she was walking another resident past Resident #39's room when she saw Resident #39 fall headfirst out of the bed that was in a high position. She stated whoever the resident's CNA was left the bed in a high position. She stated she told the nurse who was sitting at the desk, and she went in with another person. CNA #16 stated she thought the resident was sent out. She stated she was not questioned about the fall or what she saw and did not write a witness statement. During an interview on 08/05/2024 at 9:42 AM, LVN #2 stated that when she went into Resident #39's room after the fall on 06/29/2024, the bed was in a position that if the resident were to swing their legs over the side, their feet would touch the floor. She stated she interviewed the CNA that reported it to her but not the CNA assigned to the resident. She stated she did her normal paperwork about the fall, but she sent the resident out to the emergency room, so she did not put in any new interventions. She stated the management team should have done that when the resident returned. She stated no one from the management team asked her about the fall or any details of it. During an interview on 08/04/2024 at 10:52 AM, the Interim Director of Nursing (IDON) stated that an investigation for a fall would include interviews with the resident, staff, and roommate if applicable. She stated they would meet as a team, determine the root cause, and implement new interventions. During an interview on 08/06/2024 at 10:16 AM, the IDON stated she was not able to find any interviews or further investigation for Resident #39's falls in May 2024 or June 2024. She stated the IDT was responsible for implementing new interventions. She stated they met in the morning and reviewed the falls from the previous day or evening. She stated therapy staff, social services staff, the Activities Director, and the whole team discussed the fall and the root cause and determined what was the best interventions to prevent injury or another fall that was specific to the resident. She stated if the interventions were related to CNA care, then the interventions would be put on the task section in the CNA charting to alert the CNAs and it would also be put on the care plan. During an interview on 08/06/2024 at 11:37 AM, the Administrator stated a fall investigation should be initiated by the nurse on the floor and they should get statements from the CNA or other staff to get a picture of the situation and notify the physician, the on-call supervisor, and the responsible party. He stated the nurse should assess the resident and complete change of condition documentation. He stated the root cause analysis was completed with the IDON in collaboration with the Administrator. He stated interventions were put in by the IDT. The Administrator stated there should have been a more thorough investigation into Resident #39's falls.

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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Based on interview, record review, and facility policy review, the facility failed to ensure pharmacy recommendations were implemented for 3 (Residents #29, #42, and #50) of 5 sampled residents reviewed for unnecessary medications. Findings included: An undated facility policy titled, Consultant Pharmacist Services Provider Requirements, indicated, 1) Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions, incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review (see IIIA1: MEDICATION REGIMEN REVIEW(MONTHLY REPORT)), and documenting the review and findings in the resident's medication record. The policy revealed 10. A written or electronic report of findings and recommendations resulting from the activities as described above is given to the administrator and/or director of nursing (at least monthly). 11. Resident-specific recommendations are documented in the resident's (active record). 1. An admission Record revealed the facility admitted Resident #29 on 04/29/2021. According to the admission Record, the resident had a medical history that included a diagnosis of essential primary hypertension. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/15/2024, revealed a Staff Assessment for Mental Status (SAMS) determined Resident #29 had short- and long-term memory problems and had severely impaired cognitive skills for daily decision making. Resident #29's care plan included a focus area initiated 04/16/2023 that indicated the resident had the potential for altered tissue perfusion related to hypertension. Interventions directed staff to give metoprolol as ordered by the physician. Resident #29's Consultant Pharmacist's Medication Regimen Review, dated 05/30/2024, revealed a pharmacy recommendation for hold parameters for systolic blood pressure (SBP) and heart rate (HR) to be added to the resident's metoprolol physician order. Resident #29's Orders Summary Report, with active orders as of 08/04/2024, contained an order dated 06/07/2021, for metoprolol tartrate tablet 50 milligrams (mg) with instructions to give one tablet by mouth two times a day for hypertension. Further review revealed there were no hold parameters included in the order. On 08/04/2024 at 2:16 PM, the Interim Director of Nursing (IDON) stated she would send any note to the physician by fax (facsimile) and follow his response. She stated the physician needs to be notified of all medication regimen reviews. She stated if there was a change to the order the Director of Nursing (DON) was responsible for following up and overseeing the medication regimen reviews were being completed. She stated Resident #26's metoprolol orders should have hold parameters and did not. 2. An admission Record revealed the facility admitted Resident #42 on 08/25/2022. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus and hypokalemia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #42's care plan included a focus area initiated 08/07/2022, that indicated the resident had the potential for alteration in blood glucose. Interventions directed staff to administer medications as ordered, such as metformin. The care plan included a focus area initiated 08/27/2022 that indicated the resident had the potential for complications related to hypokalemia. Interventions directed staff to give potassium gluconate per physician orders. Resident #42's Consultant Pharmacist's Medication Regimen Review, dated 05/30/2024, revealed a pharmacy recommendation for potassium supplements to be given with food and a full glass of fluid and do not crush or chew. Further review revealed a pharmacy recommendation for metformin to be given with meals. Resident #42's Consultant Pharmacist's Medication Regimen Review, dated 06/27/2024, revealed a pharmacy recommendation for potassium supplements to be given with food and a full glass of fluid and do not crush or chew. Further review revealed a recommendation for metformin to be given with meals. Resident #42's Orders Summary Report, with active orders as of 08/04/2024, contained an order dated 08/25/2022 for metformin hydrochloride (HCL) tablet 500 milligrams (mg), with instructions to give one tablet by mouth two times a day for diabetes mellitus. Further review revealed there were no special instructions for the medication to be given with meals included in the order. Further review revealed the Orders Summary Report contained an order dated 11/25/2023, for potassium chloride extended release (ER) tablet 10 milliequivalent (meq), with instructions to give one tablet by mouth two times a day for supplement. Further review revealed there were no special instructions included in the order to be given with food and a full glass of fluid and not to crush or chew. On 08/04/2024 at 2:16 PM, the Interim Director of Nursing (IDON) stated she would send any note to the physician by fax (facsimile) and follow his response. She stated the physician needs to be notified of all medication regimen reviews. She stated if there was a change to the order the Director of Nursing (DON) was responsible for following up and overseeing the medication regimen reviews were being completed. She stated Resident #42's potassium supplement and metformin should have had special instructions per the Consultant Pharmacist recommendations, and there were no special instructions. 3. An admission Record revealed the facility admitted Resident #50 on 04/30/2024. According to the admission Record, the resident had a medical history that included a diagnosis of cerebral infarction. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2024, revealed Resident #50 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #50's Consultant Pharmacist's Medication Regimen Review, dated 05/30/2024, revealed a pharmacy recommendation for the resident's spironolactone and carvedilol orders to include hold parameters for systolic blood pressure (SBP) and heart rate (HR), and the resident's Colace order to include a hold for loose stools. Further review revealed a pharmacy recommendation for the resident's Flomax order to include that the capsules should be swallowed whole; do no crush, chew, or open, and to give 30 minutes after mealtime. Resident #50's Medication Administration Record [MAR], for the timeframe from 08/01/2024 through 08/04/2024, revealed a transcription of an order dated 05/13/2024 for Colace 100 milligrams (mg) with instructions to give two capsules by mouth in the morning for constipation. The transcription of the Colace order did not include instructions to hold for loose stools. The MAR revealed a transcription of an order dated 05/15/2024 for Flomax 0.4 mg with instructions to give one capsule by mouth at bedtime for difficulty voiding. The transcription of the Flomax order did not include instructions to swallowed whole; do no crush, chew, or open, and to give 30 minutes after mealtime. The MAR revealed a transcription of an order dated 05/03/2024 for spironolactone 25 mg with instructions to give one tablet by mouth one time a day for hypertension. The transcription of the spironolactone order did not include hold parameters for SBP and HR. The MAR revealed a transcription of an order dated 06/04/2024 for carvedilol 3.125 mg with instructions to give one tablet by mouth two times a day for hypertension. The transcription of the carvedilol order did not include hold parameters for SBP and heart rate HR. On 08/04/2024 at 2:16 PM, the Interim Director of Nursing (IDON) stated she would send any note to the physician by fax (facsimile) and follow his response. She stated if there was a change to the order the Director of Nursing (DON) was responsible for following up and overseeing the medication regimen reviews were being completed. She stated Resident #50's spironolactone, carvedilol, Flomax, and Colace should have had special instructions per the Consultant Pharmacist recommendations, and there were no special instructions. On 08/04/2024 at 2:50 PM, the Administrator stated the staff should follow up on pharmacy recommendations when they were sent. He stated it was the responsibility of the DON with the support of the interdisciplinary team (IDT) team. On 08/05/2024 at 4:52 PM, the Consultant Pharmacist stated medication regimen reviews should be followed up within 72 hours, but it should be done by at least the time they reviewed it again. She stated the recommendations should be updated in the order. She stated the medication regimen reviews were completed on medications monthly. The Consultant Pharmacist stated the facility was trying to be consistent with all blood pressure medications and ensure they had hold parameters. On 08/06/2024 at 11:03 AM, the Physician stated he was notified during rounds or by fax of the medication regimen reviews. He stated that after the facility received the signed agreed upon recommendation, the change should be made the same day or the next day. He stated if there was a new order given it should be addressed within 24 hours.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview, record review, and facility policy review, the facility failed to have a medication error rate less than 5 percent (%). The facility had 4 errors out of 28 total opportunities, resulting in a medication error rate of 14.28%, affecting 2 (Resident #61 and Resident #43) of 5 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, no staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication; b. preventing potential medication or food interactions; and c. honoring resident choices and preferences, consistent with his or her care plan. The policy further specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications: and b. Vital signs, if necessary. An admission Record indicated the facility admitted Resident #61 on 07/06/2024. According to the admission Record, the resident had a medical history that included diagnoses of congestive heart failure, hypertensive heart disease, and unspecified atrial fibrillation. Resident #61's Order Summary Report, listing active orders as of 08/05/2024, contained the following orders: -an order, dated 07/06/2024, for amlodipine 2.5 milligrams (mg) one time a day for hypertension. The order included instructions to Hold if SBP [systolic blood pressure] less than 100 or HR [heart rate] below 60; -an order, dated 07/06/2024, for metoprolol tartrate 12.5 mg two times a day for atrial fibrillation. The order included instructions to Hold if SBP less than 100 or HR less than 60; -an order, dated 07/06/2024, for Valsartan 80 mg one time a day for hypertension. The order did not include any specific instructions or hold parameters; and -an order, dated 07/06/2024, for ascorbic acid (vitamin C) 250 mg one time a day. On 07/31/2024 at 8:34 AM, Licensed Vocational Nurse (LVN) #6 entered Resident #61's room and obtained the resident's blood pressure, which measured 90/63 millimeters of mercury (mmHg), and HR, which measured 100 beats per minute (bpm). LVN #6 was observed to prepare and administer ascorbic acid 500 mg, instead of 250 mg as ordered by the physician. LVN #6 held all of Resident #61's blood pressure medications due to the resident's SBP, including their Valsartan 80 mg, despite the Valsartan order not specifying any hold parameters. An admission Record indicated the facility admitted Resident #43 on 03/23/2024. Resident #43's Order Summary Report, listing active orders as of 08/05/2024, contained orders, dated 03/23/2024 for ferrous sulfate (iron supplement) 325 mg two times a day for supplement and calcium carbonate 600 mg with vitamin D 200 units and minerals one time a day for supplement. The calcium carbonate with vitamin D and minerals order specified not to give the medication within one to two hours of the ferrous sulfate. Resident #43's 07/2024 Medication Administration Record (MAR) revealed the ferrous sulfate was scheduled to be given at 8:00 AM each day, and the calcium carbonate with vitamin D and minerals was scheduled to be given at 9:00 AM each day. On 07/31/2024 at 9:09 AM, LVN #2 prepared and administered medications to Resident #43. LVN #2 administered calcium carbonate 600 mg with vitamin D 800 units, instead of calcium carbonate 600 mg with vitamin D 200 units, as ordered by the physician. LVN #2 also administered the resident's ferrous sulfate 325 mg at the same time. During an interview on 07/31/2024 at 11:26 AM, LVN #2 confirmed she gave Resident #43's ferrous sulfate and calcium carbonate with vitamin D at the same time. LVN #2 also confirmed she gave calcium with 800 units of vitamin D, instead of 200 units. During an interview on 08/05/2024 at 4:52 PM, the Consultant Pharmacist stated calcium and iron should be given at different times because if given at the same time, the calcium inhibited the absorption of the iron, and it would not be effective. She stated the iron should be given with food or a snack and should be separated from the calcium by at least two hours for the maximum efficiency. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated that when nurses were administering medications, they should open their computer, look at each physician order that was due, take the medication pack and validate the card with the order on the computer, and validate the label with the physician order. She stated they should be following any special instructions included with the orders. She stated the nurses should do a triple check to ensure they have the right resident, right medication, right dose, right route, and right time. During an interview on 08/06/2024 at 11:37 AM, the Administrator stated nurses should follow the orders, and they should contact the physician to clarify orders when needed.

CONCERN (F)

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected most or all residents

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Based on interview, record review, and facility policy review, the facility failed to provide a response and resolution for resident grievances in a timely manner. This deficiency had the potential to affect all residents that resided in the facility. Findings included: An undated facility policy titled, Theft/Loss/Complaint/Grievance Policy, indicated, Policy Statement: [Facility name] will promptly resolve all grievances and will provide a copy of this policy to the resident upon request. The policy indicated, A resident or representative will be notified of: A reasonable expected time frame for completing the review of the grievance and The right to obtain a written decision regarding his or her grievance. The policy indicated, A Grievance Official will: Notify resident or representative's RP [responsible party] of results of investigation and corrective action within 7 days of the completion of the investigation. The policy indicated, Written grievance decisions will include: Date the grievance was received; A summary statement of the resident's grievance; A summary of the pertinent findings or conclusions regarding the resident's concern(s); A statement as to whether the grievance was confirmed or not confirmed; Any corrective action taken by the care center as result of the grievance; The date the written decision was issued. The facility's Grievance/Complaint Investigation Reports, for the timeframe from 01/01/2024 through 07/28/2024 revealed nine of 11 reports provided had no documented investigation initiated or follow-up information provided on the form. The Resident Council Minutes for the timeframe from 01/04/2024 through 07/05/2024, revealed the following patterns of repeat grievances: call light response time was noted all seven months without a documented resolution; meal set up assistance was noted five months (01/04/2024, 02/01/2024, 03/07/2024, 04/04/2024, and 07/05/2024) without a documented resolution; noisy staff in the hallways was noted two months (04/04/2024 and 05/02/2024) without a documented resolution; and call lights needing clipped within reach was noted two months (05/02/2024 and 07/05/2024) without a documented resolution. An admission Record revealed the facility admitted Resident #5 on 12/20/2018. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis, epilepsy, atrial flutter, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. During an interview on 08/01/2024 at 1:10 PM, Resident #5, who had attended the Resident Council Meetings, stated they had voiced complaints to staff; however, the staff did not come back and tell them what happened regarding any resolutions. Resident #5 stated they had expressed complaints regarding staff shutting off the call light and not returning for a long period of time. Resident #5 stated they had also expressed concerns with the staff being very loud at night, laughing and yelling down the hallway. During an interview on 08/04/2024 at 12:57 PM, the Social Services Director (SSD), who was also the Grievance Officer, stated that when she received a complaint from a resident or family member, the team would try to solve it in a timely manner. The SSD stated if the concern was taken care of immediately a form was not filled out. The SSD stated the Activities Director (AD) had a different form for grievances. The SSD stated, if the AD received the grievance, then the AD would see the process through to the end and the AD would make Social Services aware of the issue. She stated the form would be brought to the morning meeting and given to the appropriate department head to address. During an interview on 08/05/2024 at 12:40 PM, the AD stated she wrote down grievances in the Resident Council Meeting every month, and she would then pass them out to the appropriate department heads at the next morning meeting. The AD stated she would sometimes receive the forms back, or the department head would address the situation verbally with her and she would make follow-up notes on the form. The AD stated she had never gone back to the resident to give an answer for the concern. The AD stated she was not aware she was responsible for the concerns she received during the meetings. The AD agreed the same concerns were written down month after month and the residents did not receive a resolution to their concerns. The AD stated she knew it looked bad on paper, and it was very frustrating to her and the residents that items were mentioned month after month and not fixed. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated the expectation was for the staff member who took the grievance to fill out the grievance form and give it to Social Services. The IDON stated Social Services responsibility was to interview and understand what the grievance was addressing and to find a resolution in a timely manner. The IDON stated a copy of the grievance was to go to the appropriate department head to ensure resolution. The IDON further stated the facility staff should be following up with residents and, if they were not, then that was an issue. During an interview on 08/06/2024 at 11:30 AM, the Administrator stated the expectation was to assign the SSD as the one responsible for the grievance and to ensure every grievance was followed through. The Administrator stated he expected grievances to be followed through timely and given to him after resolution for his signature.

CONCERN (F)

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

Grievances (Tag F0585)

Could have caused harm · This affected most or all residents

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Based on interview, record review, and facility policy review, the facility failed to provide a means for residents to file an anonymous grievance. This deficiency had the potential to affect all residents that resided in the facility. Findings included: An undated facility policy titled, Theft/Loss/Complaint/Grievance Policy indicated, A resident or representative will be notified of: The right to file grievances orally (meaning spoken) or in writing; The right to file grievances anonymously; The contact information of the grievance official with whom a grievance can be filed. The policy also indicated, Anonymous grievances will have written decisions completed as related to a resident and if needed. 1. An admission Record revealed the facility admitted Resident #5 on 12/20/2018. According to the admission Record, the resident had a medical history that included diagnoses of multiple sclerosis, epilepsy, atrial flutter, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2024, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. During an interview on 08/01/2024 at 1:10 PM, Resident #5 stated they did not know how to file a complaint other than to tell a staff member and were not aware of how to file an anonymous complaint. 2. An admission Record revealed the facility admitted Resident #40 on 05/16/2022. According to the admission Record, the resident had a medical history that included diagnoses of unspecified dementia, type 2 diabetes mellitus, and hypertension. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/28/2024, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. During an interview on 08/01/2024 at 1:17 PM, Resident #40 stated they did not know how to file an anonymous complaint or that there was a form to complete to submit one. 3. An admission Record revealed the facility admitted Resident #59 on 04/24/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's with late onset, hypothyroidism, anxiety, and hypertension. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2024, revealed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. During an interview on 08/01/2024 at 2:11 PM, Resident #59 stated they did not know how to file a grievance outside the resident council meetings. During an interview on 08/04/2024 at 12:57 PM, the Social Services Director (SSD), who was the Grievance Officer, stated there were hard copy grievance forms located at the nurses' station for anonymous grievances. She stated that if a staff member had to hand the form to a resident, it was not anonymous, so she guessed facility staff needed to put the forms somewhere else in the building where residents could get the forms themselves. She further stated most of the residents came to her directly or requested she go to their room, so residents may not know how to file an anonymous grievance. She stated that the residents were directed to come to her. During an interview on 08/05/2024 at 12:40 PM, the Activities Director stated there were forms at the nurses' station the residents could ask for if she was not available; however, that was not an anonymous system because someone would have to get the form for the resident. She further stated, No, we do not have a way for residents to make an anonymous complaint at this time. During an interview on 08/06/2024 at 10:16 AM, the Interim Director of Nursing (IDON) stated the facility had a grievance process, however, they did not currently have a place for a resident to file an anonymous grievance as they had to ask staff for a grievance form to fill out. During an interview on 08/06/2024 at 11:30 AM, the Administrator stated he expected residents to be able to file an anonymous grievance, and if they could not, that was an issue.

May 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident rights were implemented according to the facility's policy and procedure (P&P) for call lights and Resident rights for three of four sampled residents (Resident 1, Resident 2, and Resident 3) when Resident 1, Resident 2, and Resident 3's call lights were ignored while CNAs were observed by staff and residents to be using personal cellphones and not providing requested assistance. This failure resulted in Resident 1, Resident 2 and Resident 3 to have feelings of being ignored, loss of dignity and respect from the facility staff and had the potential to cause skin breakdown and falls when requested assistance to use the restroom or changing of soiled briefs was not honored. Findings: During a concurrent observation and interview on 5/15/24 at 10:52 a.m. with Resident 1, Resident 1 was observed crying while recalling events that transpired in the facility. Resident 1 stated the facility staff were not answering her call lights when she needed assistance with activities of daily living (ADL) that included changing soiled bed sheets. Resident 1 stated she was sitting in bed for two to three hours with the call light on, but no staff went to assist. Resident 1 stated when she requested assistance with changing soiled linen on her bed, the staff informed her they were not able to assist her if the meal trays were out in the hallway and proceeded to exit her room without providing assistance or returning after meals. Resident 1 stated, I felt degraded and demeaned , when staff would not answer her call light and refused to provide assistance. During a review of Resident 1's admission Record (AR-a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 1 was admitted to the facility on [DATE] with diagnosis, difficulty in walking, pressure ulcer (injury to the skin resulting from prolonged pressure on the skin) of the right buttock (healed), morbid obesity, abnormalities of gait (manner of walking) and mobility. During a review of Resident 1's Minimum Data Set [MDS - a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 4/18/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 13 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During a review of Resident 1's Mobility Care Plan (CP) , dated 3/18/24, the CP indicated, . needs assistance with transfers, bed mobility and ambulation . need extensive assistance (requires hands on assistance more than half of the time or is totally dependent) of 2 staff with bed mobility, transfers and ambulation . During a review of Resident 1's Physical functioning Care Plan , dated 2/24/24, the CP indicated, . Has physical functioning deficit related to Morbid Obesity . bed mobility assistance of 1-2 . call bell within reach . During a review of Resident 1's Braden Scale for predicting pressure injury risk , dated 2/24/24, the Braden scale indicated Resident 1 had a score of 13-14 (15-18 at risk, 13-14 moderate risk, 10-12 high risk, 9 or below very high risk). Which indicated Resident 1 was moderate risk. During an interview on 5/15/24 at 11:20 a.m. with Resident 2, Resident 2 stated he felt the facility staff ignored his call light when it was turned on to request assistance with going to the restroom. Resident 2 stated the staff will answer the call light, turn it off and exit the room without returning. Resident 2 stated he was continent (ability to control bowel and bladder) and used the bathroom but had requested to use briefs due to feeling unsafe when going to the bathroom alone without assistance when he was waiting for the call light to be answered. Resident 2 stated the facility staff was observed standing in the hallways, using their cellphones, and talking instead of answering the call lights. Resident 2 stated he felt ignored and felt some of the staff did not see me as a human being . During a review of Resident 2's AR, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis, Parkinson's disease (disorder that affects movement causing shaking, stiffness or difficulty with balance), muscle weakness, abnormalities of gait and mobility, history of falling, orthostatic hypotension (sudden drop in blood pressure upon standing), syncope (fainting) and collapse, other age-related cataract (clouding of the eye), chronic kidney disease (kidneys are damaged over a long period of time), difficulty walking. During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 12 out of 15 (8-12 moderate cognitive impairment), which indicated Resident 2 was moderately cognitively impaired. During a review of Resident 2's, Braden Scale for predicting pressure injury risk , dated 4/21/24, the Braden Scale indicated Resident 2 had a score of 16 , (15-18 at risk, 13-14 moderate risk, 10-12 high risk, 9 or below very high risk). Which indicated Resident 2 was at risk for skin breakdown. During a concurrent interview and record review on 5/15/24 at 12:42 p.m. with the social services director (SSD), Resident 2's, Progress Note (PN) , dated 5/16/2024, was reviewed. The PN indicated, . interdisciplinary team (IDT- consisting of various members including nurses, therapists, administration) met and discussed regarding resident concern expressed to social services department (SSD) on 5/15/24 regarding resident was not being changed timely . The SSD stated Resident 2 complained about his call light not being answered for assistance to go to the restroom to change his soiled brief. During a review of Resident 2's, Bladder & Bowel Management (B&B) , dated May 2024, the B&B indicated Resident 2 was continent of bowel and bladder. During an interview on 5/15/24 at 11:35 a.m. with Resident 3, Resident 3 stated the facility staff would take a long time to answer the call light when requiring assistance with changing his soiled brief. Resident 3 stated he had waited 2 hours for staff to answer the call light and provide assistance. Resident 3 stated he had observed the facility staff standing outside his room using their cellphones and talking, while his call light was on for assistance with brief changes. Resident 3 stated the facility staff would not provide brief changes until after the meal trays were served and would, at times, not return. Resident 3 stated he felt mad, ignored, and asked himself, . why bother . During a review of Resident 3's AR, AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of unspecified dementia (group of symptoms affecting memory, thinking, and social abilities), chronic pain, osteoarthritis (disease in which the tissues in the joint break down over time), acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), repeated falls, major osseus defect (extensive bone loss), muscle weakness. During a review of Resident 3's MDS dated [DATE], the MDS indicated, Resident 3's BIMS score was 3 out of 15 (0 7 indicated severe cognitive impairment [memory loss, poor decision-making skills) which indicated Resident 2 was cognitively impaired. During a review of Resident 3's Toileting Care Plan , dated 5/1/24, the CP indicated, . use of brief/pads for incontinence (lack of control over urination or defecation) protection . During a review of Resident 3's Skin Care Plan , dated 5/3/14, the CP indicated, . at risk for impairment to skin integrity related to decrease mobility with high risk for friction . During a review of Resident 3's Weekly assessment (WA) , dated, the WA indicated, toilet use self-performance total dependance . toilet use support provided one person physical assist . bed mobility self-performance extensive assistance . bed mobility support provided one person physical assist . During an interview on 5/15/24 at 11:45 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated during mealtimes the residents in the facility could not be changed if they were soiled. CNA 1 stated it was the facility process that the residents were asked politely to wait until mealtimes were completed and all the meal trays were taken back to the kitchen. CNA 1 stated the residents who required assistance were changed if needed only if the meal trays were not present in the residents' room. CNA 1 stated all call lights should have been answered right away and residents should have been assisted as needed. During an interview on 5/15/24 at 11:50 a.m. with CNA 2, CNA 2 stated if the resident requested assistance with brief changes during mealtimes it should have been completed by the facility staff. CNA 2 stated when a resident was soiled, they should not have been left in that condition because it was uncomfortable to eat and could have caused skin damage. CNA 2 stated when a resident uses their call light, it was the expectation for all staff who are available, to answer the call light immediately and assist the resident. During an interview on 5/15/24 at 11:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the CNAs had a problem with cell phone usage during resident care times. LVN 1 stated the CNAs were observed ignoring resident call lights and walking past them in the hallways on several occasions. LVN 1 stated the CNAs had been observed using cellphones in resident rooms during resident care. LVN 1 stated the use of cellphones was reported to the facility administration with no results of disciplinary action taken. During an interview on 5/15/24 at 12:29 p.m. with CNA 3, CNA 3 stated residents have the right to have assistance with ADLs as needed. CNA 3 stated it was not acceptable to leave a resident soiled during meals because of the risk of skin breakdown. CNA 3 stated it was not an acceptable practice to use cellphones in resident care areas. During an interview at 5/15/24 at 12:58 p.m. with the Director of nurses (DON), the DON stated it was the facility process for the staff to wait to assist residents until after the mealtimes were completed. The DON stated it was the expectation for the facility staff to ask the residents to wait if they were soiled, to be changed until after the mealtimes due to the inconvenience of the smell for other residents in the room. The DON stated all call lights should have been answered immediately by any staff member who observed the call light. The DON stated it was not acceptable to ignore a resident's call light. The DON stated all facility CNAs should not have been using their cellphones during resident care times. The DON stated the facility nurses were allowed to use their cellphones only if the physician was called. During an interview on 5/15/24 at 12:59 p.m. with CNA 4, CNA 4 stated the facility had issues with staff not answering call lights and CNAs cell phone usage. CNA 4 stated there were complaints from Resident 1 regarding other staff not assisting with brief changes during mealtimes and staff ignoring the call light when it was turned on. CNA 4 stated it was not acceptable practice for staff to walk by residents' rooms, ignore the call light and refuse to change the resident when soiled. CNA 4 stated it was not acceptable to make the resident wait to be changed because they had a right to feel comfortable. CNA 4 stated the CNAs were taking time from the residents' care when they were using the cell phones and not responding to residents' requests for assistance. During an interview on 5/15/24 at 1:14 p.m. with LVN 2, LVN 2 stated it was the facility process for all staff to answer resident call lights immediately when they required assistance. LVN 2 stated it was not an acceptable practice for staff to leave a resident soiled during mealtimes as there was a potential for skin breakdown. LVN 1 stated it was the facility expectation that no staff use cellphones during resident care, as it took time away from the resident. During an interview on 5/15/24 at 1:23 p.m. with LVN 3, LVN 3 stated it was the facility expectation that if a call light was turned on by a resident, it should have been immediately answered by facility staff. LVN 3 stated if the resident was using their call light to ask for assistance with changing a soiled brief during mealtimes, it was the expectation for the staff to assist the resident due to the potential for skin breakdown. LVN 3 stated the CNAs had a problem with cellphone usage during resident care times. LVN 3 stated the cellphone usage was a concern that had been reported to the administration, but no disciplinary action was taken. LVN 3 stated she had observed the CNAs standing, talking and using their cellphones by Resident 1's room ignoring the call light while it was turned on. LVN 3 stated staff will ignore Resident 1's call light at times for more than 30 minutes to an hour prompting LVN 3 to answer the call light while the CNAs were outside Resident 1's room. LVN 3 stated Resident 1 had the right to use the call light to requests assistance. During a concurrent interview and record review on 5/15/24 at 1:40 p.m. with the Director of Staff Development (DSD), the facility in-service titled, Call lights , dated 1/31/24-2/7/24 was reviewed. The in-service indicated the facility CNAs had been educated on the importance of answering all resident call lights. The DSD stated the facility expectation was for all staff to answer all the call lights immediately if the staff were available. The DSD stated it was not an acceptable practice for the facility staff to ignore residents' call lights and neglecting their requests for assistance. The DSD stated the CNAs should not have been using their cellphones during working hours because it took time away from the resident's care. The DSD stated there was no in-service provided for CNAs to address the cell phone usage. The DSD stated changing the residents while the meal trays were out in the hallway, could have been an infection control issue because there was food possibly going into the residents' room. The DSD stated it was the facility process to ask the resident to wait until after mealtimes, but believed it was not acceptable to ask the resident to wait when needing a soiled brief change because that was demeaning and a dignity issue. During an interview on 5/15/24 at 2:11 p.m. with the administrator (ADM), the ADM stated it was the facility expectation for the staff to assist the resident during mealtimes when the residents were requesting to be changed or assisted with soiled brief changes. The ADM stated it was not an acceptable practice to leave any resident in that environment and expected to consume their meals. The ADM stated it was not acceptable to leave a resident soiled for more than two hours because it was a dignity issue and there was a potential for skin breakdown. The ADM stated CNAs should not have been using cellphones during resident care times and should have been answering resident call lights timely to assist with all care needs. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light , dated March 2021, the P&P indicated, . The purpose of this procedure is to ensure timely responses to the resident's requests and needs . if the resident needs assistance, indicate the approximate time it will take for you to respond. If the resident's request requires another staff member, notify the individual. If the resident's request is something you can fulfill, complete the task within five minutes if possible. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. If assistance is needed when you enter the room, summon help by using the call signal. Document any significant requests or complaints made by the resident and how the request or complaint was addressed . During a review of the facility's P&P titled, Activities of Daily Living (ADL) , dated March 2018, the P&P indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting) . interventions to improve or minimize a resident's functional abilities will be in accordance with the residents assessed needs, preferences, stated goals and recognized standards of practice . During a review of the facility's P&P titled, Resident Rights for all Nursing Procedures , dated October 2010, the P&P indicated, . To provide general guidelines for resident rights while caring for the resident . resident rights, including . resident dignity and respect . resident freedom of choice .

May 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 a sexual abuse allegation in accordance with the facility's policy and procedure and state regulations, for one of three sampled residents (Resident 1), when Resident 1 reported alleged sexual abuse to Licensed Vocational Nurse (LVN) 1 and the allegation was not reported immediately to the State Licensing Agency and Adult Protective Services as required by law. This failure resulted in a delayed investigation of the alleged sexual abuse and placed Resident 1 at risk for physical, emotional, and psychological harm. Findings: During a review of Resident 1's admission Record (a document containing resident ' s information), indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Diagnosis Report (a document listing resident's diagnoses) dated 04/17/24, indicated Resident 1 was admitted to the skilled nursing facility with diagnoses which included, Dementia (progressive or persistent loss of intellectual functioning), Parkinson ' s Disease [disorder of the central nervous system (made up of the brain and spinal cord)]. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive ( mental process involved in knowing, learning, and understanding things) and physical functional level) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 11 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderate impairment, and 00-07 indicates severe impairment) indicating Resident 1 had moderate cognitive deficits. During an interview on 04/24/24 at 9:00 am., with the Director of Nursing (DON), the DON stated, Resident 1 stated, two male staff were trying to rape (unlawful sexual activity carried out by force) her during the night on 04/19/24. The DON stated, she was not made aware of the alleged sexual abuse until 04/22/24. The DON stated, LVN 1 and LVN 2 did not report the allegation to the Administrator (ADM) or DON when Resident 1 informed LVN 1 on 04/20/24. During a telephone interview on 04/24/24 at 9:55 am., with LVN 1, LVN 1 stated, she walked into Resident 1 ' s room and was told by Resident 1 that two males had been in her room trying to rape her. LVN 1 stated, she informed LVN 2, who was the charge nurse. LVN 1 stated, I did not report the abuse. LVN 1 stated, she reported to LVN 2 and thought she would notify appropriate authorities. During a telephone interview on 04/24/24 at 10:30 am., with LVN 2, LVN 2 stated, she overheard staff talking about Resident 1 making accusations of rape and sexual assault. LVN 2 stated, LVN 1 came to her on 04/20/24 and reported the alleged accusation by Resident1. LVN 2 stated, she did not call the ADM or DON or complete required documents. LVN 2 stated, she did not call the police. LVN 2 stated she should have called the ADM and DON. LVN 2 stated, We are mandated reporters (required by law to report reasonable suspicions of abuse.) and are to report all abuse allegations to the proper authorities immediately. During a concurrent interview and record review on 04/24/24 at 11:20 am., with Registered Nurse (RN), the RN reviewed Resident 1's Nursing Note dated 04/20/24, the Nursing Note indicated, LVN 2 failed to document immediate reporting of the abuse. The RN stated, staff who were aware of abuse allegations were responsible to notify the Ombudsman, law enforcement and complete a form SOC-341 (a Report of Suspected Dependent Adult/Elder Abuse) and fax to the Ombudsman's office. The RN stated the allegation was serious and should have been reported immediately. During an interview on 04/24/24 at 12:25 pm., with the DON, the DON stated, LVN 1 was made aware by Resident 1 that she may have been raped by two male staff on 04/20/24 and reported the allegation to LVN 2. The DON stated she was not aware of the allegation until 4/22/24. The DON stated, LVN 2 failed to follow the facility Policy & Procedure (P & P) which indicates all abuse allegations are to be reported immediately. The DON stated, the alleged abuse or suspected abuse should be reported to local district office of the California Department of Public Health (CDPH) within 24 hours. DON stated, Resident 1 could be in danger as well as other residents if action was not taken immediately. DON stated, residents ' health and wellness could be in jeopardy when facility staff did not follow state law, and facility ' s policies and procedures (P&P) on reporting. During an interview on 04/24/24 at 1:00 pm., with ADM, the ADM stated, staff did not report the alleged abuse according to state law and facility P&P. ADM stated, the potential for harm was increased due to lack of knowledge and immediate action by staff. ADM stated, we did not follow our P & P. ADM stated, we failed to ensure the safety of our residents in the facility. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation dated September 2022, the P&P indicated, .Policy Statement . All reports of resident abuse (including injuries of unknown origin) .are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting Allegations to the Administrator and Authorities .1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to law. 2. The administrator or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies .state licensing/certification agency .local and state ombudsman .The residents representative .Law enforcement .The residents attending physician .The facility medical director .3. Immediately is defined as; .within two hours of an allegation involving abuse .or within 24 hours of an allegation .Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone . During a review of the facility's P&P titled, Reporting Suspicion of a Crime dated September 2022, the P & P indicated, .Policy Statement . The administrator, director of Nursing services, or any other designated individual will report (within the required time frame) any reasonable suspicion of a crime against a resident to state agency and local law enforcement agency . Based on interview and record review, the facility failed to report a sexual abuse allegation in accordance with the facility's policy and procedure and state regulations, for one of three sampled residents (Resident 1), when Resident 1 reported alleged sexual abuse to Licensed Vocational Nurse (LVN) 1 and the allegation was not reported immediately to the State Licensing Agency and Adult Protective Services as required by law. This failure resulted in a delayed investigation of the alleged sexual abuse and placed Resident 1 at risk for physical, emotional, and psychological harm. Findings: During a review of Resident 1's admission Record (a document containing resident's information), indicated, Resident 1 was admitted to the facility on [DATE]. During a review of Resident 1's Diagnosis Report (a document listing resident's diagnoses) dated 04/17/24, indicated Resident 1 was admitted to the skilled nursing facility with diagnoses which included, Dementia (progressive or persistent loss of intellectual functioning), Parkinson's Disease [disorder of the central nervous system (made up of the brain and spinal cord)]. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive ( mental process involved in knowing, learning, and understanding things) and physical functional level) assessment dated [DATE], indicated Resident 1's Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 11 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderate impairment, and 00-07 indicates severe impairment) indicating Resident 1 had moderate cognitive deficits. During an interview on 04/24/24 at 9:00 am., with the Director of Nursing (DON), the DON stated, Resident 1 stated, two male staff were trying to rape (unlawful sexual activity carried out by force) her during the night on 04/19/24. The DON stated, she was not made aware of the alleged sexual abuse until 04/22/24. The DON stated, LVN 1 and LVN 2 did not report the allegation to the Administrator (ADM) or DON when Resident 1 informed LVN 1 on 04/20/24. During a telephone interview on 04/24/24 at 9:55 am., with LVN 1, LVN 1 stated, she walked into Resident 1's room and was told by Resident 1 that two males had been in her room trying to rape her. LVN 1 stated, she informed LVN 2, who was the charge nurse. LVN 1 stated, I did not report the abuse. LVN 1 stated, she reported to LVN 2 and thought she would notify appropriate authorities. During a telephone interview on 04/24/24 at 10:30 am., with LVN 2, LVN 2 stated, she overheard staff talking about Resident 1 making accusations of rape and sexual assault. LVN 2 stated, LVN 1 came to her on 04/20/24 and reported the alleged accusation by Resident1. LVN 2 stated, she did not call the ADM or DON or complete required documents. LVN 2 stated, she did not call the police. LVN 2 stated she should have called the ADM and DON. LVN 2 stated, We are mandated reporters (required by law to report reasonable suspicions of abuse.) and are to report all abuse allegations to the proper authorities immediately. During a concurrent interview and record review on 04/24/24 at 11:20 am., with Registered Nurse (RN), the RN reviewed Resident 1's Nursing Note dated 04/20/24, the Nursing Note indicated, LVN 2 failed to document immediate reporting of the abuse. The RN stated, staff who were aware of abuse allegations were responsible to notify the Ombudsman, law enforcement and complete a form SOC-341 (a Report of Suspected Dependent Adult/Elder Abuse) and fax to the Ombudsman's office. The RN stated the allegation was serious and should have been reported immediately. During an interview on 04/24/24 at 12:25 pm., with the DON, the DON stated, LVN 1 was made aware by Resident 1 that she may have been raped by two male staff on 04/20/24 and reported the allegation to LVN 2. The DON stated she was not aware of the allegation until 4/22/24. The DON stated, LVN 2 failed to follow the facility Policy & Procedure (P & P) which indicates all abuse allegations are to be reported immediately. The DON stated, the alleged abuse or suspected abuse should be reported to local district office of the California Department of Public Health (CDPH) within 24 hours. DON stated, Resident 1 could be in danger as well as other residents if action was not taken immediately. DON stated, residents' health and wellness could be in jeopardy when facility staff did not follow state law, and facility's policies and procedures (P&P) on reporting. During an interview on 04/24/24 at 1:00 pm., with ADM, the ADM stated, staff did not report the alleged abuse according to state law and facility P&P. ADM stated, the potential for harm was increased due to lack of knowledge and immediate action by staff. ADM stated, we did not follow our P & P. ADM stated, we failed to ensure the safety of our residents in the facility. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation dated September 2022, the P&P indicated, .Policy Statement . All reports of resident abuse (including injuries of unknown origin) .are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management .Reporting Allegations to the Administrator and Authorities .1. If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to law. 2. The administrator or the individual making the allegation immediately reports his or her suspicions to the following persons or agencies .state licensing/certification agency .local and state ombudsman .The residents representative .Law enforcement .The residents attending physician .The facility medical director .3. Immediately is defined as; .within two hours of an allegation involving abuse .or within 24 hours of an allegation .Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone . During a review of the facility's P&P titled, Reporting Suspicion of a Crime dated September 2022, the P & P indicated, .Policy Statement . The administrator, director of Nursing services, or any other designated individual will report (within the required time frame) any reasonable suspicion of a crime against a resident to state agency and local law enforcement agency .

Mar 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide necessary care and services to ensure that residents ' abilities in activities of daily living did not diminish for two of three sampled residents (Resident 1 and Resident 2) when Resident 1 and Resident 2 did not receive showers as scheduled. These failures resulted in Resident 1 and Resident 2 not having their needs met and feeling like staff did not care. Findings: During a review of Resident 2 ' s admission Record (AR), dated 9/30/22, the AR indicated, Resident 2 was admitted on [DATE], with diagnosis of Cerebral Infarction (stroke resulting from a blockage in the blood vessels supplying blood to the brain), Muscle weakness, Hemiplegia (complete paralysis (loss of the ability to move and sometimes to feel anything in part or most of the body)) and hemiparesis (weakness of one entire side of the body) affecting left side. During a review of Resident 2 ' s Brief Interview for Mental Status (BIMS- a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility), dated 8/26/22, the BIMS indicated Resident 2 had BIMS of 15 out of 15 total possible points, meaning his cognition was intact (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). During an interview on 9/30/22, at 10:15 a.m., with Resident 2, Resident 2 stated he did not get enough showers, maybe twice a week. Resident 2 stated the facility always has issues with staffing. During a review of Resident 2 ' s Shower Sheets (documentation that a shower was or was not performed on a specific date) for the Months of August 2022 and September 2022, the sheets indicated, Resident 2 had showers on the following days: 8/1/22, 8/3/22, 8/5/22, 8/8/22, 8/17/22, 8/19/22, 8/23/22, 8/26/22, 8/30/22, 9/10/22, 9/16/22. During a review of the Facility ' s Shower Schedule based on room numbers, Resident 2 shower days were scheduled for Tuesday and Friday morning shift. During an interview on 9/30/22, at 10:40 a.m., with Resident 1, Resident 1 stated she gets showers maybe once a week and has gone 1-2 months without a shower. During a review of Resident 1 ' s AR, dated 9/30/22, the AR indicated Resident 1 was originally admitted on [DATE] and last readmission was on 9/29/22. Resident 1 ' s AR indicated she was admitted with a diagnosis of Hereditary ataxia (degenerative changes in the brain and spinal cord that lead to an awkward, uncoordinated walk accompanied often by poor eye-hand coordination and abnormal speech), Muscle weakness, spinal stenosis (narrowing of the space in the backbone causing pain, numbness, muscle weakness, and impaired bladder or bowel control), left foot drop (having difficulty lifting the front part of the foot). During a review of Resident 1 ' s BIMS, dated 9/25/22, the BIMS indicated, Resident 1 BIMS was an 11 meaning she had some moderate cognitive impairment. During a review of Resident 1 ' s Shower Sheets for the Month of August 2022 and September 2022, the shower sheets indicated Resident 1 had showers on the following days: 8/2/22, 8/16/22, 8/19/22, 9/10/22. During a review of the Facility ' s Shower Schedule based on room numbers, Resident 1 shower days were scheduled for Tuesday and Friday morning shift. During an interview on 6/22/23, at 1:58 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was responsible to take residents vital signs, feeding, bathing them and all other activities of daily living (ADL ' s). CNA 1 stated she remembered working on 9/26/22, she was the only CNA on, and the census was around 60. CNA 1 stated there should be four or more CNAs on night shift and if there were less CNAs scheduled it was a struggle for us. CNA 1 stated it was very hard to get showers done, answer call lights, get residents to bed and feed other residents when they were short staffed. CNA 1 stated she did not feel she was able to get her job done when there was just her on, she had to pull up residents by herself. CNA 1 stated we had shower sheets we fill in for each resident we offer a shower to, if the resident refused, we asked them couple of times and then let the nurse know and had the nurse sign the shower sheet and put it in the shower binder. CNA 1 stated bath/showers were very important for resident ' s, It is their right. During an interview on 6/22/23, at 2:25 p.m., with Registered Nurse (RN) 1, RN 1 stated she worked night shift usually 6 p.m. to 6 a.m. RN 1 stated the average census for the facility was 66. RN 1 stated there were usually two nurses on the night shift and she did not have time to help CNAs with bath/showers for residents. RN 1 stated the CNA was responsible for bath/showers, they were supposed to ask the resident on three separate occasions if they want a bath/shower and if the resident declined, then they fill in the shower sheet bring it to the nurse and the nurse would go and explain the importance of preventing skin issues to the resident and some will accept, and others still decline to have showers. RN 1 stated residents were offered baths/showers twice a week and the shower sheet should be filled in every time. During an interview on 6/22/23, at 3:02 p.m. with RN 2, RN 2 stated she works night shift at this facility from 6 p.m. to 6 a.m. and there were usually two nurses for the night shift. RN 2 stated the average census for this facility is 60. RN 2 stated she did not help CNA ' s give resident bath/showers. RN 2 stated the CNA will offer the resident a shower and would bring me the shower form if they refused, I would sign it and would give it to the Director of Nursing (DON), I also would go and speak with the resident to see if there was a specific reason and I educate them at the same time about the importance of skin care. RN 2 stated general grooming and hygiene were the resident right and help with their wellbeing and dignity. RN 2 stated Resident 1 complained about not getting her showers for the week and when this happens she would go and look at the shower binder and if no showers would ask the CNA to give her one right then. RN 2 stated CNAs were supposed to fill in the bath/shower sheets every time. During an interview on 6/22/23 at 3:15 p.m., with the Assistant Director of Nursing (ADON), the ADON stated she was responsible for the scheduling of the RN ' s and licensed vocational nurses (LVNs). The ADON stated the Director of Staff Development (DSD) was responsible for scheduling of the CNAs and the DSD was responsible for the disciplinary actions for the CNAs if the showers were not done for the residents. During an interview on 6/22/23, at 3:34 p.m., with the DSD, the DSD stated she became the DSD on 6/1/23 and was working on the staffing issues for the CNAs. The DSD stated currently the CNAs doing 12-hour shifts. The DSD stated the average census for the facility was 66. The DSD stated on average she would have 5-7 CNAs on AM (morning) shift and 5-6 on PM (afternoon) shift and for night shift 4-5 CNAs.The DSD stated she had heard about the night when there was only one CNA on because she was asking what issues she might have to deal with when she took the job. The DSD stated if she had been in that position at that time, she would have gotten a hold of registry staff and called them in. The DSD stated when there was only one CNA on, the residents would not receive the care that they were supposed to, and it could be dangerous. During a review of the facility ' s policy and procedure(P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 2021, the P&P indicated, .Policy Statement Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Policy Interpretation and Implementation . 2. Appropriate care and services will be provided for residents . a. Hygiene (bathing, dressing, grooming, and oral care) . 6. Interventions to improve or minimize a resident ' s functional abilities will be in accordance with the resident ' s assessed needs, preferences, stated goals and recognized standards of practice . During review of a professional reference titled, California Advocates for Nursing Home Reform (CANHR), Retrieved from http://www.canhr.org/factsheets/nh_fs/html/fs_CareStandards.htm, dated 1/1/2016, the reference indicated, .Nursing Home Care Standards Overview In exchange for Medicare and Medi-Cal payments, certified nursing homes agree to give each resident the best possible care. Specifically, they are required to help each resident attain or maintain the highest practicable physical, mental and psychosocial well-being. Unless it is medically unavoidable, nursing homes must ensure that a resident ' s condition does not decline . Accommodation of Needs a resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences . Adequate Staff Nursing homes must have sufficient nursing and other employees to meet the needs of each resident in the nursing home at all 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

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for one of four sampled staff members (Licensed Vocational Nurse (LVN) 1) when the facility did not follow its policy and procedure (P&P) UNIFORM AND DRESS CODE ACKNOWLEDGEMENT and LVN 1 was observed to have long black acrylic (fake) nails on. This failure had the potential to spread germs/infection between residents/staff and placed residents at risk of injury from the nails. Findings: During a concurrent observation and Interview on 9/30/22, at 11 a.m., with LVN 1, LVN 1 was seen with approximately 1-inch-long black nails. LVN 1 stated her nails were acrylic, were at least an inch long and that she knew she should not have them on. LVN 1 stated the nails are an infection issue and no one at the facility has told her anything about removing them. During an interview on 9/30/22, at 11:20 a.m., with the Director of Nursing (DON) 1, DON 1 stated she thought acrylic nails were an issue for hospitals and not nursing homes, but she would look into it. DON 1 stated the nails could be an infection control issue. During a review of the facility ' s P&P titled, UNIFORM AND DRESS CODE ACKNOWLEDGEMENT, dated 11/2019, the P&P indicated, .I, the undersigned, employee of [name of facility], hereby acknowledge that I have been informed and understand the Uniform and Dress Code policies, which included but not limited to: . Nursing Department: No artificial nails. Keep nails short and groomed . During a review of an article by the CDC Centers for Disease Control and Prevention titled, Nail Hygiene, Retrieved from: https://www.cdc.gov/hygiene/personal-hygiene/nails.html, dated 6/15/22, the article indicated, . Fingernails should be kept short, and the undersides should be cleaned frequently with soap and water. Because of their length, longer fingernails can harbor more dirt and bacteria than short nails, thus potentially contributing to the spread of infection .

Dec 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 person-centered care plan for one of six sampled residents (Resident 4) when Resident 4 was assessed with a pressure injury (PI -localized damage to the skin as well as underlying soft tissue) on 11/14/22 and a care plan was not developed and implemented to address the PI. Resident 4 was admitted to the Acute Care Hospital (ACH) on 11/24/23 and returned to the facility on [DATE] with an unstageable PI (when the PI depth cannot be determine because the base of the wound is covered by a layer of dead tissue that may be yellow, grey, green, brown, or black) and a care plan identifying effective interventions was not developed and implemented. This failure resulted in not addressing the skin integrity of Resident 4, led to avoidable worsening of the PI and Resident 4 experienced decreased mobility, pain, and suffering. Findings: During a record review Resident 4 ' s admission Record (AR- a document also named Face sheet that includes identifying information and diagnoses), undated, the AR indicated, Resident 4 was first admitted to the facility on [DATE], transferred to acute care hospital (ACH) on 11/24/22 and was readmitted to the facility on [DATE]. Resident 4 ' s diagnoses included; kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance), morbid obesity (a complex chronic disease in which a person has excess body fat that increases the risk of health problems), diabetes mellitus with ketoacidosis (a condition that develops when blood sugar-glucose is too high and the body cannot produce enough insulin to lower the glucose), hypertension (abnormally high blood pressure), anemia (a condition marked by a deficiency of red blood cells that lead to reduced oxygen flow), and malaise(a general feeling of discomfort, or illness). During a review of Resident 4 ' s Minimum Data Set (MDS) assessment (a comprehensive assessment tool used to identify physical and psychosocial abilities of the resident), dated 11/14/22, the MDS indicated, under Brief Interview for Mental Status (BIMS) a score of 8 (a score of 8-12 out of 15 means moderate cognitive impairment in memory or judgement). During a phone interview on 4/25/23 at 2:57 p.m. with the ADON, the ADON stated there was no care plan for the PI assessed on 11/14/22. The ADON stated, I don ' t have an excuse for it not being done on 11/14/22. It would 100% affect [Resident 4 ' s] care. It is needed so that we have a goal. Without a care plan there is no goal to reach. The ADON stated a care plan was initiated for the pressure injury on 12/2/22 and no written care plan prior to 12/2/22 addressed the PI. During a review of Resident 4 ' s care plan, untitled, dated 12/2/22, the care plan indicated, .Focus .Pressure ulcer actual or at risk due to: [blank] .Date Initiated 12/02/2022 .Goal .Will remain free from further breakdown .Interventions .Nutritional and Hydration support .Provide thorough skin care after incontinent episodes and apply barrier cream .Treatments as ordered . During a review of Resident 4 ' s clinical record titled, admission & baseline care plan/summary, dated 11/30/22, the .admission & baseline care plan/summary, indicated, .Assessment Type .readmission .Pressure Sore Risk Score .Moderate Risk (13-14) .Condition of skin .[check mark] Pressure ulcer .Site .Coccyx .Type . Pressure .Stage .Unstageable .Does the resident currently have RISK FOR OR ACUTAL [ACTUAL] IMPAIRED SKIN INTEGRITY? .Yes . During a review of Resident 4 ' s MDS assessment titled, Section M Skin Conditions, dated 12/5/22, the document indicated, .F. Unstageable - Slough (the yellow/white material in the wound) and/or eschar (dead skin tissue that forms over healthy skin) Known but not stageable due to coverage of wound bed by slough and/or eschar .Enter Number 1[in box] .1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar .Enter Number 1 [in box] .2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry . During a review of the facility ' s Policy and Procedure (P&P) titled Pressure Ulcers/Skin Breakdown dated 1/2022, the P&P indicated, .The nursing staff and practitioner may evaluate and document an individual ' s significant risk factors for developing pressure ulcers .the nurse shall describe and document/report the following as applicable: full assessment of pressure sore including location, stage, length, width and depth .the staff and practitioner may examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions .Monitoring .The physician may guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . During a review of the facility ' s Policy and Procedure (P&P) titled, Prevention of Pressure Ulcers/Injuries undated, the P&P indicated, .Risk Assessment .4. Inspect the skin on a routine basis when performing or assisting with personal care or ADLs .a. Identify any signs of developing pressure injuries .b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows .e. Reposition resident as indicated on the care plan Mobility/Repositioning .1. Choose a frequency for repositioning based on the resident ' s mobility, the support surface in use, skin condition and tolerance, and the resident ' s stated preferences. Reposition more frequently as needed, based on the condition of the skin and the resident ' s comfort .

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

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 dignity and respect in an environment that promoted and enhanced their self-esteem for one of three sampled residents (Residents 1) when the urinary catheter (a flexible tube inserted into the bladder to drain urine) bag for Resident 1 was uncovered. This failure resulted in Resident 1 feeling embarrassed. Findings: During an observation on 10/12/23, at 9:01 a.m., in Resident 1's room, her urinary catheter bag was filled with urine and was visible to anyone who walked by the room. During an interview on 10/12/23, at 9:04 a.m., with Resident 1, Resident 1 stated she felt embarrassed knowing that her urinary catheter bag was visible to everyone. During a review of Resident 1's Minimum Data Set (MDS-is a standarized assessment tool that measures health stats in nursing home residents) assessment, dated 9/4/23, the MDS assessment indicated, Resident 1 had no cognitive impairment with a Brief Interview for Mental Status (BIMS- 0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) assessment score of 13. During a concurrent observation and interview on 10/12/23, at 9:35 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1's urinary catheter bag was filled with urine and was visible to everyone who walked by the room. LVN 1 stated the urinary catheter bag should not have been exposed and should have been in a bag for privacy and for Resident 1's dignity. During concurrent interview and record review on 10/12/23, at 12:10 p.m., with the Director of Nursing (DON), the facility policy and procedure titled Dignity dated 2/2021 indicated, . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . residents are treated with dignity and respect at all times . Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered . The DON stated it was the facility policy to keep the catheter bag covered to promote dignity.

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 resident-centered comprehensive care plan for one of three sampled residents (Resident 1) when Residents 1 did not have a care plan for urinary catheter (a tube placed in the body to drain and collect urine from the bladder). This failure placed resident 1 at risk for complications from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed. Findings: During an observation on 10/12/23 at 9:04 a.m., in Resident 1's room, Resident 1 was lying in bed with the catheter bag attached to the bed frame. During a review of Resident 1's Order Summary Report (OSR) , dated 9/18/23, the OSR indicated, .[brand name urinary catheter] .for wound management . During a concurrent interview and record review on 10/12/23 at 9:48 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's care plans were reviewed. LVN 1 stated there was no care plan developed for the urinary catheter. LVN 1 stated the care plan should have been developed when the order for the urinary catheter was placed. LVN 1 stated the purpose of the care plan was to ensure Resident 1 received care that was measurable to monitor progress. During concurrent interview and record review on 10/12/23, at 11:14 a.m., with the Director of Nursing (DON), the facility policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered dated 3/2022 was reviewed. The P&P indicated, . A comprehensive, person-centered care plan that includes measurable, objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT-team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The DON stated it was the interdisciplinary team's responsibility to develop and implement care plan. The DON stated the purpose of the care plan was to have goals and expectations for the plan of care. The DON stated the care plan for the urinary catheter should have been developed the day it was placed.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. One of three sampled residents restrooms (Resident 1's) portable raised toilet seat (equipment goes on top of a toilet bowl to increase its height) had a brown colored smear. 2. One of three sampled residents (Resident 1's) urinary catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the ground. This failure had the potential for cross contamination. Findings: 1. During a concurrent observation and interview on 10/12/23 at 9:15 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's restroom, a portable raised toilet seat was on the ground and had a brown colored smear inside the seat. CNA 1 stated there was a dirty brown smear on the raised toilet seat. CNA 1 stated the raised toilet seat should been cleaned after each use for infection control. During a concurrent interview and photo review on 10/12/23 at 12:06 a.m., with the Director of Nursing (DON), a photo of the portable raised toilet seat in Resident 1's restroom was reviewed. The DON stated the brown smear appeared to be dry feces and that it should have been clean for infection control. During a review of the facility policy and procedure titled Infection Control dated 10/2018 indicated, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .infection control policies and practices are to: a. Prevent .Maintain a safe, sanitary .for .residents . 2.During an observation on 10/12/23 at 9:04 a.m., in Resident 1's room, Resident 1 was lying in bed with the catheter bag attached to the bed frame touching the ground. During a concurrent observation and interview on 10/12/23, at 9:35 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1's catheter bag was touching the ground. LVN 1 stated, the catheter bag should not be on the ground because there was a risk for infection and cross contamination. During a review of Resident 1's Order Summary Report (OSR) , dated 9/18/23, the OSR indicated, .[brand name urinary catheter] .for wound management . During concurrent interview and record review on 10/12/23, at 12:00 p.m., with the DON, the facility policy and procedure titled Infection Control dated 10/2018 indicated, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections .infection control policies and practices are to: a. Prevent .Maintain a safe, sanitary .for .residents . The DON stated the catheter bag should not touch the ground at any time because it was an infection control issue. The DON stated it was the responsibility of all nursing staff to ensure that the urinary catheter was not touching the ground. During a review of the professional reference titled, GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 dated 6/19, from https://www.cdc.gov/infectioncontrol/guidelines/cauti/ indicate, . Proper Techniques for Urinary Care Maintenance . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . Empty the collecting bag regularly using a separate, clean collecting container for each patient .

Aug 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Services Provided Meet Professional Standard of Quality for two of 11 Residents, (Resident 9, and Resident 11) when Certified Nursing Assistants (CNA) 2 and 6 provided wound care to Residents 9 and 11 without the skills, experience, and knowledge. This failure resulted in CNA 2 and 6 providing wound care to Residents 9 and 11 which had the potential for infection, deterioration, and inaccurate assessment of wounds. Findings: During a review of Resident 9's Minimum Data Set [(MDS- a resident assessment tool used to identify cognitive (mental processes)] and physical functional level assessment dated [DATE], the MDS indicated, Resident 3's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 which indicated Resident was cognitively intact. (Score level: 0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact)]. During a review of Resident 11's MDS dated [DATE], the MDS indicated, Resident 3's BIMS score was 15 out of 15 indicating Resident 11 was cognitively intact. During an interview on 6/23/23, at 11:50 a.m., with CNA 2, CNA 2 stated, Resident 9 had multiple wounds to her buttocks. CNA 2 stated, wound care treatment consisted of Medi Honey (reference to medical honey) covered with transparent patch. CNA 2 stated, she had been providing wound care when peri-care (cleaning the private areas of a patient) was provided. CNA 2 stated, Resident 9 had wound care supplies available in Resident 9's room and CNA 2 provided wound treatment during her shift using those supplies. CNA 2 stated, she should not provide wound care to Resident 9 as it was not in her job description and it puts Resident 9 at risk for infection. During an interview on 6/23/23 at 1:50 p.m., with Resident 9 in Resident 9's room, Resident 9 stated, there were certain CNA's that were trained to provide wound care to her buttocks. Resident 9 stated that her wound treatment consisted of Medi honey, soft gauze, Vaseline and was completed by CNA 2 on 6/23/23 a.m. shift. Resident 9 stated, she was aware that CNAs should not provide wound care but was concerned that wound care would not be completed unless the CNA's do the treatment. During concurrent interview and record review on 6/23/23 at 2:14 p.m., with Licensed Vocational Nurse (LVN) 3, reviewed Resident 9's Order Summary (OS) dated 6/22/23 and Care plans (CP), the OS indicated . left gluteal, clean with normal saline, dry, apply medi honey and cover with transparent dressing . LVN 3, reviewed Resident 9's care plans for wounds and stated there were no interventions for CNAs to provide wound treatments. LVN 3 stated, there were no interventions in Resident 9's CP that indicated Resident 9's requested or was a choice for CNAs to perform wound care treatments. LVN 3, reviewed Resident 9's OS and confirmed there were no physician orders for CNAs to complete wound treatments. LVN 3, stated, Resident 9 was at risk for infection and wound deterioration when wound care treatments were provided by CNAs. During a concurrent interview and record review on 6/23/23 at 3:10 p.m., with Director of Staff Development (DSD), DSD reviewed Document titled Job Description , for CNAs. DSD stated, when CNA deviates from job duties, they were not following the job description. DSD stated, she was aware CNA 2 provided wound care for Resident 9. DSD stated, CNAs providing wound care was out of their scope of practice and was not the standard of practice. DSD stated, the practice could lead to infectious wounds, increase in wound size, and places the Resident's health and wellness in jeopardy. During an interview on 6/27/23, at 12:56 p.m., with Resident 11, in Resident 11's room, Resident 11 stated, he had wounds to his buttocks. Resident 11 stated, his treatment consisted of cream and bandage. Resident 11 stated, CNAs completed wound care treatments to her buttocks during peri-care. Resident 11 stated, CNAs had been providing wound care to his buttocks on several occasions. During an observation and interview on 6/27/23, at 1:00 p.m., with Resident 9, in Resident 9's room, Resident 9 stated, she had wounds to her buttocks. Resident 9 stated, a CNA provided wound care on 6/27/23 a.m. shift during peri-care. Resident 9 stated, the CNAs had been providing wound care for a long time. Resident 9 stated she had two bags of wound care supplies in her room. Resident 9 stated she had packets of Medi Honey and various size dressings in her bag that were used by the CNAs when providing wound care. During an interview on 6/27/23 at 1:37 p.m., with CNA 6, CNA 6 stated Resident 11 had two wounds to her buttocks. CNA 6 stated treatment for wounds to buttocks consisted of zinc oxide cream (Medicinal Ointment) with A & D ointment and applied by CNA 6 during peri care. CNA 6 stated, zinc oxide and A & D ointment are supplied by the charge nurse every time peri care was provided. During an interview on 6/27/23 at 1:44 p.m., with CNA 7. CNA 7 stated the charge nurses were aware of wound care treatments being provided by CNAs. During an interview on 6/27/23 at 2:06 p.m., with CNA 6, CNA 6 stated she was unaware zinc oxide cream was a physician ordered medication for wounds. CNA 6 stated charge nurses provided zinc oxide cream to CNAs to apply to Resident 11. During an interview on 6/27/23, at 2:25 p.m., with CNA 7, CNA 7 stated, Resident 9 was assigned to her that morning. CNA 7 stated, she provided peri-care to Resident 9 and applied Medi Honey to her wounds. CNA 7 stated, she had not had training for providing wound care and was directed by other staff on how to care for the wounds. During a concurrent interview and record review on 6/27/23 at 3:24 p.m., with Registered Nurse (RN), Resident 11's Weekly Pressure injury/Ulcer Progress Report dated, 6/21/23, was reviewed. The weekly report indicated, Resident 11 had a stage 3 pressure ulcer (Full Thickness tissue loss) to his left buttock. RN stated, the physician order, indicated: clean with normal saline, pat dry and apply zinc oxide every shift and (as needed) PRN. RN stated treatments were completed by CNAs for Resident 9 as it is Resident 9's preference. During an interview on 6/27/23 at 3:25 p.m., with Assistant Director of Nursing (ADON), ADON stated, Resident 9 had a Physician Order (PO) in place for wound care, cleanse with Normal Saline (NS), pat dry, apply Medi Honey and cover with gauze , ADON stated, only RN's and LVN's were to carry out physician orders. ADON stated, she was not aware CNAs were providing wound care. ADON stated, if CNAs were providing wound care, it would be outside of their scope of practice. ADON stated, infections, increase in size of wound, inaccurate assessments of wounds could have a negative effect on the resident's health and wellness. During an interview on 6/27/23 at 3:56 p.m., with LVN 4, LVN 4 stated facility protocol was for a licensed nurse to complete all wound care treatments. LVN 4 stated, a physician order was needed for use of zinc oxide. LVN 4 stated, she was aware of Resident 9's request for CNAs to complete wound care treatment. LVN 4 stated, residents were at risk for wound deterioration and improperly treated wounds when CNAs provided wound care treatments. During a review of the facility's Document titled, JOB DESCRIPTION , undated, indicated, Job Title for Certified Nurse's Aide, .the primary purpose is to provide assigned residents with routine daily nursing care in accordance with current regulation .Adherence to Policies Must perform duties in a timely fashion, and within the prescribed sequence and schedules . During a review of the professional reference titled, State of California, Health and Safety Code dated July 28, 2009, indicated, .Certified nurse assistant means any person who holds himself or herself out as a certified nurse assistant and who, for compensation, performs basic patient cares services directed at the safety, comfort, personal hygiene, and protection of patients, and is certified as having completed the requirements of this article. These services shall not include any services which may only be performed by a licensed person and otherwise shall be performed under the supervision of a registered nurse .or a licensed vocational nurse .

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 F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided for one of 11 sampled residents (Resident 3) when staff failed to provide scheduled showers for 23 days. This failure resulted in Resident 3 not receiving her scheduled showers and placed her at risk for skin breakdown, infections, discomfort, and did not promote cleanliness. Findings: During a concurrent observation and interview on 6/23/23, at 12:35 p.m. with Resident 3, in Resident 3's room, Resident 3 was lying in bed with messy and matted hair. Resident 3 stated, she wanted to take a shower last night because she had not showered in over a week and a half. Resident 3 stated, she felt dirty without showering for so long. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 3's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 14 out of 15 indicating Resident 3 was cognitively intact. (Score Level-0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent interview and record review on 6/23/23, at 3:10 p.m., with the Director of Staff Development (DSD), the facility job description titled Certified Nursing Assistant undated, and Shower Binder were reviewed. The job description indicated, .A nursing assistant responsible to bathe each resident according to schedule . assist residents as needed with activities of daily living. This includes bathing . The DSD stated it was the CNA's responsibility to shower residents on their assigned shower days. Review of facility Shower Binder indicated Resident 3's assigned shower days were Tuesday and Friday PM shift. The DSD stated after the completion of the shower the CNA should document in the facility's electronic documentation system and complete a shower sheet indicating resident was given a shower. The DSD reviewed shower sheets located in Shower Binder and confirmed resident 3's last documented shower was dated on 06/03/2023. DSD stated there were no documented refusals of showers by Resident 3. During a concurrent telephone interview and record review on 07/06/22, at 1:05 p.m., with CNA 3, Resident 3's shower schedule was reviewed, CNA 3 stated Resident 3's shower days were two times a week, every week. CNA 3 stated once CNAs completed a resident shower, CNAs would document completion of the shower on the shower sheet in the shower binder. CNA 3 reviewed the shower binder and stated the last three showers for resident were 6/30/23, 6/23/23 and 6/3/23. CNA 2 reviewed the binder in the nurse's station titled Shower Schedule, CNA 3 reviewed Resident 3's shower days in the Shower Binder and stated these were the only showers documented and if the resident refuses, CNAs would make a shower sheet stating the resident refusal. During a telephone interview on 7/6/23 at 1:15 pm, with the Director of Nurses (DON). DON stated the process of documenting showers included CNAs completing a shower sheet for every shower and giving it to the charge nurse for review and signature, the CNAs will also document it on their task in the facility's electronic documentation system. DON stated the nurses should be checking that these shower sheets were being done and completed. DON stated If the shower sheets were not done, there was no quality of care, there could be skin breakdown and it was a resident right, staff was in serviced and DSD was made aware. During a review of the facility policy and procedure titled Bath, Shower/Tub dated 2/2018, indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin . During a review of the facility policy and procedure titled Activities of Daily Living (ADLs), Supporting dated 3/2018, the policy indicated . Appropriate support and assistance with: Hygiene (bathing, dressing, grooming and oral hygiene) .

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

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 resident-centered comprehensive care plan for one of three sampled residents (Resident 2) when Resident 2 was allegedly pushed by Resident 1 and Resident 2 fell and sustained a skin tear on her posterior forearm and abrasion on her mid back. This failure placed Resident 2 at risk for complications from not having care needs planned by a licensed nurse to determine if nursing interventions were sufficient. Findings: During a review of Resident 2's clinical record titled, admission Record (a document with personal and medical information) dated 2/10/23, was reviewed. The admission Record indicated Resident 2 was admitted to the facility with the diagnosis of Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 2's, Order Summary dated 2/10/23, the Order Summary, indicated, . Cleanse skin tear L. (left) posterior (back) of forearm with NS (normal saline-mixture of water and sodium chloride used to clean wound) pat dry. Apply Bacitracin (antibiotic ointment), cover with DCD (dry clean dressing) daily every evening shift for 21 Days . start date: 1/23/23 . During a concurrent interview and record review on 2/10/23, at 11:33 a.m., with the Assistant Director of Nursing (ADON), Resident 2's care plans was reviewed, the ADON stated, . there was no intervention added to the existing care plan and it was not specific to the incident . The ADON stated she was not able to find a care plan for the skin tear and abrasion sustained when Resident 2 fell. The ADON stated the expectation was to make sure there was a care plan in place. During an interview on 2/10/23, at 12:33 a.m., with the Director of Nursing (DON), the DON stated, . We checked the medical record and we are not able to find a care plan for the fall, skin tear and abrasion . DON stated licensed nurses were responsible in initiating a care plan and edited during the daily meeting to check if the interventions were appropriate. The DON stated she did not think the interdisciplinary team (IDT-a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) checked if there was a care plan in place for Resident 2. During a phone interview on 3/7/23, at 10:58 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was the nurse on-duty when Resident 2 fell after she was pushed by another resident and Resident 2 sustained a skin tear and abrasion. LVN 1 stated she did not initiate a care plan after the incident, and she should have. LVN 1 stated the expectation was for the licensed nurse to initiate a care plan to direct staff on how to take care for resident. During a review of facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, dated 2018, the P&P indicated, . 1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem . 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . During a review of facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 2018, the P&P indicated, . The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Nov 2022 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse (intentional bodily injury) for one of five sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 4 was witnessed by CNA 1, CNA 2, and Environmental Services Supervisor (EVS) to use physical contact to force Resident 1 to walk to the dining room to have lunch on 6/6/22. Resident 1 verbally told CNA 4 he did not want to go to the dining room. CNA 4 pushed Resident 1 from behind in an effort to force Resident 1 to walk to the dining room. These failures resulted in the physical abuse of Resident 1, Resident 1 falling onto his face and left shoulder in an avoidable fall caused by the physical abuse and fracture of the left humerus (a break of the upper part of the bone of the arm close to the shoulder joint) with avoidable pain and suffering and loss of mobility. Findings: During a concurrent observation and interview, on 6/22/22, at 10:41 a.m., Resident 1 was lying in bed with his left arm resting to his side. Resident 1 stated, he slid in the hall and hurt his left arm and wore a sling to his left arm. During a review of Resident 1's admission Record, dated 6/22/22 , the admission Record indicated, Resident 1 was admitted on [DATE] and had diagnoses including: Dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Cognitive Communication Deficit (condition that interferes with a person's ability to mentally process their communication with others), and Vitamin D Deficiency (not enough fat-soluble vitamin that plays an important role in maintenance and repair of bone tissue). During a review of Resident 1's 'Progress Notes (PN) dated 6/6/22, at 1:36 p.m., the PN indicated, .Event type: witnessed fall .Resident shoe stuck to the floor and res (Resident 1) went forward on to his knees and then to his left shoulder, in the double doors by the activity room, C/O (complain of) left shoulder pain .MD notification .rec (received) n/o (New orders) for left shoulder x-Ray (A specialized imaging study that can diagnose and view bones and other internal body structure) .would not move left arm or allow palpitation . During a review of the Resident 1's Radiology Results Report, dated 6/7/22, the Radiology Results Report indicated .SHOULDER COMPLETE, MIN (minimum)2V [Views] LEFT .Findings: There is an acute appearing mildly displaced fracture [the pieces of the bone moved so much that a gap formed around the fracture (broken bone)] of the proximal humerus neck (the portion near the arm's attachment to the body.) with associated involvement of the greater tuberosity (bony bump in the shoulder area) .CONCLUSION: Proximal humerus fractures described . During a review of Resident 1's 'PN dated 6/6/22, at 12:15 p.m., indicated, .Resident (Resident 1) will not move the left arm. Resident (1) is guarding and grimaces with any movement and touch .Resident (1) has blue discolored area on his inner deltoid . During a review of Resident 1's PN dated 6/7/22, at 9:41 a.m., indicated, .Full Range of Motion (the capability of a joint to go through its complete spectrum of movements) Assessment Findings .[NAME] [move all extremities (a limb of the body, such as the arm or leg) except is favoring left arm and will barely move it. Swelling noted to left shoulder .Pain level: 5-6 (pain scale 0-10-0 means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) . During an interview on 6/22/22, at 11:00 a.m., with CNA 2, CNA 2 spoke with tears in her eyes when she recalled Resident 1's fall. CNA 2 stated on 6/6/22, she saw CNA 4 walk into Resident 1's room from the dining room and overheard CNA 4 telling Resident 1 You are not a baby; you need to come with me to the dining room to eat lunch. CNA 2 stated she witnessed CNA 4 pushing Resident 1 from behind to speed him up. CNA 2 stated Resident 1 yelled out No, no, no! CNA 2 stated she saw CNA 4 fall on top of Resident 1. CNA 4 stated Resident 1 fell face forward on his knees. During an interview on 6/22/22, at 11:05 a.m., with EVSS, the EVSS stated Resident 1 wanted to eat lunch in his room on 6/6/22. EVSS was waiting for the trays to arrive and was talking with Resident 1. EVS stated Resident 1 was laughing when CNA 4 walked into Resident 1's room, grabbed Resident 1 by his feet, sat him up and pulled him up to a standing position. EVSS stated CNA 4 grabbed Resident 1's armpits to push him to walk. EVSS stated Resident 1 said no, no, no as he was being pushed down the hall EVSS told CNA 4 You need to stop what you're doing, [NAME]! EVSS stated CNA 4 paused for a second then continued to shove Resident 1 approximately twenty feet. EVSS stated Resident 1 fell to his knees and elbows, face down, and CNA 4 fell on top of Resident 1 with one knee on ground in between Resident 1's legs. The EVS stated, after he reported the incident to DON, he went to Resident 1's room. EVS stated, Resident 1 was in bed, and he was in pain. EVS stated after the incident he was using wheelchair and did not talk like Resident 1 use to talk before the accident. During a concurrent interview and record review on 6/22/22 at 11:45 a.m., with the Assistant Director of Nursing/Minimum Data Set Coordinator (ADON/MDSC) Resident 1's Minimum Data Set (MDS - a standardized assessment tool), dated 2/18/22 was reviewed, the MDS indicated, Resident 1 had severe memory and judgement impairments. The ADON/MDSC stated Resident 1 was able to walk and transfer with one person assistance before the fall. The ADON/MDSC stated Resident 1 walked with a shuffled gait. The MDSC stated CNA 1 came into her office and told the ADON/MDSC, CNA 4 rushed Resident 1 down the hall without patience and caused Resident 1 to lose his balance by pushing him. The MDSC stated the injury to Resident 1 was preventable. During a concurrent interview and record review on 6/22/22, at 2:50 p.m., with Director of Staff Development (DSD) 1, CNA 4's personnel file was reviewed. The personnel file indicated CNA 4 was initially suspended pending the findings of the investigation n regarding Resident's 1 fall occurred on 6/6/22. The DSD 1 stated CNA 4 was terminated because the investigation found CNA 4 pushed Resident 1 causing his fall and injury to his left arm. During a phone interview on 6/23/22, at 12:44 p.m., with CNA 4, CNA 4 stated he was working in the dining room and went to get Resident 1 to eat lunch. CNA 4 stated he guided Resident 1 towards the door of his room. CNA 4 stated Resident 1 held on to the doorway. CNA 4 stated when he took Resident 1's hand off the door, Resident 1 stumbled. CNA 4 stated Resident 1 fell on the ground and then he tripped and fell on top of Resident 1. CNA 4 stated, It was awful. CNA 4 stated Resident 1 fell on his left shoulder. During a phone interview on 6/28/22, at 10:01 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a fall on 6/6/22 in the hall. LVN 1 stated Resident 1 fell in front of her med (medication) cart near the double doors to the dining room. LVN 1 stated she witnessed the fall. LVN 1 stated Resident 1 fell forward on his knees and fell to his left side. LVN 1 stated CNA 4 fell on top of Resident 1. LVN 1 stated Resident 1 complained of pain to his left shoulder. LVN 1 stated Resident 1 was given [Acetaminophen (pain medication used to treat minor aches and pains, and reduces fever)], and ice was placed on Resident 1's left shoulder. LVN 1 stated Resident 1's physician also ordered an X ray for his left shoulder. LVN 1 stated Resident 1's X-ray result showed a left arm fracture. During a phone interview on 6/28/22, at 3:12 p.m., with the Administrator (ADM), the ADM stated Resident 1's fall investigation started on 6/6/22. The ADM stated she took over the investigation on 6/8/22 but had to start over because the DON left for vacation on 6/7/22. The ADM stated the DON did not give her any details about Resident 1's injury. ADM stated there was a lack of communication between her and the DON which delayed the reporting of Resident 1's injury and allegation of abuse to the local ombudsman program and Survey State Agency. The ADM stated she asked CNA 4 about the incident. The ADM stated CNA 4 thought Resident 1's injury was not a big deal. The ADM stated she thought Resident 1's injury was accidental at first. The ADM stated when the investigation was completed, CNA 4 was terminated because the witnesses (CNA 1, CNA 2 and EVS) saw CNA 4 push Resident 1 which caused Resident 1's fall and sustained a physical injury. During a phone interview on 11/16/22, at 2:00 p.m., with the DSD 2, the DSD 2 stated, the staff was trained, how to handle residents who were resistant and say no to a request for assistance during the Dementia and resident's rights training. DSD 2 stated, it was everyone's responsibility to ensure the residents were free from abuse. DSD 2 stated, CNA 4 should have respected the resident's preference to eat lunch in his room. During a phone interview on 11/16/22, at 3:45 p.m., with the ADM, the ADM stated, everyone was mandated reporter and should report abuse immediately. ADM stated the expectation for staff was to respect residents' rights and should have left Resident 1 in his room for lunch. ADM stated, Residents has freedom to do what they want. During a review of Resident 1 ' s PN, dated 6/21/22 at 11:26 a.m., the PN indicated, .Res (Resident 1) cont (continued) to c/o (Complain of) left shoulder pain s/p (is a term used in medicine to refer to a treatment (often a surgical procedure), diagnosis or just an event, that a patient has experienced previously) fall and FX (fracture) to left shoulder. Tyle #3 (Acetaminophen-Codeine #3 -pain medication for moderate/severe pain) given as needed . During a review of Resident 1 ' s PN, dated 6/22/22 at 5:43 p.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/24/22 at 10:30 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/25/22 at 8:22 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/26/22 at 8:59 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 6/28/22 at 9:44 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/1/22 at 10:01 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/2/22 at 9:31 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/4/22 at 2:03 p.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/6/22 at 3:11 p.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/7/22 at 9:46 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/8/22 at 10:07 a.m., the PN indicated, .Res (Resident 1) cont to c/o left shoulder pain s/p fall and FX to left shoulder Tyle #3 given as needed . During a review of Resident 1 ' s PN, dated 7/10/22 at 10:16 a.m., the PN indicated, .Resident (Resident 1) has fracture left arm and need to wear sling [a device used to support and keep still (immobilize) an injured part of the body)] at all times . During a review of Resident 1 ' s PN, dated 7/12/22 at 12:31 a.m., the PN indicated, .Wear a sling to support and stabilize left shoulder at all times until further notice. Every shift for proximal humerus fracture . During a review of Resident 1 ' s Medication Review Report (MRR), dated 6/6/2022 to 7/6/2022, the MRR indicated, .Order summary .Wear sling to support and stabilize left shoulder at all times until further notice, every shift for proximal humerus fracture .order date .6/7/2022 During a review of Resident 1 ' s Medication Review Report (MRR), dated 6/6/2022 to 7/6/2022, the MRR indicated, .Order summary .Acetaminophen-Codeine #3 tablet give 1 tablet by mouth every 8 hours as needed for pain .order date .6/7/2022 . During a review of Resident 1 ' s Medication Administration Record (MAR) dated 6/1/22 to 6/30/22, the MAR indicated, Acetaminophen-codeine #3 was administered to Resident 1 from 6/6/22 to 6/18/22, 6/20/22 to 6/22/22, 6/26/22 to 6/28/22 and 6/30/22 for pain level from 3 to 9 [a scale (0-10) used to measure pain- 0-3 mild pain, 4-7 moderate pain and 8 to 10 severe pain). During a review of Resident 1 ' s Medication Administration Record (MAR) dated 7/1/2022 to 7/31/2022, the MAR indicated, Acetaminophen-codeine #3 was administered to Resident 1 from 7/1/22 to 7/3/22, 7/7/22 and 7/10/22 for pain level from 4 to 6. During review of facility' document titled Resident Rights Guidelines for All Procedures (RRGP), dated 2018, the RRGP indicated, .Purpose: To provide general guidelines for resident rights while caring for the resident .1.prior to having direct care responsibilities for residents, staff must have appropriate in -service training on resident rights including .a. preventing, recognizing and reporting abuse .b. resident dignity and respect .f. resident right of refusal .h. residents freedom of choice . During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2018, the P&P indicated, .Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain rights to all residents of this facility. These rights include the resident's right to: a. dignified existence .c. be free from abuse neglect .Protect our residents from abuse by anyone including, but not necessarily limited to other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, or any other individual . During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 2018, the P&P indicated, .Protect our residents from abuse by anyone including, but not necessarily limited to: other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, or any other individual . During a professional reference review retrieved from https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html, titled, Preventing Elder Abuse, dated 7/2/21, the professional reference indicated, .Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone age [AGE] or older. The abuse occurs at the hands of a caregiver or a person the elder trusts . Elder abuse can have several physical and emotional effects on an older adult. Victims are fearful and anxious. They may have problems with trust and be wary of others . Enter comment here

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow their abuse reporting policy and procedure for one of five sampled resident (Resident 1), when the facility failed to immediately report Resident 1's left arm injury as a result of possible physical abuse by Certified Nurse Assistant (CNA) 4 to the local ombudsman program, State Survey Agency and law enforcement agency in accordance with State laws. These failures led to the delayed of immediate investigation of the cause of Resident 1's fracture (broken) left arm bone to rule out the potential for abuse. Findings: During a concurrent observation and interview, on 6/22/22, at 10:41 a.m., with Resident 1, Resident 1 was lying in bed with his left arm resting to his side and wore a sling to his left arm. Resident 1 stated, he slid in the hall and hurt his left arm. During a review of Resident 1's Progress Notes dated 6/6/22 at 1:30p.m., indicated physician was notified of Resident 1's injured left shoulder. The notes indicated physician ordered an X-ray (A specialized imaging study that can diagnose and view bones and other internal body structure). The notes indicated Responsible Party was also notified on 6/6/22 at 1:30 p.m. During a review of Resident 1's 'Progress Notes (PN) dated 6/6/22, at 1:36 p.m., the PN indicated, .Event type: witnessed fall .Resident shoe stuck to the floor and res (Resident 1) went forward on to his knees and then to his left shoulder, in the double doors by the activity room, C/O (complain of) left shoulder pain .MD notification .rec (received) n/o (New orders) for left shoulder x-Ray .would not move left arm or allow palpitation . During a review of the Resident 1's Radiology Results Report, dated 6/7/22, the Radiology Results Report indicated .SHOULDER COMPLETE, MIN (minimum) 2V [Views] LEFT .CONCLUSION: Proximal humerus fractures (a break of the upper part of the bone of the arm close to the shoulder joint) described . During a phone interview on 6/28/22, at 10:01 a.m ., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was alert and unsure if he had a history of falls. LVN 1 stated Resident 1 was diagnosed with Dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities) and Vitamin D Deficiency (not enough fat-soluble vitamin that plays an important role in maintenance and repair of bone tissue)]. LVN 1 stated Resident 1 had a fall on 6/6/22. LVN 1 stated Resident 1 complained of pain to his left shoulder. LVN 1 stated Resident 1 was given [Tylenol (pain medication used to treat minor aches and pains, and reduces fever), and ice was placed on Resident 1's shoulder. LVN 1 stated Resident 1's physician also ordered an X ray for his left shoulder. LVN 1 stated Resident 1's X-ray result showed a left arm fracture. LVN 1 stated Resident 1's left arm was placed in a sling [a device used to support and keep still (immobilize) an injured part of the body)] by the physician on 6/8/22. During an interview on 6/28/22, at 3:12 p.m., with the Administrator (ADM), the ADM stated Resident 1's fall investigation started on 6/6/22 by the Director of Nursing (DON). The ADM stated she took over the investigation on 6/8/22 but had to start over because the Director of Nursing (DON) left for vacation on 6/7/22 but had not given her any details of Resident 1's fall. ADM stated there was a lack of communication between her and the DON which led to the delay of reporting the injury and allegation of abuse to the local ombudsman program and survey state agency. During a phone interview on 11/16/22, at 1:55 p.m., with the ADM, the ADM stated she did not remember reporting the allegation of abuse for Resident 1 to law enforcement agency. ADM stated she thought, it was not necessary to report to law enforcement agency, because CNA 4 stated he was at fault and that he was sorry. ADM stated she should have reported allegation of abuse to law enforcement agency per facility's policy and procedure. During a phone interview on 11/29/22, at 2:00 p.m., with the ADM, the ADM stated she assumed the allegation of abuse was reported to the law enforcement agency by the previous DON. ADM stated upon further inspection, the allegation of abuse for Resident 1 was not reported to law enforcement agency per the facility's policy and procedure. ADM stated, she notified the county Sheriffs department on 11/17/22 of the allegation of abuse for Resident 1, letting them know the date of incident happened in early June of 2022. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 2018, the P&P indicated, .An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury: or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury . During a professional reference review retrieved from https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-21-26.aspx titled, Mandated Reporting Requirements of Potential Abuse, Neglect, Exploitation, or Mistreatment of Elders or Dependent Adults, dated 7/26/21, the professional reference indicated, .for incidents that involve abuse or result in serious bodily injury, facilities must: Call local law enforcement immediately, but no later than two hours after the allegation is made. File a written or electronic report to the LTC ombudsman, local law enforcement, and DO within two hours .for any other reasonable suspicion that does not result in abuse or serious bodily injury, facilities must: Call local law enforcement as soon as possible, but no later than 24 hours after the allegation is made. File a written or electronic report to the LTC ombudsman, local law enforcement and DO within 24 hours .

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 F0943 (Tag F0943)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to maintain an effective abuse training program (education in order to prevent improper violence or treatment of a person) for nine of twelve employees (RNA 1, LVN 1, CNA 1, CNA 4, CNA 5, CNA 7, CNA 8, CNA 9, and CNA 10) when employee training records were not tracked, and employees did not complete the required training necessary to identify and report abuse to meet the needs of the residents. These failures placed residents at risk for abuse (treat a person improperly with cruelty or violence), neglect (fail to care or supervise), and exploitation (making use of a situation to gain unfair advantage for oneself). Findings: During a concurrent interview and record review on 6/22/22, at 2:50 p.m., with the Director of Staff Development (DSD) 1, Restorative Nursing Assistant (RNA) 1's Abuse and Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) Training Abuse and Dementia Training was reviewed. RNA 1's Abuse and Dementia Training was missing for 2018 and 2019. The DSD 1 stated she was responsible for the new hire orientation and all in-service training required by the facility. The DSD stated she thought the previous DSD 1 kept all the records but could not find some of the training binders. The DSD 1 stated the previous DSD 1 did not leave on good terms and may have done something to the binders in retaliation to the facility. The DSD 1 stated she did not complete an audit of employee charts to identify which employees required additional training before she took over the DSD role. The DSD 1 stated a log of completed competencies and in-services for each individual employee was not kept. The DSD 1 stated she relied on the employees to track and make up in-services when missed. During a concurrent interview and record review on 6/22/22, at 3:00 p.m., with the DSD 1, Licensed Vocational Nurse (LVN) 1's Abuse and Dementia Training Abuse and Dementia Training was reviewed. LVN 1's Abuse and Dementia Training was missing for 2017, 2018, 2020, and 2021. During a concurrent interview and record review on 6/22/22, at 3:05 p.m., with the DSD 1, Certified Nursing Assistant (CNA) 1's Abuse and Dementia Training Abuse and Dementia Training was reviewed. CNA 1's Abuse and Dementia Training was missing for 2019, 2020, and 2021. During a concurrent interview and record review on 6/22/22, at 3:15 p.m., with the DSD, CNA 4's Abuse and Dementia Training Abuse and Dementia Training was reviewed. CNA 4's Abuse and Dementia Training was missing for 2020 and 2021. The DSD 1 stated CNA 4 was hired in 2019. The DSD 1 stated CNA 4 attended the in-service for abuse, hand hygiene, PPE skills, and infection dated 3/10/22. During a record review of CNA 5's Abuse and Dementia Training Abuse and Dementia Training was reviewed. CNA 5's Abuse and Dementia Training was missing for 2018, 2019, 2020, and 2021. During a record review of CNA 7's Abuse and Dementia Training Abuse and Dementia Training was reviewed. CNA 7's Abuse and Dementia Training was missing for 2018, 2019, 2020, and 2021. During a record review of CNA 8's Abuse and Dementia Training Abuse and Dementia Training was reviewed. CNA 8's Abuse and Dementia Training was missing for 2018, 2019, 2020, and 2021. During a record review of CNA 9's Abuse and Dementia Training Abuse and Dementia Training was reviewed. CNA 9's Abuse and Dementia Training was missing for 2018, 2019, 2020, and 2021. During a record review of CNA 10's Abuse and Dementia Training Abuse and Dementia Training was reviewed. CNA 10's Abuse and Dementia Training was missing for 2021. During an interview on 6/22/22, at 4:04 p.m., with the Assistant Director of Nursing (ADON), the ADON stated she was not aware that the abuse/dementia training binders were missing from the facility. The ADON stated the previous DSD left on bad terms. The ADON stated training was required on abuse and dementia minimum annually. The ADON stated most competencies should be done upon hire during staff orientation. The ADON stated training and competencies prepared staff to address the needs of their resident population. During an interview on 6/23/22, at 12:44 p.m., with CNA 4 , CNA 4 stated he remembers having training when first hired at the facility. CNA 4 stated he does not remember participating in abuse or dementia training in the last two years. CNA 4 stated abuse/dementia training was important to know how to care for the vulnerable (person in need of special care, support, or protection because of age, disability, or risk of abuse or neglect) residents and prevention of abuse to those vulnerable residents. During a phone interview on 11/16/22, at 2:00 p.m., with the DSD 2, the DSD 2 stated, the staff was trained, how to handle residents who were resistant and say no to a request for assistance during the Dementia and resident's rights training. DSD stated the staff was trained at new hire orientation and then twice a year for abuse. DSD stated, it was everyone's responsibility to ensure the residents were free from abuse. During review of facility' document titled Resident Rights Guidelines for All Procedures (RRGP), dated 2018, the RRGP indicated, .Purpose: To provide general guidelines for resident rights while caring for the resident .1.prior to having direct care responsibilities for residents, staff must have appropriate in -service training on resident rights including .a. preventing, recognizing and reporting abuse .b. resident dignity and respect .f. resident right of refusal .h. residents freedom of choice . During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, undated, the P&P indicated, .Require staff training/orientation programs that include such topics as abuse prevention, identification and report of abuse, stress management, and handling verbally or physically aggressive resident behavior . During a review of the facility's in-service training titled, Understanding Abuse and Neglect, undated, the in-service indicated, .the purpose of the program is to provide nurse aides with an understanding of what is considered to be abusive and neglectful behavior . During a professional reference review retrieved from https://www.nursinghomeabuse.org/articles/nursing-home-abuse-training/ titled, Abuse and Neglect Training in Nursing Homes, dated 3/31/21, the professional reference indicated, .Nursing home abuse and neglect is unfortunately still a problem in nursing homes across the country. Nursing homes can significantly reduce the incidence of abuse and neglect in their facilities by investing in training and prevention. Nursing home facilities that do offer training have shown to have fewer cases of abuse and neglect .

Aug 2019 10 deficiencies

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to protect the privacy and confidentiality of residents personal and medical information for two of seven sampled residents (Resident 51 and Resident 28), when Registered Nurse (RN) 1 left the Medication Administration Record (MAR) open and easily visible in the hallway with Resident 51 and Resident 28's personal and medical information exposed and visible to other residents, staff and visitors passing by. This failure had the potential to result in the unauthorized access to Resident 51 and Resident 28's personal and medical information and violated Resident 51 and Resident 28's rights to confidentiality. Findings: During a medication pass observation on 8/26/19, at 11:40 a.m., in the west hallway, the medication cart faced the hallway unattended with Resident 51's MAR visible to staff, residents and visitors passing by. The MAR displayed Resident 51's name, room number, date of birth , admission date, gender, height, weight, medical record number, allergies, medical diagnoses, and prescribed medications. Resident 51's personal and medical information was visible to anyone who passed by the medication cart. RN 1 returned to the medication cart, documented medications administered to Resident 51, left he MAR visible and proceeded to the next resident on her medication pass. During a medication pass observation, on 8/26/19, at 11:53 a.m., in the west hallway, the medication cart faced the hallway, unattended with Resident 28's MAR visible to staff, residents and public. The MAR displayed Resident 28's name, room number, date of birth , admission date, gender, height, weight, medical record number, allergies, medical diagnoses, and prescribed medication visible to resident, staff and visitor passing by the medication cart. RN 1 returned to the medication cart, documented medications administered to Resident 28, left the MAR open and visible and proceeded to the next resident on her medication pass. During a concurrent interview and record review with RN 1, on 8/26/19, at 11:58 a.m., RN 1 stated she should not have left the MAR open exposing residents' personal identifiable medical information. RN 1 stated the MAR should have been closed when she was not reviewing the MAR. RN 1 stated resident personal and medical information should never be left unattended, in order to prevent exposure of confidential information. During an interview with Director of Nursing (DON), on 8/28/19, at 9:44 a.m., the DON stated the MARs should have been covered when not in use in order to maintain residents' privacy. The DON stated RN 1 should have followed the facility's Health Insurance Portability and Accountability Act (HIPPA) policy. During a review of the facility policy and procedure titled, Use and Disclosure of Health Information dated January 2003, indicated, .It is this facility's policy not to use or disclose a resident's health information except as permitted by law, and adopt safeguards to protect the confidentiality of its residents' health information .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable homelike environment for one of 31 sampled residents (Resident 27) when Resident 27's dresser had visible dust. This failure resulted in an unclean and uncomfortable environment for Resident 27. Finding: During a concurrent observation and interview with Resident 27 on 8/26/19, at 10:30 a.m., during an initial environmental tour in Resident 27's room, Resident 27's dresser had visible dust on top of the dresser. Resident 27 stated, It's dusty on top . It needs to be cleaned. During an interview with House Keeping Supervisor (HKS) 1, on 8/26/19, at 10:35 a.m., HKS 1 stated dusting was supposed to be done every day. HKS 1 stated Resident 27's dresser should have been dusted. HKS 1 stated, I guess we missed cleaning it [dresser]. During a review of the facility's policy and procedure titled Housekeeping- Resident Rooms dated 9/2016 indicated, . Purpose. To promote the quality of life by providing clean and sanitary living spaces. Policy. The housekeeping Department coordinates the daily cleaning of resident room. Procedure . C. Bed stand, bedrails, nightstand, windowsill, chairs . dressers, and cabinets are damp-wiped on a regular basis .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based an interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 47) when a care plan for Resident 47's anti-coagulant (blood thinner) medication was not developed. This failure placed Resident 47 at risk of not receiving appropriate, consistent, and individualized care and monitoring interventions to ensure adverse affects of the blood thinner such as excessive bleeding were identified. Findings: During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 8/28/19, at 8:26 a.m., she reviewed Resident 47's physician's ordersThe ADON stated Resident 47 had a physician order for apixaban (medication used to prevent blood clots) with a start date 12/9/14 for a diagnosis of deep vein thrombosis (DVT - a blood clot in a deep vein). The ADON reviewed Resident 47's care plans and stated Resident 47 did not have a care plan for the use of the blood thinner. The ADON stated Resident 47 should have had a care plan developed for the use of apixaban and the continuum of care. The ADON stated the care plan would have included interventions such as monitoring for bleeding, bruising, and notifying the physician if any signs and symptoms developed. The ADON stated the development of a care plan was the licensed nurses' responsibility. The facility's policy and procedure titled, Comprehensive Person-Centered Care Planning dated 11/17 indicated, .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to meet professional standards of quality for two of five sampled residents (Resident 33 and Resident 3) when: 1. Registered Nurse (RN 1) used an inappropriate medication administration technique while using an insulin pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) during a medication pass observation for Resident 33. This failure placed resident 33 at risk for dosing errors and had the potential for adverse effects such as hyperglycemia (high blood sugar). 2. Licensed Vocational Nurse (LVN 1) pulled Resident 3's controlled medication (medications that can cause physical and mental dependence) before its scheduled time and stored the controlled medication in a clear pill crusher pouch (a pouch which safely contains pills during crushing process). This failure had the potential for resident 3 to receive the wrong medication which could have led to harmful side effects. Findings: 1. During a medication pass observation on 8/27/19, at 11:26 a.m., in Resident 33's room, RN 1 administered lispro (fast acting insulin) 100 u/ml (units/milliliters-unit of measure) 6 units subcutaneously (below the skin into the fatty tissue) (SQ) to Resident 33's left upper arm using an insulin pen. RN 1 removed the needle from the skin without waiting at least 6 seconds before removing the needle. During a review of the facility policy and procedure titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES, dated 2018, indicated, .Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer . Keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way until the needle has been pulled out from the skin . During a review of the clinical record for Resident 33, the Face Sheet (a document with demographic, personal and medical information) dated 8/27/19, indicated Resident 33 had a diagnoses which included Type 2 Diabetes (a long-term metabolic disorder that is characterized by high blood sugar levels). The Physician Orders dated August 2019, indicated Lispro 100 Unit/ml SQ . During an interview with RN 1, on 8/27/19, at 12 p.m., she stated the correct process for medication administration using an insulin pen was to prime (remove air bubbles form the needle) the insulin pen, dial the insulin to the proper dose, and administer the appropriate dose. RN 1 did not mention keeping the needle in the skin for at least 6 seconds after injecting the medication. During a phone interview with the Pharmacist Consultant (PC), on 8/28/19, at 1:35 p.m., the PC stated the insulin pen should remain in the skin for at least 6 to 10 seconds after administering the dose to ensure the full dose was administered. The PC stated, When the insulin pen is taken out too soon, there is a risk for the resident not to receive the full dose. During an interview with the Director of Nursing (DON), on 8/28/19, at 3:33 p.m., the DON stated the insulin pen should remain in the skin for at least 5 to 10 seconds after administering the insulin dose for absorption to occur and to ensure the full dose was given. During a review of the facility policy and procedure titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES dated 2018, indicated, .Inject the dose by pressing the push-button all the way in until the 0 lines up with the pointer . Keep the needle in the skin for at least 6 seconds and keep the push-button pressed all the way until the needle has been pulled out from the skin . Review of the professional reference, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278151/ titled, Insulin Recommended Safe Practice Guidelines dated 10/11 indicated, . Insulin can also leak out of the injection site if the needle is not left in for about 6 seconds after the insulin is injected . 2. During a medication pass observation on 8/27/19, at 4:00 p.m., in the east hallway, LVN 1 removed Alprazolam (medication to treat anxiety) 0.25 mg (milligrams-unit of measurement) from the bubble pack (a packet with individual pills) and placed the pill in a small clear medication cup. LVN 1 proceeded to walk to Resident 3's room and before entering Resident 3's room LVN 1 returned to the medication cart and stated she had pulled the medication to soon. LVN 1 placed Alprazolam 0.25 mg into a clear pill crusher pouch, wrote Residents 3's name, medication, scheduled time, date and room number on the pouch. LVN 1 stored the pouch with the pill in the locked medication cart compartment. During a review of the clinical record for Resident 3, the Face Sheet (a document with demographic, personal and medical information) dated 8/28/19, indicated Resident 3 had a diagnoses which included generalized anxiety disorder. The Physician Orders dated August 2019, indicated Alprazolam 0.25 mg BID (two times daily) for anxiety. The Medication Administration Record (MAR) dated 8/2019, indicated Alprazolam 0.25 mg [administer at] 8 a.m. and 6 p.m. During an interview with LVN 1, on 8/28/19, at 3:19 p.m., LVN 1 stated she should have not pulled Resident 3's Alprazolam medication before the scheduled time. LVN 1 stated she should not have made a label for the medication. LVN 1 stated she should have followed the facility policy and destroyed the medication with a witness when she recognized she made the error. During a phone interview with the PC, on 8/28/19, at 1:42 p.m., the PC stated Licensed Nurses (LN) should not pull out medications one hour before the scheduled dose. The PC stated LVN 1 should have destroyed the medication in the presence of a witness. During an interview with the DON, on 8/28/19, at 3:28 p.m., the DON stated LVN 1 should not pre-pour medications (prepairing medications for administration ahead of the prescribed time). The DON stated when a controlled medication was refused or not given at its scheduled time the medication should be destroyed. The DON stated it was not okay to place the controlled medication back into the medication cart. The DON stated LNs would not be able to perform the 6 medication rights (right patient, right drug, right time, right route, right dose, and right documentation) when giving the medication when the medication was removed from the pharmacy labeled package. During a review of the facility's policy and procedure titled, Medication Administration undated indicated, . Medications are administered at the time they are prepared. Medications are not pre-poured . Medications are administered within (60 minutes) before or after the scheduled time . During a review of the facility's policy and procedure titled, Medication Administration undated indicated, .When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed . During a review of the professional reference https://www.ismp.org/guidelines/timely-administration-scheduled-medications-acute dated 1/11 indicated, . Medications administered more frequently than daily but not more frequently than every 4 hours . Administer these medications within 1 hour before or after the scheduled time .

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 ensure a performance review of every nurse aide at least once every 12 months was completed for two of 15 Certified Nursing Assistants (CNAs) CNA 2 and CNA 3. These failures had the potential for residents' needs to go unmet by CNAs' whose competence had not been determined through annual performance reviews. Findings: During a concurrent interview and employee record review with the Director of Staff Development (DSD), on 8/28/19, at 8:02 a.m., the DSD reviewed annual competency evaluations completed for the year of 2019. The DSD stated CNA 2, and CNA 3 did not have annual performance reviews. The DSD stated the performance evaluations should have been done within 90 days after hire, then once a year, and then yearly. The DSD stated she did not know how she missed completing the evaluation for CNA 2 and CNA 3. The DSD stated, I guess, I just missed them.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview, and record review the facility failed to ensure as needed (PRN) Psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) were time limited to 14 days for two of four sampled residents (Resident 14 and Resident 15) when: 1. PRN Lorazepam (medication to treat anxiety) was prescribed Resident 14 since 3/19/19 without a 14 day time limited date and without the attending physicians' document rationale to extend the PRN Lorazepam prescription beyond the 14-day time limit. 2. PRN Lorazepam was prescribed for Resident 15 since 5/3/19, without a 14 day time limited date and without the attending physicians' document rationale to extend the PRN Lorazepam prescription beyond the 14-day time limit. This failure placed Resident 14 and Resident 15's health and safety at risk due to the continuous administration of the unnecessary psychotropic medications. Findings: 1. During a review of the clinical record for Resident 14, the Physicians Orders, indicated, Lorazepam 2MG/ML [milligrams/milliliter - unit of dose] may give 0.25ml PO [by mouth] Q [every] 6 hrs [hours] PRN for anxiety, [order date] 3/19/19 [with no end date]. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 8/28/19, at 8:38 a.m., the ADON reviewed Resident 14's physician's order for Lorazepam 0.25 ml PRN for anxiety ordered on 3/19/19. The ADON reviewed Resident 14's clinical record and was unable to find an end date and supporting documented rational for the continued use of PRN Lorazepam beyond the 14-day limit. The ADON stated there should be an evaluation and documented rational to indicate the reason for the continued use of Lorazepam. 2. During a review of the clinical record for Resident 15, the Physicians Orders, indicated, [Lorazepam] 0.5mg 1-tab PO QHS (every night) PRN for anxiety, [order date] 5/3/19 [with no end date]. During a concurrent interview and record review with the ADON, on 8/28/19, at 9:01 a.m., the ADON reviewed Resident 15's physician's order for Lorazepam 0.5mg PRN for anxiety ordered on 5/3/19. The ADON reviewed Resident 15's clinical record and was unable to find an end date and supporting documented rational for the continued use of PRN Lorazepam beyond the 14-day time limit. The ADON stated the clinical record should have an evaluation and documented rational to indicate the reason for the continued use of Lorazepam. During an interview with the Director of Nursing (DON), on 8/29/19, at 7:30 a.m., the DON stated psychotropic medications ordered as needed should have an end date. The DON stated psychotropic medication on as needed basis should not go beyond the 14-day time limit unless the prescribing physician has a documented rational for its continued use. During a review of the facility policy and procedure titled, Behavior/Psychoactive Drug Management undated, indicated .Any Psychoactive Medication ordered on a prn basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage, and write the order for the medication; not to exceed the 14-day time frame .

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review the facility failed to the maintain garbage disposal and ice machine equipment in safe operating condition when: 1. Brownish liquid was observed leaking from a garbage disposal onto a pan on the kitchen floor. 2. The Vent screen on the ice machine was covered with dust. 3. The Ice machine had an orange substance on the ice machine water distributor. These failures resulted in an unsanitary environment and had the potential to cause food contamination for the 62 Residents that received meals and ice from the kitchen. Findings: 1. During an observation in the dining room on 8/26/19, at 8:35 a.m., a brownish liquid was observed leaking from a garbage disposal into a basin placed on the floor. The basin was full with brownish water in the dish washing area. The Dietary Supervisor (DS) stated the leak had begun approximately two weeks ago. The DS stated the dietary staff had forgotten to discard the brownish water and empty the basin. During a concurrent observation and interview with the Maintenance Supervisor (MS), on 8/27/19, at 2:31 p.m., in the kitchen a black basin was observed approximately 3 feet deep by 4 feet long, on the floor underneath the garbage disposal. The basin was full of brownish fluid. The MS stated the garbage disposal had broken down the night before on 8/26/19 and he had just called [company name] to order the part to repair the leak. 2. During a concurrent observation and interview with the MS, on 8/27/19, at 2:36 p.m., in the kitchen, the front screen vent for the ice maker was covered with dust. The MS stated he would clean the dust off the screen vent of the ice machine. 3. During a concurrent observation and interview with the MS, on 8/27/19, at 2:36 p.m., in the kitchen, the ice tray had an orange substance on the top and on the bottom of the water distributor where the water flows into the ice maker curtain. The MS stated he would clean the orange substance on the top and the bottom of the water distributor of the ice machine. During an interview with MS, on 8/28/19 at 2:58 p.m., MS stated the ice machine had a manufacture cleaning instruction Manual on how to clean the ice machine but he did not follow the instructions. MS stated he cleaned the ice machine once a month the way he was instructed by the previous MS and he also watched ice machine cleaning videos on You Tube. MS stated he was using a spray bottle with a cleaner to clean the ice machine. MS produced an unlabeled clear bottle, half full with a liquid solution. MS reviewed his supplies and was unable to produce the cleaning agents that were used to clean the ice machine. MS stated the risk of not cleaning and disinfecting the ice machine in accordance with the manufacturer's instructions would place residents at risk of getting ill from the unsanitary conditions on and in the ice machine. MS stated he would begin to check the ice machine every week because once a month isn't cutting it. During an interview with the Registered Dietician (RD), on 8/29/19, at 9:13 a.m., she stated the ice machine should have been cleaned once a month. The RD stated she would review the ice machine cleaning log during her weekly visit and the log indicated the cleaning was done. The RD stated, If the ice machine water is not clean it could cause residents GI [stomach] distress. The RD stated she had questioned DS about the two meal carts stored in dietary and asked if there were other areas the carts could be stored instead of the kitchen. The RD stated there was no other place to store the meal carts and MS was going to look for a different location. The RD stated she knew the doors should not be stored in the kitchen specially when they were dirty. During a review of the facility Job Description Manual undated indicated, DIRECTOR OF PLANT MAINTENANCE JOB DESCRIPTION .Principal Responsibilities: TECHNICAL Ensure a safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, state and Corporate requirements . During a review of the facility policy and procedure titled Ice Machine-Operation and Cleaning dated, 10/1/14, indicated, Purpose: To estaglish guideline for the use and cleaning of the ice machine . Procedure . Sanitation of Equipment . Maintenance staff will clean the ice . according to manufacture's guidelines . During a review of the [Brand name] Installation and user's Manual dated 10/2014, indicated, . It is the User's reponsibility to keep the ice machine and ice storage bin in a sanitary condition. without human intervention, sanitation will not be maintained. Ice machines also require occassional cleaning of their water systems with a specifically designed chemical. This Chemical dissolves mineral build up that forms during the ice making process . 6. Pour 8 onces (chemical agent) or 10 ounces (chemical agent) . of [brand name] Clear 1 ice machine scale remover into the reservoir .

CONCERN (F)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to post the results of the most recent abbreviated survey document titled, Statement of Deficiencies in a place readily accessible to residents and their representatives. This failure resulted in depriving residents and visitors the opportunity and of their right to view abbreviated survey findings and plans of correction (POC) for the facility. Findings: During a concurrent observation and interview with the Administrator (ADM), on 8/26/19, at 10:20 a.m., the Survey Inspection binder was located in a holder on the wall in front of the lobby piano. The binder did not contain any abbreviated survey and any subsequent POCs statement of deficiencies for the facility. The Administrator stated she did not know the abbreviated surveys results and POC were supposed to be made available for review by residents and visitors. She stated abbreviated survey results and POCs were not in the binder and were not made available for review.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review the facility failed to provide a safe and sanitary environment in the kitchen for 62 of 64 sampled residents' when: 1. Brownish liquid was observed leaking from a garbage disposal. 2. Two broken dusty meal carts were stored in the kitchen. 3. Vent screen on the ice machine was covered with dust. 4. Ice machine had an orange substance on the ice machine water distributor. These failures resulted in an unsanitary environment and had the potential to cause food contamination for the 62 Residents that received meals from the kitchen. Findings: 1. During an observation in the dining room on 8/26/19, at 8:35 a.m., a brownish liquid was observed leaking from a garbage disposal into a basin placed on the floor. The basin was full with brownish water in the dish washing area. The Dietary Supervisor (DS) stated the leak had begun approximately two weeks ago. The DS stated the dietary staff had forgotten to discard the brownish water and empty the basin. During a concurrent observation and interview with the Maintenance Supervisor (MS), on 8/27/19, at 2:31 p.m., in the kitchen a black basin was observed approximately 3 feet deep by 4 feet long, on the floor underneath the garbage disposal. The basin was full of brownish fluid. The MS stated the garbage disposal had broken down the night before on 8/26/19 and he had just called [company name] to order the part to repair the leak. 2. During a concurrent observation and interview with DS, on 8/26/19, at 9:17 a.m., in the kitchen two broken dusty meal carts were stored against the wall next to the carts used to deliver resident meals. The doors for the dusty meal cart were leaning on the emergency food gate and stored near the emergency food. The DS stated, Those carts are broken. We don't use them. The DS stated, [ MS] just keeps them here. The DS stated the doors belonged to the broken meal carts and were being stored in the kitchen. The DS stated the doors had been stored in the kitchen for a while but did not recall for how long. 3. During a concurrent observation and interview with the MS, on 8/27/19, at 2:36 p.m., in the kitchen, the front screen vent for the ice maker was covered with dust. The MS stated he would clean the dust off the screen vent of the ice machine. 4. During a concurrent observation and interview with the MS, on 8/27/19, at 2:36 p.m., in the kitchen, the ice tray had an orange substance on the top and on the bottom of the water distributor where the water flows into the ice maker curtain. The MS stated he would clean the orange substance on the top and the bottom of the water distributor of the ice machine. During an interview with MS, on 8/28/19 at 2:58 p.m., MS stated the ice machine had a manufacture cleaning instruction Manual on how to clean the ice machine but he did not follow the instructions. MS stated he cleaned the ice machine once a month the way he was instructed by the previous MS and he also watched ice machine cleaning videos on You Tube. MS stated he was using a spray bottle with a cleaner to clean the ice machine. MS produced an unlabeled clear bottle, half full with a liquid solution. MS reviewed his supplies and was unable to produce the cleaning agents that were used to clean the ice machine. MS stated the risk of not cleaning and disinfecting the ice machine in accordance with the manufacturer's instructions would place residents at risk of getting ill from the unsanitary conditions on and in the ice machine. MS stated he would begin to check the ice machine every week because once a month isn't cutting it. During an interview with the Registered Dietician (RD), on 8/29/19, at 9:13 a.m., she stated the ice machine should have been cleaned once a month. The RD stated she would review the ice machine cleaning log during her weekly visit and the log indicated the cleaning was done. The RD stated, If the ice machine water is not clean it could cause residents GI [stomach] distress. The RD stated she had questioned DS about the two meal carts stored in dietary and asked if there were other areas the carts could be stored instead of the kitchen. The RD stated there was no other place to store the meal carts and MS was going to look for a different location. The RD stated she knew the doors should not be stored in the kitchen specially when they were dirty. The facility Job Description Manual undated indicated, DIRECTOR OF PLANT MAINTENANCE JOB DESCRIPTION .Principal Responsibilities: TECHNICAL Ensure a safe, comfortable, sanitary environment for residents, staff and visitors in accordance with Federal, state and Corporate requirements .

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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3. During an observation on 8/26/19, at 3:10 p.m., in Resident 49's room, Resident 49 was lying in bed. Resident 49's bed was in the lowest position with the catheter bag hanging on the bed rail touching the ground. During a concurrent interview and observation with Certified Nursing Assistant (CNA 1), on 8/26/19, at 3:39 p.m., in Resident 49's room, CNA 1 stated Resident 49's catheter bag is touching the ground. CNA 1 stated the catheter bag should not be touching the ground to prevent infection. During an interview and record review with the Director of Nursing (DON), on 8/28/19, at 9:46 a.m., the DON stated the catheter bag should not touch the ground to prevent infection. The DON reviewed the facility policy and procedure titled Catheter-Care of dated 1/12, indicated, .The catheter tubing, bag or spigot will be anchored to touch the floor . DON stated, The policy is incorrect and should include for the catheter bag to not touch the ground. During a review of the professional reference titled, GUIDELINE FOR PREVENTION OF CATHETER-ASSOCIATED URINARY TRACT INFECTIONS 2009 DATED 6/19, from https://www.cdc.gov/infectioncontrol/guidelines/cauti/ . Proper Techniques for Urinary Care Maintenance . Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . Empty the collecting bag regularly using a separate, clean collecting container for each patient . Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Six of eight sampled residents (Resident's 415, 48, 16, 414, 42, and 3's) oxygen tubing were not dated and appropriately stored to prevent cross contamination. 2. Spoiled tomatoes were stored in the refrigerator, a tub of ice cream was dripping in the freezer, one bag of noodles in the pantry were expired. 3. One of three sampled residents (Resident 49's) urinary catheter (a tube placed in the body to drain and collect urine from the bladder) bag was touching the ground. These failures had the potential for cross contamination (transfer of germs) and spread of infection. Findings: 1. During the initial tour of the facility on 8/26/19 at 10:30 a.m., Resident 415's a Nebulizer (a portable medical device used to deliver medication) sat on the top of the bed side stand with a used Nebulizer mask (oxygen tubing that allows the patient to breathe the aerosol mist [medication] in through the nose and mouth to treat the passageways and the lungs directly) that was uncovered and undated. During a review of the clinical record for Resident 415, the physician order dated 8/2019 indicated, Budesonide [medication to treat a lung condition] 0.5 mg/ML [milligrams / milliliters- unit of dosing] vial via [through] HHN [a hand held nebulizer] PO [orally] BID [twice a day]. During an observation on 8/26/19 at 10:34 a.m., Resident 48's nasal cannula was observed laying on the floor uncovered and undated. The nasal cannula was attached to oxygen tank. During a review of the clinical record for Resident 48, the physician order dated 8/2019, indicated, Oxygen 2 liters per minute [through a] N/C [nasal cannula]. During an observation on 8/26/19 at 10:39 a.m., Resident 16's oxygen tubing was coiled and laid on the floor while in use. One end was attached to the oxygen devise and the cannula was attached to the resident's nose. During a review of the clinical record for Resident 16, the physician orders dated 8/2019 indicated, Oxygen at 2 L [liters - unit of measurement] /MIN[ute] VIA N/C continuous - [for] COPD [Chronic Obstructive Pulmonary Disease - a condition involving constriction of the airways and difficulty or discomfort in breathing /ASTHMA EXACERBATION. During an interview on 8/26/19 at 10:45 a.m., with License Vocational Nurse (LVN) 2, LVN 2 stated the tubing should have been changed every Sunday night LVN 2 stated the tubing should have been labeled with the date and residents' name. LVN 2 stated the tubing should not be on the floor and would need to be changed. LVN 2 stated the tubing was considered to be contaminated because it was on the floor, not dated and not labeled. LVN 2 stated Resident could get sick from the contaminated oxygen tubing. During the initial tour of the facility on 8/26/19 at 10:47 a.m., Resident 414's small oxygen tank sat on a stand near the side of the bed. The oxygen tubing was rolled on top of the oxygen tank with a cannula uncovered and undated. During a review of the clinical record for Resident 414, the physician orders dated 8, 2019 indicated, Oxygen at 2 L/MIN VIA N/C continuous - COPD. During the initial tour of the facility on 8/26/19 at 10:48 a.m., Resident 42 had undated oxygen tubing in use while in his room. During the initial tour of the facility on 8/26/19 at 10:51 a.m., Resident 3 had a small oxygen tank on the wheelchair which sat on the side of the bed with oxygen a cannula wrapped on top of the tank uncovered and undated. During an interview on 8/26/19 at 11 a.m., with the Director of Staff Development (DSD), the DSD confirmed the oxygen tubing was not dated, not labeled with resident name and on the floor. The DSD stated the oxygen tubing should have been changed every Sunday night, and labeled with the date it was changed and resident name. The DSD stated nurses should have checked oxygen tubing to make sure the oxygen tubing was correctly labeled and to ensure oxygen tubing was not touching the floor, became contaminated tubing would get residents sick. The DSD stated the stated none of the oxygen tubing had been dated. During a review of the facility policy and procedure titled Oxygen Therapy dated 8/2017, indicated, .Procedure . The humidifier and tubing should be changed no more than every 7 days and tabled with the date of change . Oxygen-Storage, Maintenance, and Handling . Oxygen tubing, mask, cannulas will be changed no more than every seven (7) days and as needed. The [oxygen tubing] supplies will be dated each time they are changed . Humidifier equipment will be maintained and/or changed per manufactures' guidelines or no more than every 7 days. They will be dated each time they are changed . 2. During a tour of the kitchen on 8/26/19 at 8:55 a.m., with Dietary Supervisor (DS) in the walk in refrigerator a tub of 12 tomatoes with blackened areas and light whitish matter were stored on a shelf undated. DS stated the tomatoes were spoiled and were not to be used. She proceeded to throw the tomatoes away and stated the resident could get sick if the rotten tomatoes were served and ingested. During an observation in the kitchen freezer on 8/26/19 at 9 a.m., a tub of chocolate ice cream was observed with the outside of the ice cream tub stained of chocolate ice cream and dripped onto a cardboard box of vegetables which were in a plastic bag. The DS stated, That's a 3-gallon tub of chocolate ice cream that melted. It should not be there It will be thrown out right now. During a tour of the kitchen pantry on 8/26/19 at 9:15 a.m., with the DS a tied plastic bag of noodles was stored on the shelf. The bag was dated with an open date of 4/7/19 and used by date of 5/20/19. The DS stated according to the date the noodles were expired. The DS stated, They [kitchen staff] are supposed to check for expiration dates and discard the food if it's expired. The facility policy and procedure titled Food Storage dated 8/1/14, indicated, Purpose . To establish guidelines for storing, thawing, and preparing food. Policy . Food items will store, thawed, and prepared in accordance with good sanitary practice. Procedure Label and date all food items . Fresh Vegetable Storage Guidelines A. Fresh vegetables should be checked and sorted for ripeness . Vegetables should be left in cartons, bags, or paper wrapping because it retards spoilage and loss of moisture . Dry Storage Guidelines . Any opened products should be placed in storage containers with tight fitting lids .Label and date storage products .

Sept 2018 15 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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Based on observation, interview and record review, the facility failed to ensure residents were provided with reasonable accommodation for one of 42 sampled residents (Resident 3 ) when Resident 3's requested a bedbath and/or shampoo and was not accommodated. This failure resulted in not meeting Resident 3's personal needs for physical hygiene and grooming. Findings: On 9/18/18 at 9:08 a.m., during a concurrent observation and interview in Resident 3's room, Resident 3's hair was limp, greasy and uncombed. Resident 3 stated she did not have a shower in two weeks and she felt horrible. Resident 3 stated her scalp felt itchy, and when she scratched, there was oil and dirt under her fingernails. Resident 3 stated she was not able to take a bedbath or shampoo her hair prior to her doctor's appointment on 9/14 (Friday) at 9 a.m. The following day Resident 3 informed a certified nurse assistant (CNA) she needed a shower. The CNA (Resident 3 did not remember the CNA's name) stated to Resident 3 she could not get to her today or tomorrow because other residents were scheduled on their own shower days. The CNA stated Resident 3 had to wait until her next scheduled shower day. Resident 3 stated her shower days were scheduled every Tuesday and Friday of the week and she was told she would have showers only on her shower days. Resident 3 stated at home, she used to have bath and hair shampoo everyday. On 9/18/18 at 12:30 p.m., during an interview, the licensed vocational nurse (LVN) 3 stated when a resident's scheduled bath was not done or the bath was refused, the CNA assigned to the resident was expected to document and inform the LVN the reason why this was not done. If the reason was that the resident refused the shower after the CNA had asked the resident three times, LVN 3 stated she would talk to the resident and would ask the time the resident wanted the shower to be done and LVN 3 would endorse it to the next shift. LVN 3 stated Resident 3's missed shower could have been re-scheduled. Resident 3 did not need to wait until her next shower schedule. On 9/18/18 at 1:10 p.m., a concurrent interview and record review with the director of staff development (DSD), Resident 3's ADL (Activities of daily living) Flow Sheet dated 9/1/18 to 9/18/18 indicated from 9/6/18 to 9/18/18 (13 days) Resident 3 had received one bed bath and no hair shampoos. A policy and procedure on Resident's Personal Hygiene/Shower was requested but the DSD stated the facility had no policy on this. During an interview, the DSD stated, the resident had the right to refuse shower. When asked for the documentation that Resident 3 refused shower and the reason for it, the DSD stated there was no need to document if that was the first time the resident refused it but if it became frequent then there was a need to develop a care plan. When asked how could the number of times the shower was refused by the residents be traced if the refusal was not documented, the DSD stated the LNs (licensed nurses) work 4 times a week and were familiar with all the residents under their care. On 9/18/18 at 3:20 p.m., during a telephone interview, CNA 2 stated she worked on 9/14/18 from 9 a.m. to 5:30 p.m. and by 9 a.m. Resident 3 was already picked up by the transportation for the resident's doctor's appointment. When asked if she informed an LVN Resident 3's shower was missed because of a doctor's appointment, CNA 2 stated she told an LVN, but when asked who the LVN was, CNA 2 was not able to provide an answer. On 9/19/18 at 7:40 a.m. during an interview, LVN 1 stated she was on duty on 9/14/18 but there was no CNA who had informed her that Resident 3 had missed her scheduled shower due to a doctor's appointment. LVN 1 stated she had expected that the CNA had documented the missed shower schedule and reported to her so that she could have re-scheduled the resident's shower in the afternoon when the resident returned and she would have endorsed this to the next shift.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of 42 Residents (Resident 35) when Resident 35 was admitted to hospice care and the comprehensive care plan did not reflect Resident 35's significant change in status. These failures placed Resident 35 at risk of not having his hospice care needs met. Findings: Resident 35's physician's order dated 7/29/18 indicated, admitted to (name of hospice) Hospice . Diagnosis: cancer with metastasis- Lung mass . On 9/20/18 at 9:40 a.m. during a concurrent record review and interview, the nurse consultant (NC) was unable to find documented evidence in Resident 35's medical record the facility had developed a comprehensive care plan for hospice care. The NC was unable to find documented evidence a care plan was developed for Resident 35 by the the contracted hospice from 7/29/18 to 9/18/18 (49 days). On 9/21/18 at 9 a.m. during a telephone interview with hospice clinical manager (HCM), she stated the hospice agency did not have a policy with regards to the timeframe to develop the hospice care plan. The HCM stated the process was that the resident would be admitted to hospice care by the admitting nurse within 48 hours. The HCM stated the day after the resident's admission, the hospice care plan usually would be faxed to the facility. The HCM was unaware the facility did not have the hospice care plan in Resident 35's medical record. On 9/21/18 at 9;20 a.m., during an interview the director of nursing (DON) stated if the contracted hospice had faxed Resident 35's hospice care plan to the facility, it should have been in the residents chart. The DON validated a care plan for Resident 35's hospice care was not developed by staff and should have been developed.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a person centered care plan which reflected the use of supra pubic catheter (flexible tube inserted through the skin into the bladder located near the navel) for one of 42 sampled residents (Resident 60). This failure had the potential for Resident 60's catheter care needs not to be met and may result in infection and complications. Findings: Review of Resident 60's clinical record face sheet (contains resident profile) indicated, Resident 60 was re-admitted on [DATE]. On 9/18/18 at 4:09 p.m., during observation in room [ROOM NUMBER] A, Resident 60 was on his bed and an indwelling urinary catheter bag was hanging from the bottom of his bed frame. On 9/21/18 at 10:39 a.m., during concurrent interview and record review of Resident 60's clinical record, there was no base line care plan indicating the use of indwelling catheter in the clinical record (22 days after admission). Licensed vocational nurse (LVN) 2 stated Resident 60 had supra pubic catheter and was being seen by an urologist. LVN 2 was unable to show a care plan on the use of the supra pubic catheter and stated who ever admitted the resident should have started the base line care plan. LVN 2 stated the base line care plan was missed and not done. On 9/21/18 10:41 a.m., during an interview, the nursing consultant (NC) confirmed Resident 60 had no base line and comprehensive care plan. Facility policy and procedure titled Comprehensive Person-Centered Care Planning revised September 2018, indicated, a. The baseline care plan must include the minimum healthcare information necessary b. The base line care plan summary will be completed and implemented, using the necessary combination of problem specific care plans, within 48 hours of the resident admission .

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 observation, interview, and record review, the facility failed to timely revise and implement a person centered comprehensive care plan for one of 42 sampled residents (Resident 4 ) when Resident 4's fall care plan was not updated to include interventions and implementations to address Resident 4's most recent fall of 8/25/18. This failure placed Resident 4 at risk for another fall when the fall interventions were not put in place and implemented from 8/25/18 to 9/18/18 (24 days). Findings: Review of complaint CA00601304 indicated on 8/25/18 at 1:45 a.m., Resident 4 fell while transferring self from wheelchair (w/c) to bed. An X-ray showed fracture of the 5th digit to the right hand. On 9/18/18 at 3:25 p.m., during an interview, Resident 4 stated she was comfortable transferring herself independently from her bed to the w/c without assistance, Resident 4 stated she did not know how she fell down on 8/25/18. Resident 4 stated this happened in the middle of the night when she went to the bathroom. Resident 4 stated she was sent to the hospital for X-ray and she had a fracture of the 5th finger. Resident 4 stated she was seen by a doctor and braces were applied to her right hand. Resident 4 stated she continued to independently transfer herself from bed to w/c, to the toilet and back even after her fall. Resident 4's progress notes dated 8/25/18 indicated,On 0145 (1:45 a.m.) Unwitnessed fall . self-transferring from w/c to bed stated she slipped . On 9/18/18 at 3 p.m. a concurrent record review and interview was done with the MDS coordinator (MDSC). The review of Resident 4's Fall Risk Assessment & Management care plan indicated after Resident 4's fall incident on 8/25/18, the care plan was not reviewed and updated to include the incident of fall, fall interventions and implementations. On 9/20/18 at 9:35 a.m., a concurrent interview with the director of nursing (DON) and nurse consultant (NC) was done. The DON stated the MDSC was expected to update the resident's comprehensive care plan on the resident falls after the MDS (Minimum Data Set) significant change was done. The NC stated when the licensed nurse (LN) had already developed a short term care plan on the resident's fall, the comprehensive falls care plan should have been updated by the MDCS. On 9/20/18 at 10:50 a.m. during an interview, MDSC stated when Resident 4 had a fall the LN was expected to develop a short-term care plan with the intervention and its implementation to prevent the incident of another fall for Resident 4. The MDSC stated the chart should have been reviewed during the IDT stand up meeting. During the IDT review of the incident a new intervention would be added when needed. and would be documented. The MDSC stated then she would update the long-term care plan and DON would inform the nursing department of the intervention for implementation. The MDSC stated none of these were done for Resident 4's fall of 8/25/18. The facility's policy and procedure titled Comprehensive Person-Centered Care Planning dated 9/18 indicated,Purpose. To ensure that a comprehensive person centered care plan is developed for each resident. Policy . Facility to provide person-centered comprehensive and interdisciplinary (IDT) care that reflects best practice standards for meeting health safety . needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being. Procedure . IV. Comprehensive Care Plan . The comprehensive care plan will be periodically reviewed and revised by the IDT after each assessment which means after each MDS assessment as required except for discharge assessment. In addition, the comprehensive care plan will also be reviewed and revised at the following times: i. Onset of new problems ii. Change of condition . d. The IDT care plan conference and summary associated with the comprehensive care plan will be completed using the IDT Conference Record and Summary .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living to maintain personal hygiene and grooming for one of 42 residents (Resident 3) when Resident 3 did not receive a shower and shampoo for two weeks. This failure prevented Resident 42 from maintaining good personal hygiene and grooming. Findings: On 9/18/18 at 9:08 a.m., during an observation in Resident 3's room, Resident 3's hair was limp, greasy and uncombed. Resident 3 stated she did not have a shower in two weeks and she felt horrible. Resident 3 stated her scalp felt itchy, and when she scratched, there was oil and dirt under her fingernails. Resident 3 stated she was not able to take a bedbath or shampoo her hair prior to her doctor's appointment on 9/14 (Friday) at 9 a.m. The following day Resident 3 informed a certified nurse assistant (CNA) she needed a shower. The CNA (Resident 3 did not remember her name) stated to Resident 3 she could not get to her today or tomorrow because other residents were scheduled on their own shower days. The CNA stated there was no way she could have a rescheduled shower and she had to wait until her next scheduled shower day. Resident 3 stated her shower days were scheduled every Tuesday and Friday of the week and she was told she would have showers only on her showers days. Resident 3 stated at home, she used to have bath and hair shampoo everyday. Resident 3 stated because of her arthritis she was unable to shower, bath and shampoo by herself. On 9/18/18 at 12:30 p.m.,, a concurrent record review and interview was done with CNA 1. The facility's Shower List indicated, Resident 3's schedule for shower was every Tuesday and Friday in the morning. Resident 3's Skin Monitoring, Comprehensive CNA Skin/Shower Review for the month of 9/18 indicated, Resident 3 had a bed bath (no hair shampoo) on 9/7/18 (Friday). The record indicated Resident 3 did not have a bed bath or hair shampoo on 9/14/18 and the record was documented as LOA (leave of absence) (date of physician's visit). CNA 1 stated Resident 3 could not have a shower because of her pacemaker but Resident 3 should have been provided bed bath and hair shampoo during the resident's shower days schedules. CNA 1 stated when a shower was not provided to the resident for any reason, it should have been documented and the LVN (licensed vocational nurse) should have been informed about it. On 9/18/18 at 12:30 p.m., during an interview, LVN 3 stated when a resident's scheduled bath was not done or the bath was refused, the CNA assigned to the resident was expected to document and inform her the reason why this was not done. If the reason was that the resident refused the shower after the CNA had asked the resident three times, LVN 3 stated she would talk to the resident and asked the time she wanted the shower to be done and she would endorse it to the next shift. LVN 3 stated, the resident's missed shower should have been re-scheduled and not for the resident to wait until her next shower schedule. On 9/18/18 at 1:10 p.m., a concurrent record review and interview was done with the director of staff development (DSD). The review of Resident 3's ADL (Activities of daily living) Flow Sheet dated 9/1/18 to 9/18/18 indicated from 9/6/18 to 9/18/18 (13 days) Resident 3 had only received one bed bath and no hair shampoos. A policy and procedure on Resident's Personal Hygiene/ Shower was requested but the DSD stated the facility had no policy on this. During an interview, the DSD stated, the resident had the right to refuse shower. When asked for the documentation that Resident 3 refused shower and the reason for it, the DSD stated there was no need to document if that was the first time the resident refused it but if it became frequent then there was a need to develop a care plan. On 9/18/18 at 3:20 p.m., during a telephone interview, CNA 2 stated she worked on 9/14/18 from 9 a.m. to 5:30 p.m. and by 9 a.m. Resident 3 was already picked up by the transportation for the resident's doctor's appointment. When asked if she informed an LVN that Resident 3's shower was missed because of a doctor's appointment, CNA 2 stated she told the LVN, but when asked who the LVN was, CNA 2 was not able to provide an answer. On 9/19/18 at 7:40 a.m. during an interview, LVN 1 stated she was on duty on 9/14/18 but there was no CNA who had informed her that Resident 3 had missed her scheduled shower due to a doctor's appointment. LVN 1 stated she had expected that the CNA had documented the missed shower schedule and reported to her so that she can re-schedule the resident's shower in the afternoon when the resident returns and she would have endorsed this to the next shift.

CONCERN (D)

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

Deficiency F0679 (Tag F0679)

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 an individualized activity program designed to meet the interests and choices of residents for one of 42 sampled resident (Resident 12) when Resident 12 was assessed as aphasic and total care and an individualized activity program to socialize outside and in her room was not implemented. This failure had the potential to affect Resident 12's physical, mental and psychosocial well being. Findings: On 9/18/18 at 10:49 a.m., during a concurrent observation and interview in room [ROOM NUMBER] A, Resident 12 was lying on her bed with the television mounted on the wall and on. Licensed vocational nurse (LVN) 2 stated Resident 12 was aphasic (a condition following brain injury that impairs the comprehension and ability to speak). On 9/18/18 at 3:00 p.m., during an observation in room [ROOM NUMBER] A, Resident 12 was in her bed with the TV on, no activity staff or other staff visited the resident at this time; no music was on. On 9/19/18 at 8:48 a.m., during an observation in room [ROOM NUMBER] A, Resident 12 was lying in her bed covered with blankets, no activity staff or other staff visited the resident at this time; no music was on. On 9/19/18 at 11:19 a.m., during an observation in room [ROOM NUMBER] A, Resident 12 was lying in her bed with a gown on, and no activity staff or other staff visited the resident at this time; no music was on. On 9/19/18 at 2:30 p.m., during an observation in room [ROOM NUMBER] A, Resident 12 was dressed in a gown and lying on her bed. No activity staff were in her room at this time and no activity had been offered to Resident at this time; no music was on. On 9/20/18 at 10:30 a.m., during an interview, Certified Nursing Assistant (CNA) 2 stated she will get Resident 12 up as soon she finished getting up the other residents who were going to dialysis. CNA 2 stated when Resident 12 was up in a chair, staff would place her by the nurses' station or by the lobby. On 9/20/18 at 11:24 a.m., during an observation, Resident 12 was up in her chair and was placed in front of the nurses station. Staff did not offer activities to Resident 12. On 9/20/18 at 4:20 p.m., during a concurrent interview and record review, the Activity Director (AD) stated Resident 12 was provided activity in her room. AD stated the expectation for residents with room activity is to provide sensory stimulation, taking out to the lobby, discussion by talking to the resident. AD reviewed the Resident Participation Log which indicated no documentation on 9/18, 9/19 and 9/20 on whether or not room visits, sensory stimulation, group or discussion occurred. The Room Visits Response Form indicated, no documentation for 9/18, 1/19, and 9/20. AD stated she did not do any room visits on Resident 12 since Tuesday 9/18/18 but could not provide documentation. Review of Resident 12's care plan indicated the following current activities: TV, patio outing, music, church and pet therapy. The intervention indicated Music at bed side. The facility Resident Participation Log did not document any of the activities described in the care plan. The facility policy and procedure titled,Room Visit Program revised November 1, 2013, indicated, the facility will provide recreational opportunities for residents who are not physically able, or choose not to leave their room . Procedure .II Visitation A. Activities staff will maintain a list of residents who receive room visits, and room visit schedule. B. Residents who cannot or choose not to leave . will be visited by activity staff on a regular basis. III Documentation B Activities staff will maintain a record of the activities provided for each resident .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure dental services were provided for one of 42 sampled residents (Resident 14), when the social services director (SSD) did not follow up on unrepaired dentures between 9/10/18 and 9/21/18. This failure resulted in Resident 14 not receiving the needed dental services within three days of referral. Findings: On 9/18/18 at 10:56 a.m., during an interview, Resident 14 stated the dentist evaluated her dentures about 3 weeks ago and they still did not fit. Resident 14 stated she would like her dentures to be fixed so she can eat comfortably with dentures. Resident 14 stated she currently eat without her dentures because they hurt. On 9/19/18 at 1:55 p.m., during a concurrent interview and record review, Registered Nurse (RN) 1 stated she could not find documentation in Resident 14's clinical record indicating communication of dentures being fixed. On 9/19/18 at 4:40 p.m., during an interview, Resident 14's daughter (D) 1, stated Resident 14 had a sore mouth a few months back. The daughter stated the facility dentist saw her and took the resident's dentures for adjustment. When the dentures were returned, they did not fit and had been filed down. They do not fit any longer and she needs a new pair. The daughter stated the social services director (SSD) called her a week ago and indicated the dentures needed to be replaced. The SSD indicated she would adjust her diet. The daughter stated she had not heard anything since. On 9/20/18 at 8:34 a.m., during an interview, the SSD stated the dentist took Resident 14's dentures to repair, but did not fit correctly. The SSD stated the dentist took the resident's dentures on 7/23/18 to repair. The SSD stated the dentist brought back the resident dentures on 9/4/18 and the dentures did not fit the resident. The SSD stated the resident's dentures remain unrepaired. Resident 14's dental notes dated 7/23/18, indicated routine dental exam for complaint of mouth pain. The resident's dental notes dated 9/10/18, indicated the dentist was unable to resolve resident's complaint to repair her dentures. There was no documentation found in the resident's clinical record addressing dental services after 9/10/18. The facility policy and procedure titled Oral Healthcare & Dental Services dated 7/14/17, indicated, .When lost or damage is the responsibility of the facility, the facility is obligated to replace or repair the dentures .

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to accommodate food allergy and preferences for two of 42 sampled residents (Residents 3 and 23) when: 1. Resident 3 was served whole wheat bread which she communicated to staff that she disliked. 2. Resident 23 was served pork sausages which she disliked. These failures resulted in the failure to honor the residents' food allergy and food preference as written in the resident's tray cards. Findings: 1. On 9/18/18 at 9:08 a.m., during a concurrent observation and interview, Resident 13's breakfast tray included two pieces of toasted wheat bread. Resident 13 stated, I did not eat the whole wheat bread because it made my skin itch. On 9/19/18 at 2:24 p.m., during an interview, the Dietary Supervisor (DS) stated the dietary department should have honored the resident's likes and dislikes and allergy on food. Resident 3's tray card dated 9/18/18 indicated, Dislikes .Whole wheat bread . 2. On 9/19/18 at 9:30 a.m., during an observation of Resident 23 in her room, Resident 23 had just finished eating her breakfast. Resident 23's breakfast tray had sausages that were not eaten. On 9/19/18 at 9:58 a.m., during an interview in the presence of MDSC, the DS was asked what was the breakfast sausages made of and the DS stated the sausages were made of pork. Resident 23's tray card dated 9/19/18 indicated Dislike -Pork. On 9/19/18 at 2:24 p.m., during an interview, the DS stated the dietary department should have honored the resident's likes and dislikes on food. The facility's policy and procedure dated 4/1/14 indicated, . Procedure .IV. The Dietary Department will provide residents with meals consistent with their preferences as indicated on the tray card .

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to perform hand hygiene and proper food handling for two of 42 sampled residents (Residents 1 and 162) when: 1. [NAME] trainee (CT) dropped the residents' tray cards with gloved hands, picked them up and did not discard gloves and wash hands and continued to perform trayline duties. The dietary supervisor (DS) was handed the dropped tray cards and included the contaminated tray cards in the residents' tray. These failures placed the residents' at risk for cross contamination and food borne illnesses. Findings: 1. On 9/19/18 at 12:12 p.m., during a meal tray line lunch observation in the kitchen, cook trainee (CT) dropped on the floor Resident 1's tray card. While the DS looked on the CT with her gloved hand picked up the dropped card on the floor and handed it to the DS. At 12:26 p.m., CT dropped Resident 162's tray card on the floor. While the DS looked on, the CT again with her gloves hand picked up the dropped tray card on the floor and handed it to the DS. The CT finished the lunch tray line using the same contaminated gloves. The DS both times accepted from the CT the contaminated tray cards and included them in Resident 1's and 162's food trays. The CT was unavailable for interview. On 9/19/18 at 2:45 p.m. during an interview, the DS stated she should have instructed the CT to remove and discard the contaminated gloves, wash her hands, wear a new pair of gloves before she continued to finish the tray line. The DS stated she should not have included the contaminated meal tickets to go with the residents' meal trays. On 9/21/18 at 9:20 a.m., during an interview, the director of nursing (DON) stated the DS should have instructed the CT to remove the contaminated gloves, wash her hands, wear a new pair of gloves then continue with the tray line. The DON stated the DS should not have included the contaminated tray cards on the two residents' meal trays to prevent the risks for cross contamination and food borne illnesses. The facility's policy and procedure titled Hand Hygiene dated 2/1/13 indicated, Policy .considers hand hygiene the primary means to prevent the spread of infections . Procedure .V. Hand hygiene is always the final step after removing and disposing of personal protective equipment. VI. The use of gloves does not replace hand hygiene procedures .

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 ensure infection control procedures were followed for two of 42 sampled residents (Residents 49 and 15) when: 1. Certified nurse assistant (CNA) 1 failed to perform hand hygiene before and after the use of gloves in the provision of care to Residents 49 and 15. 2. CNA 1 did not wear gloves while providing personal care to Residents 49 and 15. These failures had the potential to place the residents at risk for cross contamination and spread of infections. Findings: 1. On 9/18/18 at 10:15 a.m., during an observation in Resident 49's room, CNA 1 donned a pair of gloves and made resident 49's bed. CNA 1 then removed her gloves, repositioned the resident's bedside table, picked up Resident 49's eyeglasses and put it on the resident. CNA 1 did not wash her hands before and after the use of gloves and prior to providing care to Resident 49. On 9/18/18 at 10:32 a.m., during an observation in Resident 15's room, CNA 1 transferred Resident 15 from the bed to the wheelchair with the use of a gait belt (a belt used to transfer a resident). CNA 1 removed her gloves then picked up the resident's blanket and draped it on the back of the resident's wheelchair. CNA 1 did not wash her hands after the use of gloves. At 10:46 a.m. CNA 1 donned another pair of gloves and wheeled Resident 15 inside the bathroom for toileting. When the resident's toileting was done, CNA 1 opened the door removed her gloves then placed some water on the resident's hair. CNA 1 did not wash her hands before and after the use of gloves. On 9/20/18 at 9:30 a.m., during an interview, CNA 1 stated she should have washed her hands before and after the use of gloves when providing personal care to the residents to prevent cross contamination 2. On 9/18/18 at at 10:10 a.m., during an observation in Resident 49' room, CNA 1 transferred Resident 49 from bed to a wheelchair with the use of a Hoyer Lift (a device used to transfer a resident with limited to no mobility from one area to another) without wearing gloves. On 9 /18/18 at 10:32 a.m., during an observation in Resident 15's room, CNA 1 without wearing gloves made Resident 15's bed and did not wash her hands after removing the gloves. On 9/20/18 at 9:30 a.m., during an interview, CNA 1 stated she should have washed her hands before and after the use of gloves and when providing personal care to the residents to prevent cross contamination. On 9/20/18 at 9:45 a.m., during an interview, the licensed vocational nurse (LVN) 1 stated the CNA should have washed her hands before and after the use of gloves and during the provision of personal care to the residents to prevent cross contamination and possible spread of infection from one resident to another. On 9/20/18 at 9;50 a.m., during an interview, the director of nursing (DON) stated the CNA should have washed her hands before and after the use of gloves and during the provision of care to the residents to protect the residents and others from cross contamination and possible spread of infections. The World Health Organization (WHO) titled Hand Hygiene: Why, How & When dated 9/25/18 indicated, Why? . Hand hygiene is therefore the most important measure to avoid transmission of harmful germs and prevent health care-associated infections. WHO? Any health - care worker, care giver or person involved in direct or indirect patient care needs to be concerned about hand hygiene and should be able to perform it correctly and at the right time When ? . 1. Before touching a patient. Why? - to protect the patient against colonization (Germs in or on the body, but not make you sick.) When? .b) Before assisting a patient in personal care activities: to move, to take a bath, to eat, to get dressed . 4. After touching a patient why? To you from colonization with patient germs and to protect the health care environment from germ spread. When? b) After assisting a patient in personal care activities: to move, to take a bath . 5. After touching the patient surroundings. Why? To protect you from colonization with patient germs that may be present on surfaces/ objects in patient surroundings and to protect the health - care environment against germ spread. When? . a) After an activity involving physical contact with the patient immediate environment: changing bed linen with the patient out of bed, holding a bed rail, clearing a bedside table . c) After other contacts with surfaces or inanimate objects . leaning against a bed, night table /bedside table.- The facility's policy and procedure titled Hand Hygiene dated 2/1/13 indicated, Purpose. To ensure that all individuals use appropriate hand hygiene while at the Facility. Policy. The facility considers hand hygiene the primary means to prevent the spread of infections Procedure .V. Hand hygiene is always the final step after removing and disposing of personal protective equipment. VI. The use of gloves does not replace hand hygiene procedures .

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to provide a sanitary and safe environment when: 1. room [ROOM NUMBER] had dead insects on the floor. 2. The dining room's ceiling and walls were observed with cobwebs. These failures created an environment not sanitary and homelike and placed Resident 1 and the residents who used the dining room at risk for cross contamination from bugs and unclean dining room ceilings. Findings: 1. On 9/18 /18 at 10:40 a.m., during an observation in Resident 1's room (Rm 9), the floor near the door entrance had a gray, crusted insect and a dead brownish bug on the floor near the window. On 9/18/18 at 1045 a.m., during an interview, the Maintenance employee stated It is fuzz. He stated there were bugs outside the room and they came in and out of the rooms. On 9/18/18 at 12:26 p.m., during an interview, the housekeeping manager (HM) stated the presence of the bug in Resident's 1's room was not good and they did not want that. the HM stated the bugs would be taken care of. The Facility's policy and procedure titled Housekeeping- General dated 1/1/12 indicated, Purpose. To ensure that the facility is clean, sanitary and in good repair at all times so as to promote the health and safety of residents, staff, and visitors. 2. On 9/18/18 at 12:17 p.m., during lunch observation in the dining room, white spider webs were on the dining room ceiling. On 9/18/18 at 12:26 p.m., during an interview, the HM stated the dusters did not reach that high and it was hard to get in the dining room while the residents were eating. The Facility's policy and procedure titled Housekeeping- General dated 1/1/12 indicated, Purpose. To ensure that the facility is clean, sanitary and in good repair at all times so as to promote the health and safety of residents, staff, and visitors.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 30's physician orders dated September 2018, indicated attend dialysis 3 x/week (three times per week) at [name of dialysis center] Dialysis . On 9/18/18 at 3:49 p.m., during concurrent observation and interview in Resident 30's room, the bed was empty. Licensed vocational nurse (LVN) 1 stated Resident 30 was at dialysis. On 9/20/18 at 8:37 a.m., during an interview, Resident 30 stated he goes to dialysis in town three times per week. On 9/20/18 at 3:30 p.m., during record review on the MDS with Assessment Reference Date (ARD) Section O, Special Treatments, Procedures and Programs . J. dialysis was not mark. On 9/20/18 at 3:40 p.m., during a concurrent interview and record review, the section of the MDS which documents dialysis was not coded correctly. MDSC stated she missed it. 3. On 9/18/18 at 10:43 a.m., during observation in room [ROOM NUMBER] A, Resident 12 was lying on her bed with a bottle of feeding formula hanging on her bedside, unconnected to her G-tube. On 9/21/18 at 9:39 a.m., during a concurrent interview and record review, the MDS assessment dated [DATE] the section for mood indicated Resident 12 had poor appetite. Social Service Director (SSD) stated she coded this section incorrectly. On 9/21/18 at 9:45 a.m., during an interview, the director of nursing (DON) stated Resident 12 had G-tube with continuous feeding and was not right to mark poor appetite. DON stated Resident 12 had tube feeding due to diagnosis of dysphagia (difficulty of swallowing). The facility policy and procedure titled, RAI Process revised October 4, 2016, indicated, Purpose .Policy the facility will utilize the Resident Assessment Instrument (RAI) process as the basis for accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 manual. Based on observation, interview and record review the facility failed to ensure the Minimum Data Set (MDS) (a resident assessment tool used to identify resident care needs) assessment accurately reflected the resident's status for three of 42 sampled residents (Resident 62, 30 and 12) when: 1. Resident 62's facility discharge was not coded (process of data entry) correctly in the section of the MDS for Discharge Status. 2. Resident 30's use of dialysis (process of removing waste products and excess fluid from the body) was not coded correctly in the MDS. 3. Resident 12's use of gastric tube (G-tube; tube inserted through the abdomen that delivers nutrition directly to the stomach) was not coded correctly in the MDS. These failures resulted in inaccurate coding and documentation of Resident 62's discharge from the facility; For Resident 30 and 12, these inaccurate codings had the potential to result in unmet care needs. Findings: 1. On 9/20/18 at 4 p.m., Resident 62's closed record was reviewed with the MDS coordinator (MDSC). Resident 62's clinical record dated 8/13/18 indicated, Res request to D/C (discharge), feels safe to go home & has met personal goals for safe D/C. States he has assistance if needed. Therapy recommends w/c (wheelchair), HH (Home Health) to f/u (follow up) with RN (Skilled Nursing), PT (physical therapy) & OT (occupational therapy). Res advised, must follow-up with PCP (primary care physician) with in 3-5 days of D/C. Resident also states he has O2 (oxygen) [at] home for his O2 needs. Resident 62's physician's telephone order dated 8/13/18 indicated,Res may D/C home with HH to evaluate [and] f/up with RN, PT, & OT. Res requires w/c for safe ambulation upon D/C when all arrangements made. Resident 62's discharge section of the MDS assessment indicated Resident 62 was discharged to an acute hospital on 8/15/18. On 9/21/18 at 9:40 a.m., during an interview, the MDSC stated when she reviewed again Resident 62's MDS she noted the discharge section of the MDS was not coded correctly. The MDSC stated she should have coded the MDS consistent with resident being discharged home and not to the hospital.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a complete comprehensive person centered care plan for four of 42 sampled residents (Residents 4, 60, 14 and 12) when: 1. Resident 4 did not have a nursing intervention developed and implemented to prevent falls. 2. Resident 60 did not have a care plan which addressed the use of supra pubic catheter. 3. Resident 14 did not have a care plan addressing appropriate diet for unrepaired dentures. 4. Resident 12's person centered care plan was not implemented for activities. These failures resulted in not meeting the identified needs of the residents. Findings: (related to CA00601304) 1. Review of complaint CA00601304 indicated on 8/25/18 at 1:45 a.m., Resident 4 fell while transferring self from wheelchair (w/c) to bed. An X-ray showed fracture of the 5th digit to right hand. On 9/18/18 at 3:25 p.m., during an interview, Resident 4 stated she was comfortable transferring herself independently from her bed to the w/c without assistance, Resident 4 stated she did not know how she fell down on 8/25/18. Resident 4 stated this happened in the middle of the night when she went to the bathroom. Resident 4 stated she was sent to the hospital for X-ray and she had a fracture of the 5th finger. Resident 4 stated she was seen by a doctor and braces were applied to her right hand. Resident 4 stated she continued to independently transfer herself from bed to w/c, to the toilet and back even after her fall. Resident 4's progress notes dated 8/25/18 indicated,On 0145 Unwitnessed fall . self-transferring from w/c to bed . stated she slipped . On 9/19/18 at 8:15 a.m., during a concurrent record review and interview, the MDS (Minimum Data Set) coordinator (MDSC) stated there was a short-term care plan for Resident 4's fall on 8/25/18 but the care plan did not have nursing interventions and therefore interventions were not implemented. On 9/19/19 at 9 a.m., during an observation in Resident 4's room, the MDCS inspected the socks and the fluffy house slippers Resident 4 was wearing. The MDSC stated the resident was not wearing a non-skid socks and the resident's house slippers did had not have a good grip on the floor surface for walking. The MDSC looked at the resident's drawer and was not able to find non-skid socks. The MDSC stated to prevent the resident from accidental falling again, the resident should have been provided with non-skid socks and a new house slippers with a better grip on the floor surface. The MDSC stated it was the responsibility of the licensed vocational nurse (LVN 4) to ensure a short-term care plan was developed and the interventions were put in place then implemented it. The MDSC stated LVN 4 did not do the care plan. On 9/19/18 at 9:58 a.m., during an interview, LVN 4 stated she should have included in Resident 4's short-term fall care plan the interventions to prevent another incident of falls. LVN 4 stated she should have included the resident's use of non-skid socks and provided these to the resident but she did not. 2. On 9/18/18 at 4:09 p.m., during an observation in room [ROOM NUMBER] A, Resident 60 was on his bed and indwelling urinary catheter bag hanging from the bottom of his bed. On 9/21/18 at 10:39 a.m., during concurrent interview and record review of Resident 60's clinical record and unable to find person centered care plan indicating the use of supra pubic catheter. Licensed vocational nurse (LVN) 2 stated Resident 60 has supra pubic catheter and being seen by urologist. LVN 2 unable to show a care plan on the use of the supra pubic catheter and stated who ever admitted the resident should have start the base line care plan then the minimum data set coordinator (MDSC) will revised it to comprehensive care plan. LVN 2 stated the care plan was missed and not done. On 9/21/18 10:41 a.m., during an interview, the nursing consultant (NC) confirm Resident 60 has no person centered comprehensive care plan. On 9/21/18 11:00 a.m., during an interview, the MDSC stated she missed doing the comprehensive care plan indicating the use of supra pubic catheter care plan. 3. On 9/18/18 at 10:56 a.m., during an interview, Resident 14 stated she had her dentures filed down about 3 weeks ago and has difficulty eating. The resident stated she cannot eat certain foods such as meat because she cannot chew. The resident stated she asks for soups so she can swallow food and she waits for her cereal to get soggy before she eats it. On 9/19/18 at 1:49 p.m. during an interview, certified nurse assistant (CNA) 1 stated the dentist took dentures a few weeks ago to get new ones because they were not fitting Resident 14. CNA 1 stated Resident 14 will ask for soup if food is too hard for her to chew. CNA 1 stated the resident won't eat certain foods because it is too hard for her to eat. On 9/19/18 at 1:55 p.m., during a concurrent interview and record review, registered nurse (RN) 1 stated if Resident 14 had trouble with eating because her dentures didn't fit, she would have put in an order to change the resident's diet. RN 1 reviewed the clinical record of Resident 14 and stated she could not find anything indicating diet change. On 9/19/18 at 2:56 p.m. during an interview, the director of nursing (DON) stated her expectation is for there to be a care plan regarding appropriate diet for Resident 14. DON stated there was no care plan addressing diet change. Resident 14's care plan titled Resident Care Plan Nutrition and Hydration shows no documentation of diet change related to poor fitting dentures. The facility policy and procedure titled Oral Healthcare & Dental Services dated 7/14/17, indicated, .Develop a plan of care to ensure that the resident can eat and drink adequately while awaiting dental services . 4. On 9/18/18 at 10:49 a.m., during a concurrent observation and interview in room [ROOM NUMBER] A, Resident 12 was lying on her bed with the television mounted on the wall and on. Licensed vocational nurse (LVN) 2 stated Resident 12 was aphasic (a condition following brain injury that impairs the comprehension and ability to speak). On 9/18/18 at 3:00 p.m., during an observation in room [ROOM NUMBER] A, Resident 12 was in her bed with the TV on, no activity staff or other staff visited the resident at this time; no music was on. On 9/19/18 at 8:48 a.m., during an observation in room [ROOM NUMBER] A, Resident 12 was lying in her bed covered with blankets, no activity staff or other staff visited the resident at this time; no music was on. On 9/19/18 at 11:19 a.m., during an observation in room [ROOM NUMBER] A, Resident 12 was lying in her bed with a gown on, and no activity staff or other staff visited the resident at this time; no music was on. On 9/19/18 at 2:30 p.m., during an observation in room [ROOM NUMBER] A, Resident 12 was dressed in a gown and lying on her bed. No activity staff were in her room at this time and no activity had been offered to Resident at this time; no music was on. On 9/20/18 at 10:30 a.m., during an interview, Certified Nursing Assistant (CNA) 2 stated she usually got Resident 12 up as soon as she finished getting up the other residents who were going to dialysis. CNA 2 stated when Resident 12 was up in a chair, staff would place her by the nurses' station or by the lobby. On 9/20/18 at 11:24 a.m., during an observation, Resident 12 was up in her chair and was placed in front of the nurses station. Staff did not offer activities to Resident 12. On 9/20/18 at 4:20 p.m., during a concurrent interview and record review, the Activity Director (AD) stated Resident 12 was provided activity in her room. AD stated the expectation for residents with room activity is to provide sensory stimulation, taking out to the lobby, discussion by talking to the resident. AD reviewed the Resident Participation Log which indicated no documentation on 9/18, 9/19 and 9/20 on whether or not room visits, sensory stimulation, group or discussion occurred. The Room Visits Response Form indicated, no documentation for 9/18, 9/19, and 9/20. AD stated she did not do any room visits on Resident 12 since Tuesday 9/18/18 but could not provide documentation. Review of Resident 12's care plan indicated the following current activities: TV, patio outing, music, church and pet therapy. The intervention indicated Music at bed side. The facility Resident Participation Log did not document any of the activities described in the care plan. The facility's policy and procedure titled Comprehensive Person-Centered Care Planning dated 9/18 indicated,Purpose. To ensure that a comprehensive person centered care plan is developed for each resident. Policy . Facility to provide person-centered comprehensive and interdisciplinary (IDT) care that reflects best practice standards for meeting health safety . needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being.

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to provide sufficient staffing to five of 42 sampled residents (Residents 14, 21, 30, 49, 54) when certified nursing assistants (CNA) did not assist residents with care needs during meals. This failure resulted in residents to have care needs unattended during meal times. Findings: On 09/18/18 at 10:56 a.m., during a concurrent interview and record review, Resident 14 stated the staff needs help. Resident stated the CNAs always need help. Resident 14's brief interview for mental status (BIMS) was 13, meaning cognitively intact. On 9/20/18 at 3:27 p.m., during an interview, Resident 21 stated there is not enough staffing. The resident stated the facilities' budget is under budget and understaffed. The resident stated the CNAs do not attend residents in a decent time. He stated time could be 3 minutes or 3 hours. Resident 21's BIMS was 14, meaning cognitively intact. On 9/20/18 at 4:06 p.m., during an interview, Resident 49 stated the CNAs are more concerned with passing trays during lunch then attending the needs of residents. The resident stated when someone needs to be changed, the CNAs will pass meal trays rather than attend needs of residents. The resident stated that it seems meal trays are more important than the needs of the residents. The resident stated, It makes me angry when needs don't get met. Resident 49's BIMS was 13. On 9/21/18 at 8:09 a.m., during an interview, Resident 30 stated that during lunch time, the CNAs do not attend the needs of other residents because they are busy with passing trays during meal times. Resident 30's BIMS was 99. On 9/21/18 at 8:12 a.m., during an interview, Resident 54 stated the staff will come in and turn off call lights and walk out of the room. Resident stated, The CNAs leave my room without attending to my needs. On 9/21/18 at 9:49 a.m., during an interview, CNA 2 stated during meal time, CNAs do not attend to residents needing toilet assistance due to passing meal trays to residents. On 9/21/18 at 12:57 p.m., during an interview, CNA 3 stated the p.m. shift CNAs have had staffing issues. He stated that during meal times, the CNAs have been instructed not to give toileting care to residents until the meal trays have been delivered to all residents. This occurs from 5-7 p.m. CNA 3 stated that if a resident needs assistance with toileting, the resident must wait until a CNA can assist the resident. The facility's policy and procedure titled Communication - Call System dated 1/1/12, indicated, .Nursing Staff will call bells promptly, in a courteous manner .In answering to request, Nursing Staff will return to resident with the item or reply promptly .Assistance will be offered before leaving .

CONCERN (F)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected most or all residents

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Based on interview, and record review, the facility failed to implement their policy regarding food for residents brought in by visitors for four of 42 sampled residents (Residents 3, 44, 22, and 54) when: 1. Residents 3, 44, 22 and 54 were not provided a copy of the facility policy regarding food brought in by family or visitors and were unaware of the opportunity to have food brought in by outside sources and reheated in the facility. 2. Staff were unaware of the requirement to permit food brought in by outside sources be stored and reheated in the facility. Staff were not trained in safe food handling practices for food brought in by family and visitors. These failures denied residents the choice to have food brought in by family and visitors and stored and reheated in the facility for later consumption in a safe manner. Findings: 1. On 9/18/18 at 9:52 a.m., during an interview, the dietary supervisor (DS) stated food brought in by the family and visitors was not stored or reheated in the kitchen for reason of the possibility of cross contamination. The DS stated only foods from the facility suppliers were stored at the kitchen. When asked if the facility staff reheat food from the outside at the facility when the residents' requested it, the DS stated whatever the staff did on the floor outside of the kitchen was not her concern. On 9/18/18 at 10 a.m., Resident 3 stated she was not aware food from the outside could be stored and reheated at the facility for later consumption. On 9/18/18 at 10:10 a.m., during an interview, Resident 44 stated she did not know food from the outside could be reheated if she wanted to. On 9/18/18 at 10:30 a.m., during an interview, Resident 4 stated she did not know food from the outside could be stored and reheated for later consumption. On 9/19/18 at 2:45 p.m. during a concurrent record review and interview, when reading the facility policy regarding food for the resident brought by visitors, the DS stated she was not aware of this policy that the facility could store and reheat food from the outside. The DS stated because she did not know the facility could store foods of the residents from the outside she had not trained staff on safe food handling practices. 2. On 9/19/18 at 3:21 p.m., during an interview, certified nurse assistant/restorative nurse assistant (CNA/RNA) 1 stated no residents had asked her to store or re-heat food for them. CNA/RNA 1 stated she did not know the facility had a policy that the resident's food could be stored and reheated at the facility. CNA/RNA 1 stated she had not undergone any training on handling food safely. On 9/19/18 at 3:30 p.m., during an interview, CNA 1 stated she had not reheated any food from the outside for residents. CNA 1 stated she did not know residents' food from the outside could be reheated at the facility. On 9/19/18 at 3:40 p.m. during an interview, CNA/RNA 2 stated she was not aware the facility had a policy that food from the outside could be stored and reheated later for the residents and she was not trained on handling food safely. On 9/19/18 at 3:50 p.m. during an interview, CNA/RNA 3 stated she did not know about the facility policy on storing and reheating residents' food from the outside for later consumption and she was not trained on handling food safely. On 9/20/18 at 9:50 a.m., during a concurrent record review and interview, the director of nursing (DON) stated the facility did not follow it's policy on Food Brought in by Visitors which allowed resident's food from the outside to be stored, handled and reheated for later consumption because the DS did not even know about the policy. The DON stated the residents did not know about the food brought in by visitors policy because it was not included in the admission packet. The DON stated the dietary and facility staff were not trained on safe food handling practices for food brought in from the outside. The facility's policy and procedure titled California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities dated 5/11 indicated, Snacks. Please make sure that all food or snacks left with the patient are stored in a sealed Tupperware like container. The charge nurse must be notified in advance of any meals that will be brought in for the patient The facility's policy and procedure titled Food Brought in by Visitors dated 3/18 indicated, Purpose. To provide residents with the options of having food prepared or purchased by the resident's visitors brought into the Facility . Procedure: 1. If the resident desires to have food brought in by visitors, the Dietary Staff will review the resident's diet with the visitor, and provide education regarding the resident's diet orders and safe food handling practices. A. Food from outside sources should be stored in a sealable container . V. The nurse assigned to the resident will account for the proper temperature of the food served and log it on the temperature log . A. Food items that are reheated to the proper temperatures: i. The potentially hazardous food (PHF) or time/temperature controlled for safety (TCS) food that is cooked and cooled must be reheated so that all parts of the food reach an internal temperature of 165 degrees Fahrenheit (F) for at least 15 seconds before holding for hot service; and ii. Ready- to -eat foods that require heating before consumption are best taken directly from a sealed container (secured against the entry of microorganisms ) or an intact package from an approved processing source and heated to at least 135 degrees F for holding for hot service. VI. Perishable food requiring refrigeration will be discarded after 48 hours .

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?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 2 life-threatening violation(s), Special Focus Facility, 3 harm violation(s), $100,597 in fines, Payment denial on record. Review inspection reports carefully.
• 61 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $100,597 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 is on CMS's Special Focus list for poor performance. Consider alternatives strongly.

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About This Facility

What is Majestic Mountain's CMS Rating?

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

How is Majestic Mountain Staffed?

CMS rates MAJESTIC MOUNTAIN CARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 67%, which is 20 percentage points above the California average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Majestic Mountain?

State health inspectors documented 61 deficiencies at MAJESTIC MOUNTAIN CARE CENTER during 2018 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 56 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Majestic Mountain?

MAJESTIC MOUNTAIN CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BAYSHIRE SENIOR COMMUNITIES, a chain that manages multiple nursing homes. With 66 certified beds and approximately 62 residents (about 94% occupancy), it is a smaller facility located in OAKHURST, California.

How Does Majestic Mountain Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, MAJESTIC MOUNTAIN CARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (67%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Majestic Mountain?

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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "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 facility's high staff turnover rate, and the below-average staffing rating.

Is Majestic Mountain Safe?

Based on CMS inspection data, MAJESTIC MOUNTAIN CARE CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). 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 Majestic Mountain Stick Around?

Staff turnover at MAJESTIC MOUNTAIN CARE CENTER is high. At 67%, the facility is 20 percentage points above the California average of 46%. Registered Nurse turnover is particularly concerning at 71%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Majestic Mountain Ever Fined?

MAJESTIC MOUNTAIN CARE CENTER has been fined $100,597 across 2 penalty actions. This is 3.0x the California average of $34,085. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Majestic Mountain on Any Federal Watch List?

MAJESTIC MOUNTAIN CARE CENTER is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 66
Avg. Residents: 62
Occupancy: 94.7%
Ownership: For profit - Corporation
Chain: BAYSHIRE SENIOR COMMUNITIES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
2 Immediate Jeopardy citations: -24
3 Actual Harm citations: -15
61 Deficiencies: -10
Fines ($100,597): -15
Special Focus Facility: -20
Final Score: 0/100

Nearby Alternatives

PALMS CARE CENTER 4-star GOLDEN MADERA CARE CENTER 4-star CHOWCHILLA MEMORIAL HEALTHCARE... 3-star

View all in OAKHURST →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555115