What is NEW ORANGE HILLS's CMS rating?

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

How many inspection deficiencies does NEW ORANGE HILLS have?

NEW ORANGE HILLS has 94 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at NEW ORANGE HILLS?

NEW ORANGE HILLS has a two-star staffing rating from CMS with 0.51 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 NEW ORANGE HILLS located?

NEW ORANGE HILLS is located in ORANGE, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does NEW ORANGE HILLS have?

NEW ORANGE HILLS has 145 certified beds.

Who owns NEW ORANGE HILLS?

NEW ORANGE HILLS is a for profit - corporation facility and is part of the THE ENSIGN GROUP chain.

Is NEW ORANGE HILLS safe?

NEW ORANGE HILLS has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at NEW ORANGE HILLS stick around?

NEW ORANGE HILLS has average staff turnover at 40%, which is typical for the nursing home industry.

Was NEW ORANGE HILLS ever fined?

Yes, NEW ORANGE HILLS has been fined $15,397 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is NEW ORANGE HILLS on any federal watch list?

No, NEW ORANGE HILLS is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at NEW ORANGE HILLS?

Medicare inspectors have found 94 deficiencies at NEW ORANGE HILLS: 87 moderate, 7 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting NEW ORANGE HILLS?

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

How does NEW ORANGE HILLS compare to other nursing homes?

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

NEW ORANGE HILLS | 48/100 (Grade D)

Sept 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the necessary care and services were provided when m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the necessary care and services were provided when monitoring the blood pressure for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2's blood pressure was monitored as per the physician's order. In addition, the facility failed to ensure the staff had used an approved device to monitor Resident 2's blood pressure. This failure posed the risk for the resident to have inaccurate blood pressure readings.Findings: On 9/18/25 at 1430 hours, an interview was conducted with Resident 2. Resident 2 verbalized his concern about the facility nurses using a wrist blood pressure machine to obtain his blood pressure readings. Resident 2 stated he did not want his blood pressure obtained with a wrist blood pressure machine because it was inaccurate and often gave a systolic blood pressure (SBP) reading of 99 mmHg. Resident 2 stated the nurses would have to retake his blood pressure five times before getting an accurate blood pressure reading. Resident 2 further stated the nurses were obtaining his blood pressure from his dialysis access site on the left arm, which was not supposed to happen. Medical record review for Resident 2 was initiated on 9/18/25. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 11/14/24, showed Resident 2 had the capacity to understand and make decisions. Resident 2's diagnoses included End Stage Renal Disease (ESRD) on hemodialysis, high blood pressure, and history of diabetes. Review of Resident 2's Order Summary Report showed the following physician's orders:- dated 11/9/24, for amlodipine (blood pressure medication) 10 mg daily for hypertension, with instructions to hold if Resident 2's systolic blood pressure was less than 110 mmHg; and- dated 2/1/25, no blood pressure readings to be obtained from Resident 2's hemodialysis access site on the left arm. Review of Resident 2's Physician Progress Note dated 9/9/25, showed Resident 2's plan of treatment included the monitoring of Resident's 2 blood pressure for his high blood pressure diagnosis. On 9/18/25 at 1530 hours, concurrent interview and medical record review was conducted with LVN 1 and the DON. When asked what machine was used to obtain Resident 2's blood pressure readings, LVN 1 stated she used a wrist blood pressure machine. When asked which arm LVN 1 used to obtain the blood pressure readings, LVN 1 stated Resident 2 would offer the arm where he wanted to have his blood pressure readings done. The DON stated the nurses were to use the facility's blood pressure machines, not a wrist blood pressure machine. The DON also stated the nurses should check the orders to ensure the blood pressures were obtained as ordered by the physician. The DON and LVN 1 verified Resident 2 had an order to not have his blood pressure obtained from Resident 2's left arm hemodialysis access site.

Aug 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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections for one of three sampled residents (Resident 3). * The facility failed to ensure the EBP was implemented for Resident 3. This failure had the potential risk for transmission of communicable diseases or organisms to residents in the facility.Findings: Review of the facility's P&P titled Infection Prevention and Control Program: Standard and Transmission Based Precautions dated 3/2024 showed EBP are used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves in during high contact resident care that provide opportunities for indirectly transfer of the MDROs to staff hands and clothing then indirectly transferred to the resident to resident; resident with wounds and indwelling medical devices re at especially high risk of both acquisition of and colonization with MDROs. Medical record review for Resident 3 was initiated on 8/5/25. Resident 3 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 6/4/25, showed Resident 3 had the capacity to make needs known and the capacity to make medical decisions. Resident 3 had a cranioplasty done on 5/4/24. Resident 3's surgical wound was healing slowly and dehisced on 5/2025. Review of Resident 3's Order Summary Report dated 8/6/25, showed the following physician orders: - dated 7/30/25, to cleanse the scalp surgical wound with normal saline, pat dry, apply xeroform (a non-adhesive, petrolatum-impregnated gauze dressing that maintains a moist wound environment and prevents adherence to the wound bed, promoting healing) and cover with ABD pad, secure with kerlix wrap every day shift x 30 days- dated 7/30/25, to cleanse the left temple surgical wound with normal saline, pat dry, apply collagen powder (treatment essential for wound healing and tissue regeneration) and cover with ABD pad, secure with kerlix wrap every day shift for 30 days Further review of Resident 3's Order Summary Report failed to show a physician's order for EBP was in place. On 8/5/25 at 1500 hours, an observation was conducted of Resident 3. Resident 3 was observed in bed with kerlix wrapped around his head. There was no PPE set-up or EBP sign outside the door. On 8/5/25 at 1505 hours, an observation of Resident 3 and concurrent interview was conducted with LVN 1 and the IP. LVN 1 stated Resident 3 was not on EBP. LVN 1 further stated Resident 3 should have been on EBP because he had a wound on his head. The IP stated Resident 3 should be on EBP because of his surgical wound. The IP verified there was no physician's order for EBP, no PPE set-up, and EBP was not implemented. On 8/6/25 at 1455 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 3 has surgical wound on the head and there was no physician's order for EBP or PPE set- up and EBP was not implemented. On 8/6/25 at 1535 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and verified the above findings.

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the licensed nurses had compet...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the licensed nurses had competencies and skill sets needed to care for one of five sampled resident (Resident 1). * LVN 1 reported the abnormal laboratory values to Resident 1's physician without clarifying the physician's orders, which only addressed the resident's fluid status but not the severely low Hgb and Hct, and elevated WBC count. This failure created the potential risk of not providing qualified staff for the resident's care. Findings:Review of the facility's P&P titled Diagnostic Test Results Notification revised 1/2022 showed the results of the laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be reported to the resident's attending physician promptly or as specified in the order. 1. Closed medical record review for Resident 1 was initiated on 6/24/25. Resident 1 was admitted to the facility on [DATE], and discharged on 5/21/25. Review of Resident 1's H&P examination dated 5/20/25, showed Resident 1 had fluctuating capacity. Resident 1 had diagnoses of chronic respiratory failure, tracheostomy, ventilator dependence, and anemia of chronic disease. Review of Resident 1's Order Summary Report showed a physician's order dated 5/20/25, for laboratory blood levels on the morning of 5/21/25, CBC and BMP. Review of Resident 1's laboratory results report dated 5/21/25 at 0929 hours, showed the following values and normal reference ranges:WBC - 17.7 High (normal range: 4.0 - 10.5 thous/mcl)HGB - 7.5 Low (normal range: 13.5 - 16.9 g/dl)HCT - 23.4 Low (normal range: 39.5 - 50 %) Review of the communication exchange between Resident 1's physician and LVN 1 showed on 5/21/25 at 1154 hours, a picture of Resident 1's CBC and BMP report was sent via text on the facility's cell phone. The following message was included with the laboratory results: Here are Resident 1's lab results and Resident 1's room number was provided. On 5/21/25 at 1157 hours, Resident 1's physician responded back with the question, what water flushes is she getting? On 5/21/25 at 1200 hours, LVN 1 responded back that Resident 1 was the male resident, repeated Resident 1's room number, and Resident 1 was receiving water flushes at 40 cc per hour. On 5/21/25 at 1203 hours, Resident 1's physician texted an order for the water flushes to be increased to 50 cc per hour. Review of the communication exchange between Resident 1's physician and LVN 6 showed on 5/21/25 at 2142 hours, LVN 6 notified Resident 1's physician that Resident 1's blood pressure was 78/48 mmHg and after elevating Resident 1's legs for 15 minutes the blood pressure was up to 90/50 mmHg. Resident 1's physician responded with a request for Resident 1's laboratory values which he had ordered. LVN 6 responded it was the male resident, the labs were sent earlier, the BUN was 58, and the WBC was 17.1. Resident 1's physician responded nobody had sent those labs to him and he needed to see them. LVN 6 then sent the lab values to Resident 1's physician. The physician ordered blood cultures, a urine test, chest x-ray, an antibiotic every eight hours, and one liter of normal saline. Resident 1's physician wrote back having two residents with the same last name was confusing. Review of Resident 1's progress note dated 5/21/25 at 2230, showed Resident 1's blood pressure was 90/56 mmHg, pulse was 95, and SpO2 was 85%. Resident 1's physician was notified and the physician ordered Resident 1 to be transferred to the acute care hospital via 911. On 7/1/25 at 1328 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1 stated she worked primarily as the desk nurse and one of the responsibilities of the desk nurse was to inform the physician of the laboratory results and to receive any new orders. The abnormal laboratory results the LVN had sent to Resident 1's physician on 5/21/25 were reviewed. When LVN 1 was asked if she had any concerns about the low Hgb and Hct levels, and the high WBC count, LVN stated, I just followed the orders. On 7/9/25 at 1350 hours, an interview and concurrent closed medical record review was conducted with LVN 4. LVN 4 stated when abnormal laboratory values were received, the first action was to assess the resident and communicate with the charge nurse taking care of the resident. LVN 4 stated she would then personally assess the resident. LVN 4 stated she would write the prior laboratory results on the report and highlight any significant laboratory results, before sending them to the physician. LVN 4 stated she would also communicate any significant information about the resident to the physician. During the review of Resident 1's laboratory results, LVN 4 stated she would talk with the RN supervisor about it. LVN 4 stated she would have assessed the resident for bleeding. LVN 4 stated she would have contacted the resident's physician and made sure he saw the low Hgb and Hct levels and asked if the resident could be sent out. On 7/9/25 at 1315 hours, an interview was conducted with the Administrator. The Administrator stated the nurses should have a basic understanding of the laboratory values. On 7/10/25 at 1045 hours, an interview was conducted with the DON. The DON stated she expected the nurses to question orders that did not make sense. The DON stated when LVN 1 communicated Resident 1's laboratory values to the resident's physician, the LVN did not clarify with the physician if there was no order to address the abnormal WBC count or the low Hgb and Hct. On 7/10/25 at 1334 hours an interview was conducted with the DSD. The DSD stated the nurses had three days of orientation with a brief review about laboratory values but nothing specific to verify competency.

May 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and servic...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of eight sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1 was seen for the outpatient physician's follow-up appointments. * The facility failed to ensure Resident 2's wound care was followed as ordered by the physician. These failures had the potential to negatively affect the residents' well-being as the necessary care and services were not provided. Findings: 1. Review of Resident 1's medical record was initiated on 4/25/25. Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of acute and chronic respiratory failure, tracheostomy, and congenital malformation of skull and facial bones. Review of Resident 1's Order Summary Report showed the following physician's orders for the following: -dated 4/3/25, showed appointment speech evaluation MD on 4/7/25 -dated 4/2/25, showed appointment for plastic surgeon on 4/9/25 Review of Resident 1's Social Services Progress Notes dated 4/7/25, showed Resident 1 had an appointment for speech evaluation at 1430 hours. Further review of the medical record showed the appointment was cancelled per the SSD. Review of Resident 1's Social Services Progress Note dated 4/7/25, showed the SSA reached out to the transportation company, and they could not accommodate the doctor's appointment and would have to be private pay. On 5/9/25 at 0846 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated if a resident had an outpatient appointment, the facility would arrange the transportation and pay out of pocket if needed. When the DON was asked if a follow-up appointment should have been made for Resident 1, the DON stated, yes. On 5/9/25 at 0925 hours, an interview and concurrent medical record review for Resident 1was conducted with the SSD and DON. The SSD stated Resident 1 had a speech evaluation appointment scheduled for 4/7/25 at 1430 hours. The SSD stated she attempted to arrange transportation for the appointment scheduled for 4/7/25; however, the transportation could not be arranged due to Resident 1's insurance. The DON stated Resident 1 had a plastic surgery appointment scheduled. When asked if Resident 1 went to the appointment, the DON stated the resident did not go to any appointments. 2. Closed medical record review for Resident 2 was initiated on 4/25/25. Resident 2 was admitted to the facility on [DATE], and discharged on 3/12/25. Review of Resident 2's Order Summary Report dated 3/6/25, showed for the right lower extremity, to remove Prevena Dressing (wound management system used after surgery to manage closed surgical incison) on 3/7/25, one time only. Review of Resident 2's Progress Notes dated 3/7/25, showed Prevena dressing removed per PCP orders, no complaints of pain or discomfort before, during and post procedure. Slight ss drainage noted on sections of the surgical incision to the right hip, ecchymosis also noted during procedure. Right hip surgical incision noted with 65 staples measuring 35.0 x 1.0 cm. Areas werecleanse with betadine, covered with dry dressing, Tx as ordered. On 5/8/25 at 1451 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 verified there wasno physician's order to apply betadine to Resident 2's wound care, and it would require a physician's order. On 5/14/25 at 1335 hours, an interview was conducted with the DON. The DON verified the betadine wound care would require a physician's order. On 5/14/25 at 1437 hours, the Administrator and the DON acknowledged the above findings.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary ca...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure injuries for one of eight sampled residents (Resident 7). * The facility failed to apply barrier cream to Resident 7's sacrum during the wound care as ordered by the physician. * Resident 7's wound care assessment failed to reflect Resident 7 had underminingto the sacrococcyx pressure injury. * The facility failed to ensure the low air loss mattress settings for Resident 7 were set correctly. These failures had the potential for Resident 7 to not receive the appropriate care and services to promote healing of the pressure injury. Findings: Review of the facility P&P titled Skin and Wound Monitoring and Management revised 1/2023 showed the following: 1. A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not be limited to: - measuring the skin injury; - staging the skin injury (when the cause is pressure); - describing the nature of the injury; - describing the location of the skin alteration; - describing the characteristics of the skin alteration 2. Suggestions for measuring: assessment of the pressure injury for tunneling, and undermining is an important part of the complete pressure injury assessment. 3. If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative note documenting that notification. 4. Monitoring: daily via medication administration and treatment administration records; confirm all orders have implemented as ordered. 5. Communication of Changes: any changes in the condition of the resident's skin as identified daily, weekly, monthly or otherwise, must be communicated to: resident/responsible party, the resident's physician, others as necessary to facilitate healing. 1. Review of Resident 7's medical record was initiated on 5/8/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 7 had a diagnosis of anoxic brain damage. Review of Resident 7's H&P examination dated 5/8/25, showed Resident 7 was able to open eyes occasionally with tracking, non-verbal, and unable to follow commands. Review of Resident 7's Order Summary Report showed the following orders dated: - 5/6/25, apply barrier cream to perineal and sacral areas everyday shift for skin management and as needed; - 5/8/25 Santyl (medication to treat wounds) external ointment, apply to sacrum topically every day shift for wound management for 30 days. On 5/8/25 at 0941 hours, an observation was made of LVNs 1 and 2 performing wound care to Resident 7's sacrococcyx pressure injury. During the observation, Resident 7 had undermining from 8 o'clock to 12 o'clock. LVN 2 performed woundcare to the exposed tissue areas and did not perform wound care to the undermining areas. On 5/8/25 at 1100 hours, an interview was conducted with LVN 2. When LVN 2 was askedif Resident 7 had any undermining present, LVN 2 stated, I didn't notice, didn't see any loose skin. On 5/8/25 at 1139 hours, a concurrent observation of Resident 7 and interview was conducted with LVNs 1 and 2. LVN 2 verified Resident 7's sacrococcyx pressure injury had undermining from 8 o'clock to 12 o'clock of 3 cm. On 5/8/25 at 1148 hours, an interview was conducted with LVN 1. LVN 1 stated he did not notice the undermining upon initial assessment but will notify the physician regarding the undermining. 2. Review of Resident 7's LN-Initial admission Record dated 5/6/25, showed Resident 7 had a coccyx pressure injury. Further review of the Initial admission Record did not show the measurements or staging of the pressure injury. Review of Resident 7's LN Skin Evaluation PRN/Weekly document dated 5/7/25, did not address Resident 7 had undermining to the sacrococcyx pressure injury. Review of Resident 7's Care Plan Report showed the following: - dated 5/6/25, hadpressure ulcer of the sacrum related to been immobile, incontinent. The interventions included to assess/record/monitor wound healing; assess and document status of the wound perimeter,wound bed and healing progress; report improvements and declines to the MD; to administer treatments as ordered; and to monitor for effectiveness. On 5/8/25 at 1100 hours, an interview and concurrent observation of Resident 7 was conducted with LVNs 1 and 2. When LVN 2 was asked if Resident 7 was observed to have undermining, LVN stated she did not see any undermining. On 5/9/25 at 1006 hours, an interview was conducted with the DON. The DON stated the undermining areas for Resident 7's sacrococcyx pressure injury would also require cleaning the wound and applying the treatment as ordered by the physician. 3. Review of Resident 7's Weights and Vitals Summary dated 5/7/25, showed Resident 7's weight was 116 pounds. Review of Resident 7's MDS assessment dated [DATE], showed the following assessment in section GG Functional Abilities: - roll left and right 1 , indicating dependent - sit to lying 88 , indicating not applicable due to medical condition or safety concerns. -l [NAME] to sitting on side of bed 88 indicating not applicable due to medical condition or safety concerns. - sit to stand, 88 indicating not applicable due to medical condition or safety concerns. Review of Resident 7's Order Summary Report dated 5/6/25, showed to use the LAL mattress for wound management and check the placement and settings every shift. Review of Resident 7's Care Plan Report dated 5/7/25, showed Resident 7 had Stage 4pressure injury to the sacrum. The interventions included to use the LALM for wound management and check the placement and settings every shift. Review of the Med-Air 8 Alternating Pressure Mattress Replacement System with Low Air Loss User Manual showed for the pressure range selection, the users can adjust the pressure levels of the air mattress using the analog pressure dial to a desired firmness based on personal comfort or weight settings. On 5/8/25 at 0952 hours, a concurrent observation of Resident 7 and interviewwas conducted with LVN 1. LVN 1 verified Resident 7's LALM setting was set to 180 pounds, and Resident 7 weighs 116 pounds. On 5/9/25 at 1006 hours, an interview was conducted with the DON. The DON stated the LALM setting would be dependent on the resident'sweight. The DON verified the LALM setting for Resident 7 was not set according to Resident 7's weight of 116 pounds. On 5/14/25 at 1437 hours, the Administrator and the DON acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection con...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices were followed for one of eight sampled residents (Resident 1). * The facility failed to ensure the isolation gown found in the clean linen's drawer outside Resident 1's room was free from the soiled gloves. * The facility failed to change the soiled tracheostomy tie after performing the neck wound care for Resident 1. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms. Findings: Review of the facility's P&P titled Infection Prevention and Control Program revised 10/2022 showed the following: a. Facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. b. Facility personnel will handle, store, process, and transport linens so as to prevent the spread of infection. c. The facility personnel will use effective methods for safe storage, transport, and disposal of garbage, refuse and infectious waste, consistent with all applicable local, state, and federal requirements for such disposal. Review of the facility's P&P titled Securing Tracheostomy Tubes (undated), showed all the tracheostomy tube ties shall be changed after the resident had a shower/bath, per trach tube tie change schedule, and as needed if soiled. 1. Review of Resident 1's medical record was initiated on 4/25/25. Resident 1 was admitted to the facility on [DATE]. Resident 1 had a diagnosis of acute and chronic respiratory failure, tracheostomy, and congenital malformation of skull and facial bones. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had moderate cognitive impairment with a BIMS score of 10, indicating moderate cognitive impairment. On 5/7/25 at 1004 hours, an observation of Resident 1's wound care treatment was conducted with LVN 1. During the observation, an isolation cart containing clean yellow folded isolation gowns was observed outside Resident 1's room. During the surveyor's donning of the yellow isolation gown, the wadded up gloves were found inside the left sleeve of the gown. LVN 1 verified the findings. On 5/7/25 at 1312 hours, an interview was conducted with the IP nurse. When asked about the facility's process when gloves were found inside the isolation gown, the IP nurse stated the isolation gown should be checked before placing them in the clean linen drawers. On 5/7/25 at 1344 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the process for washing the isolation gowns was to take out the gloves and wash the gowns separately from the other linens; however, sometimes the gloves got stuck in the gowns, and since the gloves were plastic, it melted, but the laundry staff tried to check the gowns two to three times to make sure there were no gloves in the gowns. The Maintenance Director stated the best thing they coulddo to resolve the situation was to conduct an in-service. On 5/9/25 at 1006 hours, an interview was conducted with the DON. The DON stated she believed the gloves found inside the gown was an isolated incident and stated,I have no explanations, except that it shouldn't be there. 2. Review of Resident 1's Order Summary Report showed a physician's order for the following dates: - dated 3/11/25, to provide trach care every day and night shift. - dated 5/2/25, cleanse right neck wound with normal saline, pat dry, collagen powder, xeroform gauze (a wound dressing to maintain a moist wound environment), place abdominal dressing under trach tie, every day shift for wound management for 14 days until finished. Review of Resident 1's eINTERACT Change in Condition Evaluation V4.2 dated 4/20/25, showed Resident 1 had a 5 cm x 2.3 cm laceration to the right side of the neck inflicted by trach tie. The recommendations of the primary clinician showed the following: consult with the wound MD, treatment order received from the wound MD to cleanse right neck with NS (normal saline), pat dry, apply xeroform, cover with abdominal dressing under trach tie for support. Review of Resident 1's Respiratory Ventilation Records dated from 5/2-5/4/25, showed an order dated 5/4/25, equipment change 1 Further review of the Respiratory Ventilation Records dated from 5/2-5/4/25,showed the Equipment Change Code legend was coded as trach tie, 1. On 5/7/25 at 1004 hours, an observation was conducted with LVN 1 performing the wound care to Resident 1's right side neck wound. Resident 1 was observed to be present with a tracheostomy tube and a wound to the right side of the neck, and right sided facial and neck mass. LVN 1 began performing the wound care to Resident 1's right side of the neck. LVN 1 was observed to cleanse the wound with normal saline, patted dry, while working around the trach tie moving it up to gain access to the wound. LVN 1 was observed to walk to the restroom to wash his hands. LVN 1 returned to Resident 1, donned gloves, and applied xeroform, and an abdominal pad. LVN 1 completed the wound care and the same trach tie remained on Resident 1. On 5/7/25 at 1048 hours, LVN 1 verified Resident 1's trach tie was soiled. RT 1 and LVN 1 began changing the trach tie. After removal of the trach tie, the inner trach tie lining was observed with curled strands of hair, and shades of light brown, dark brown, bright red, dark red, and black to the inner lining of the trach tie and dated 5/4. On 5/7/25 at 1102 hours, an interview was conducted with RT 1. RT 1 stated the trach tie for Resident 1 was soiled and would require the trach tie to be changed. On 5/7/25 at 1104 hours, an interview was conducted with Resident 1. Resident 1stated the trach ties were changed once a week to one and half weeks. On 5/7/25 at 1127 hours, an interview was conducted with the IP nurse. The IP nurse stated the trach ties were changed every seven days, and if soiled. On 5/7/25 at 1440 hours, an interview was conducted with the DON. The DON stated if thetrach ties were visibly soiled, they should be changed regardless of if they were just recently changed. On 5/14/25 at 1437 hours, the Administrator and the DON were informed andacknowledged the findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical records...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical records for one of eight sampled residents(Resident 2). This failure had the potential for the resident's record not maintained to show accurate information. Findings: Review of the facility's P&P titled Documentation (undated) showed the resident's clinical record is a concise and accurate account of treatment, care, response to care, signs, symptoms and progress of the resident's condition. Closed medical record review for Resident 2 was initiated on 4/25/25. Resident 2 was admitted to the facility on [DATE], and discharged on 3/12/25. Review of Resident 2's MAR for March 2025 showed the following were checked off as completed on 3/13/25, when the resident had been discharged from the facility the day before: - heel protectors daily; - monitor apical pulse every shift, heart rate of 80 beats per minute; - monitor for signs and symptoms of pacemaker malfunction; - monitor pacemaker site to left side every shift for protrusion, bleeding, tenderness, redness, drainage, and discomfort; and - potassium chloride ER (extended release) oral tablet (potassium supplement). On 5/8/25 at 1451 hours, an interview and concurrent medical record review for Resident 2 was conducted with LVN 1. LVN 1 verified Resident 2's MAR showed the task was completed on 3/13/25. On 5/9/25 at 0846 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON stated the check marks on Resident 2's MAR indicated as administered. The DON acknowledged and verified the above findings. On 5/14/25 at 1437 hours, the Administrator and the DON acknowledged the above findings.

Feb 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary wound care and services were provided for three of five sampled residents (Residents 2, 3, and 5). * The facility failed to ensure Resident 2's wound care treatment orders were clarified and communicated when there were two physiciansproviding two different wound care orders. * The facility failed to ensure Resident 3 was provided with the appropriate bed mattress to promote healing of the pressure injury. * The facility failed to ensure the physician's order for the correct sequence of Resident 5's wound care treatment was followed. These failures had the potential for Residents 2, 3, and 5 to not receive the appropriate care and services to promote wound healing. Findings: 1. Medical record review for Resident 2 was initiated on 2/25/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Physician Order Summary showed the following physician's orders: - dated 12/10/24, to apply mupirocin (antibiotic)external ointment 2%, apply to the affected area topically every day shift for infection for 30 days until 1/10/25 - dated 1/10/25, to cleanse the incision site with sterile saline and Q-tip's BID and follow up in threeweeks for re-evaluation of wound or sooner if sign of infection was observed. Review of Resident 2's Neurosurgeon Progress Note dated 1/17/25, showed Resident 2 was status post cranioplasty on 5/8/24. The physician recommended for wound care evaluation and management, cleaning of the incision site twice a day with sterile saline and Q-tips and following up in four weeks for re-evaluation of the wound or sooner if there were signs of infection. Review of Resident 2's Wound Specialist Progress Notes dated 1/8, 1/15, 1/22, and 1/29, 2/5, 2/12, and 2/19/25, showed Resident 2 was seen for the scalp wound evaluation and treatment. The treatment plans showed to cleanse with NSS, pat dry, apply mupirocin ointment,cover with the ABD pad, wrap with Kerlix gauze,and secure with tape QD for 14 days. Review of Resident 2's TAR for January 2025 showed Resident 2 received the following wound treatments: - for mupirocin external ointment 2%, apply to the affected area topically every day for skin infection from 1/1 – 1/9/25, and - to cleanse the incision with sterile saline and Q-tips BID from 1/10 – 1/31/25. Review of Resident 2's TAR for February 2025 showed Resident 2 received the wound treatment as ordered to cleanse the incision with sterile saline and Q-tips BID from 2/1 - 2/25/25. However, further review of Resident 2's TAR failed to show if Resident 2 received the wound treatments as recommended by the wound specialist to apply the mupirocin ointment after 1/9/25. On 2/26/25 at 1359 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated the mupirocin ointment was being used to treat Resident 2's scalp abscess per the wound specialist's recommendations since 12/10/24, however the order in the EHR did not reflect the order. LVN 1 stated the mupirocin ointment order was discontinued on 1/10/25. LVN 1 verified the TAR treatments reflected the incorrect order and did not show the mupirocin ointment. LVN 1 verified there were two separate orders for Resident 2, and he should have clarified the orders with the neurosurgeon. On 2/28/25 at 1603 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the wound care specialists recommendations were not changed in the EHR to reflect the current treatment plan, and the expectations were to follow the physician's orders, communicate and clarify between the two physicians providing the wound care orders, and carry out the recommendations by the neurosurgeon. 2. Review of the User's Manual for Med-Aire 8 Alternating Pressure Mattresses Replacement System with Low Air Loss, showed the system is a high-quality powered air support surface that is specifically designedfor the prevention and treatment of pressure injuries while optimizing patient support. Review of the facility's P&P titled Skin and Wound Monitoring and Management revised 1/2023 showed a resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. Medical record review for Resident 3 was initiated on 2/25/25. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident Plan of Care initiated on 2/20/25, showed a care plan problem addressing Resident 3's actual impairment to the skin integrity relate to the unstageable pressure injury to the sacral lumbar area. Review of Resident 1's Order Audit Report showed a physician's order dated 2/20/25, to provide a LAL mattress for the skin management. On 2/26/25 at 1356 hours, an observation and concurrent interviewwas conducted with the DON. Resident 3 was observed in bed, lying on the Direct Supply Air overlay mattress. The DON verified Resident 3 was not lying on an LAL mattress. 3. Medical record review for Resident 5 was initiated on 2/26/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's Order Summary Report showed a physician's order dated 2/5/25, for the chronic right and left lower leg venous ulcers, to cleanse the areas with normal saline, pat dry, apply the collagen sheet, then the xeroform or adaptic dressing, cover with the absorbent pad, wrap with Kerlix, and secure with tape every day shift on Mondays, Wednesdays, andFridays for skin management. On 2/26/25 at 0951 hours, a wound care observation for Resident 5 was conducted with LVN 1. LVN 1 treated Resident 3's left leg venous ulcer first then treated the right leg venous ulcers doing the same sequence of wound treatment. LVN 1 cleansed the right and left leg venous ulcers with normal saline and patted the ulcers dry, then LVN 1 was observed applying the xeroform first, then the collagen sheet to the leg venous ulcers, then applied ABD pad, wrapped with Kerlix and taped. On 2/26/25 at 1035 hours, an interview was conducted with LVN 1. LVN 1 verified Resident 3's physician's order for the right and left leg venous ulcers were, after cleaning the wounds to apply the collagen sheet first then the xeroform or adaptic dressing. LVN 1 acknowledged he applied the xeroform first then the collagen sheet on Resident 3 during the wound care treatment. On 2/28/25 at 1603 hours, an interview and concurrent medical record review was conducted with the DON. The DON was made aware and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sample residents (Resident 2) remained free from accident hazards. * The facility failed to provide the bilateral floor mats at Resident 2's bedside as ordered by the physician for safety. This failure had the potential to place Resident 2 at risk for serious injury. Findings: Review of the facility's P&P titled Falls Prevention revised 8/2020 showed the following: - A post fall assessment including recommendations and care plan changes will be completed for all residents who have experienced a fall. - If appropriate, interventions will be initiated by per ID Team member recommendation and when necessary, physician's orders for any fall related incident. - The falls team will generate recommendations which may include but are not limited to nursing interventions. Medical record review for Resident 2 was initiated on 2/25/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's Order Summary Report showed a physician's order dated 6/26/24, to place the bilateral floor mats at the resident's bedside for safety. Review of Resident 2's Plan of Care initiated on 6/21/24, showed a care plan problem to address Resident 2's actual fall on 6/21/24. The interventions included to place the bilateral floor mats at the resident's bedside. Review of Resident 2's Quarterly Fall Risk Evaluation dated 12/19/24, showed the resident was a high risk for falls. On 2/26/25 at 1443 hours, an observation and concurrent interview was conducted with the ADON. Resident 2 was observed lying in bed with no floor mats at bedside for safety as ordered and care planned. The ADON verified Resident 2 did not have the bilateral floor mats at bedside as ordered and care planned for safety due to the risk for falls. On 2/28/25 at 1603 hours, an interview was conducted with the DON. The DON was made aware and verified the above findings.

Jan 2025 1 deficiency

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Quality of Care (Tag F0684)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary ca...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of eight sampled residents (Residents 3 and 5). * The facility failed to follow the physician's order to administer the GT feedings at the scheduled times for Residents 3 and 5. This failure had the potential to negatively affect the residents' health conditions and well-being. Findings: Review of the facility's P&P titled Physicians Orders revised 11/2019 showed all orders must be specific and complete with all necessary details to carry out the prescribed order without any question. a. Medical record review for Resident 3 was initiated on 12/18/24. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 3's Order Summary Report showed an order dated 9/6/24, to start the enteral feeding at 1500 hours every day to provide 1100 cc of Jevity 1.5 formula at 55 cc/hr for 20 hrs to provide 1650 kcal via PEG tube until the total volume was delivered. On 12/20/24 at 1330 hours, a concurrent observation and interview was conducted with Resident 3's RP. Resident 3's RP stated Resident 3's GT feeding was not supposed to start until 1500 hours and was already infusing. Upon observation, 39 ml of Jevity 1.5 cal had already been infused. b. Medical record review for Resident 5 was initiated on 12/18/24. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's Order Summary Report showed an order dated 10/4/24, to start the enteral feeding at 1500 hours every day to provide 1200 cc water at 60 cc/hr for 20 hrs via PEG tube until the total volume was delivered. On 12/20/24 at 1538 hours, an interview was conducted with LVNs 1 and 3. When asked what time the feedings for Residents 3 and 5 were started, LVN 3 stated he started the GT feedings around 1300 hours. LVN 1 stated the feedings were ordered to be started at 1500 hours and the nurses had one hour before and one hour after the scheduled times to administer the feedings. LVNs 1 and 3 verified the feedings for Residents 3 and 5 were started at 1300 hours instead of the scheduled ordered time at 1500 hours (two hours earlier than ordered). On 1/3/25 at 1423 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified Residents 3 and 5's GT feedings were ordered to start at 1500 hours. The DON stated the licensed nurses should have followed the physician's orders. On 1/7/25 at 1423 hours, the Administrator and DON acknowledged the above findings.

Nov 2024 20 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/12/24 at 1219 hours, on observation of Resident 775 was conducted. Resident 775 was observed sitting in the wheelchair ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 11/12/24 at 1219 hours, on observation of Resident 775 was conducted. Resident 775 was observed sitting in the wheelchair at the left side of the bed. Resident 775's call light was observed on the floor and not within the resident's reach. On 11/12/24 at 1446 hours, an observation of Resident 775 was conducted. Resident 775 was observed lying in bed on his back. Resident 775's call light was observed on the floor and not within the resident's reach. Medical record review for Resident 775 was initiated on 11/12/24. Resident 775 was admitted to the facility on [DATE]. Review of Resident 775's H&P examination dated 11/9/24, showed Resident 775 did not have the capacity to understand and make decisions. On 11/12/14 at 1456, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified Resident's 775's call light was on the floor and not within the resident's reach. CNA 2 stated the call light should always be within the resident's reach. CNA 2 was observed to put the call light within the resident's reach. On 11/15/24 at 1504 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. On 11/12/24 at 0919 hours, during the initial tour of the facility, Resident 78's call light was observed on the right shoulder of Resident 78. Medical record review for Resident 78 was initiated on 11/12/24. Resident 78 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 78's H&P examination dated 8/7/24, showed the resident did not have the capacity to understand and make decisions. On 11/12/24 at 0928 hours, a concurrent observation of Resident 78's call light and interview was conducted with LVN 13. LVN 13 verified Resident 78's call light was on Resident 78's right shoulder and not within Resident 78's reach. LVN 13 stated Resident 78 was able to use the call light and had movement on both hands. LVN 13 moved the call light under Resident 78's right hand. On 11/14//24 at 1435 hours, an interview was conducted with the DON. The DON stated most residents in the Subacute Unit used the call light. The DON further stated the staff needed to place the call light where the resident could access it. The DON stated the staff determined what kind of call light to use based on observation and informed the maintenance for the appropriate call light. On 11/15/24 at 1451 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of four of 27 final sampled residents (Residents 96, 108, 775, and 78). * The facility failed to ensure Residents 96, 108, 775, and 78's call lights were within the residents' reach. This failure created the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Nursing clinical, Subject Call Lights/Bell Revised May 2020 showed to leave the resident comfortable and place the call device within the resident's reach before leaving the room. If the call light/bell is defective, immediately report this information to the unit supervisor. 1. On 11/13/24 at 1554 hours, an observation for Resident 96 and concurrent interview was conducted with LVN 11. Resident 96's call light was observed hanging at the back of the bed which was not within the resident's reach. LVN 11 verified it was at the back of the head of bed hanging close to the wall. LVN 11 removed the call light and placed it close to the resident's right arm. LVN 11 verified the call light was functioning. Medical record review for Resident 96 was initiated on 11/13/24. Medical record showed Resident 96 was admitted to the facility on [DATE]. 2. On 11/13/24 at 1558 hours, an observation for Resident 108 and concurrent interview was conducted with LVN 7. Resident 108's call light was seen at the back of the head underneath the pillow, which was out of Resident 108's reach. LVN 7 verified the findings and stated it should be within reach. Medical review for Resident 108 was initiated on 11/13/24. Medical record for Resident 108 showed initial admission date to facility on 6/04/24, and readmitted on [DATE].

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to notify the physician tim...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to notify the physician timely of the resident's changes in status for two of 27 final sampled residents (Residents 51 and 56). * Resident 51's physician was not notified timely for a change in swallow status. * Resident 56's physician was not notified of the resident's recent episodes of emesis and of the resident's tube feeding being placed on hold. These failures resulted in a delay of physician notification, intervention and/or implementation of the physicians' orders with the potential for an adverse resident outcomes. Findings: Review of the facility's P&P titled Change of Condition Reporting dated May 2019 showed all changes in the resident's condition will be communicated to the physician. The staff will document the change of condition in the eInteract Change of Condition UDA and in the nursing progress notes. All attempts to notify the physician will be documented in the nursing progress notes. 1. Medical record review for Resident 51 was initiated on 11/12/24. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's Order Summary Report dated 11/14/24, showed a physician's order dated 5/24/24, for diet to include thin liquids consistency. Review of Resident 51's Progress Notes showed the Social Services note dated 11/4/24. The note showed the resident's family member informed the SSD that he noticed the resident was having a hard time swallowing liquids. The note showed the SSD notified the nursing staff, and the nursing staff would notify the physician. On 11/13/24, an interview was conducted with the Speech Therapist. The Speech Therapist stated she heard a few days ago that the resident was having difficulty swallowing and just did her screening today and recommended a swallow study. The Speech Therapist stated the resident's family member told her today the resident was having difficulty drinking liquids with a straw and they were using a syringe to give her liquids. Review of Resident 51's Progress Notes showed a Change in Condition note dated 11/13/24 at 1803 hours, showed the resident was having increased difficulty with the use of straw and the physician was notified at 1540 hours. On 11/14/24 at 1404 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated there was a change in condition for Resident 56's difficulty swallowing yesterday. When asked the expectation for reporting a change in condition, the DON stated for swallowing changes with liquids, to address right away since there was an increased risk of injury. The DON stated the nursing communicated to the Director of Rehabilitation and a Speech Therapy screen was done. The DON then reviewed the Social Services note dated 11/4/24, and verified the facility failed to notify the physician timely of a change in condition. 2. Medical record review for resident 56 was initiated on 11/12/24. Resident 56 was readmitted to the facility on [DATE]. Review of Resident 56's Order Summary Report dated 11/14/25, showed a physician order dated 10/21/24, for Vital 1.5, to provide 1900 ml daily at 95 ml/hr for 20 hours; to start at 1500 hours and run until the total volume delivered. On 11/13/24 at 1510 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. LVN 1 stated the resident's tube feeding was held since the resident had episodes of vomiting and constipation since last night. LVN 3 stated they ran the resident's tube feeding and the resident received their tube feeding approximately for two hours during the shift. LVN 3 stated they did not notify the physician of the resident's vomiting or need to hold the resident's tube feed and was unsure if the prior shift, night shift, had notified the physician. When asked how much formula the resident received since yesterday's feeding was started at 1500 hours, LVN 6 went to Resident 56's feeding pump and stated the resident received 612 ml (1288 ml less than the ordered dose) of formula since she hung the current 1000 ml bottle yesterday at 1500 hours. The LVN stated the bottle had approximately 500 ml of formula left. On 11/14/24 at 1328 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated even though Resident 56 had a history of vomiting, since there was no current order for Zofran (an antiemetic) the nurse should have notified the physician. The DON also stated since the resident's weight was already low, the nursing staff should have notified the physician and obtained an order prior to holding the resident's tube feeding. Cross reference to F693.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide a safe and comfortable environment fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide a safe and comfortable environment for one nonsampled residents (Resident 35). * The staff went through the resident's belongings without the resident's consent. This failure resulted in the resident being upset staff went through her personal belongings, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 35 was initiated on 11/12/24. Resident 35 was readmitted to the facility on [DATE]. Review of Resident 35's H&P examination dated 9/22/24, showed the resident was legally blind. Review of Resident 35's IDT -BIMS dated 11/6/24, showed the resident was cognitively intact. Medical record review for Resident 325 was initiated on 11/12/24. Resident 325 was readmitted to the facility on [DATE]. Review of Resident 325's IDT -BIMS dated 11/12/24, showed the resident was cognitively intact. On 11/14/24 at 0833 hours, during a medication administration observation with LVN 2 and Resident 35, Resident 35 told the nurse I need state, after informing the resident again I was present, the resident stated early in the morning while she was sleeping, someone came into her room with a flashlight and went through her things while she was sleeping, and to talk to her roommate (Resident 325) who witnessed it. Resident 35 repeated the above two more times during her medication administration, and stated her roommate saw it. On 11/14/24 at 0912 hours, an interview was conducted with Resident 325. Resident 325 stated on 11/13/24 at 0445 hours, she observed two people dressed like staff, entered the room, and went to Resident 35's bedside. Resident 325 stated one staff member had a flashlight and was going through Resident 35's personal belongings on top of their tray table and bedside table, and then looked through items in the drawer. Resident 325 stated Resident 35 was slept through everything. She told the resident later in the morning and Resident 35 was very upset. On 11/14/24 at 1350 hours, an interview was conducted with the DON. The DON stated on 11/12/24, the staff was instructed to check the resident's bedside to ensure proper labeling of items and check the food expiration dates. The DON stated the staff should have gotten permission of the resident's before checking their belongings.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Change of Condition Reporting dated 5/2019 showed the licensed nurse responsible for the ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Change of Condition Reporting dated 5/2019 showed the licensed nurse responsible for the resident will continue assessment and documentation every shift for at least 72 hours or until condition has stabled. Medical record review for Resident 33 was initiated on 11/12/24. Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's MDS dated [DATE], showed Resident 33 had severe cognitive impairment. Review of Resident 33's eINTERACT (a program to reduce the frequency of transfers to the acute hospital) Change in Condition Evaluation V4.2 dated 11/4/24, showed Resident 33's change of condition was weight loss. Further review of Resident 33's medical record failed to show Resident 33 was continuously monitored every shift for at least 72 hours after a change of condition identified related to Resident 33's weight loss. On 11/14/24 at 1447 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON verified Resident 33 was not monitored on the night shift on 11/5/24, and the day shift on 11/7/24. The ADON stated the licensed nurse should be monitoring and reassessing the resident when there was a change of condition. On 11/15/24 at 0942 hours, a concurrent interview and medical record review was conducted with RN 3. RN 3 verified Resident 33 was not monitored on the night shift of 11/5/24, and day shift on 11/7/24. RN 3 stated the licensed nurses should have checked the residents who were being monitored for 72 hours so they would know if the residents were improving or not. On 11/15/24 at 1531 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Based on interview and medical record review, the facility failed to ensure the necessary care and services provided to two of 27 final sampled residents (Residents 33 and 73). * Resident 73's skin and wound consult recommendations were not followed up timely by the facility. * Resident 33 was not monitored every shift for at least 72 hours following the weight loss. These failures resulted in a potential delay of identifying changes in the residents' statuses and/or a delay of implementing the interventions to ensure the quality of care was provided. Findings: 1. Medical record review for Resident 73 was initiated on 11/12/24. Resident 73 readmitted to the facility on [DATE]. Review of Resident 73's skin and wound consult dated 10/30/24, showed the resident was seen for dry scattered rashes. The note showed the resident was already being treated with Triamcinolone 0.1% (a topical cream used for skin conditions) for sever itchiness. The dermatologist's recommendations included the following: - Ensure a daily adequate gentle skin care regimen: daily lukewarm baths, aggressive emollient therapy with either Aquaphor or Vaseline afterwards, with frequent reapplication of emollients two to three times a day. - Switch all personal hygiene products to fragrance-free - Avoid harsh soaps and hot water showers, lukewarm is best. Review of Resident 73's medical record failed to show the physician was notified of the dermatologist's recommendations. On 11/12/24 at 1137 hours, an interview was conducted with Resident 73 at their bedside. Resident 73 stated the skin was so itchy, got a cream to put on which helped a little, but at night, the itching was worse. On 11/14/24 at 1615 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated once a consultant report was received, the protocol was for the nurse to notify the physician of the recommendations, obtain new orders if any, and document everything in the resident's medical record. The DON then reviewed Resident 73's wound and skin consultant report and medical record, and verified Resident 73's medical record failed to show the physician was notified of the consultant's recommendations.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the staff reported and addressed a new...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the staff reported and addressed a new pressure ulcer timely for one of three final sampled residents (Resident 51) reviewed for pressure ulcers. This failure had the potential to result in a delay of treatment and interventions being put in place to prevent further decline. Findings: Medical record review for Resident 51 was initiated on 11/12/24. Resident 51 was admitted to the facility on [DATE]. On 11/14/24 at 1024 hours, an observation of Resident 51's being transferred to the wheelchair after her shower and morning ADL care provided by the CNA and RNA. After CNA 1 and the RNA left the resident's bedside, an observation of Resident 51's right heel showed an open area of approximately 2 cm with a minimal depth. Review of Resident 51's medical record showed no documented evidence of a wound located on the resident's right heel. On 11/14/24 at 1409 hours, an interview and medical record review were conducted with Treatment Nurse 1. Treatment Nurse 1 stated Resident 51 had a resolved non-pressure skin issue to their right medial foot, and there was no injury to the right heel. Treatment Nurse 1 reviewed a photograph of Patient 51's right heel taken on 10/14/24 at 1024 hours, and stated they were not aware of that wound. On 11/14/24 at 1432 hours, an interview was conducted with CNA 1 and the DON. CNA 1 stated today was their first time being assigned to Resident 51 and this morning, they observed the wound to Resident 51's right heel during the shower. CNA 1 stated they reported it to Treatment Nurse 2 sometime after lunch. The DON stated the CNA should have notified the treatment nurse timelier, and not wait until after lunch. On 11/15/23 at 0810 hours, an interview was conducted with Treatment Nurse 2. Treatment Nurse 2 stated they were notified about Resident 51's right heel pressure injury by CNA 1 yesterday afternoon. On 11/15/24 at 0817 hours, an interview was conducted with the DON. On 11/15/24 at 1140 hours, a telephone interview was conducted with CNA 2. CNA 2 stated they were assigned to Resident 51 two days earlier in the week and observed a callous to the resident's right heel. CNA 2 stated they did not report it because they did not realize it was a new skin issue, since they had seen the treatment nurse in the resident's room in the past.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to implement two staff assistance for ADL care for one of eigh...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to implement two staff assistance for ADL care for one of eight final sampled residents (Resident 51) reviewed for accident harzards. This failure resulted in the resident sustaining another fall, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 51 was initiated on 11/12/24. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's Fall Committee IDT note dated 8/23/24 at 2023 hours, showed Resident 51 sustained a fall on 8/19/24. The note showed a CNA rolled the resident in bed to place a mechanical lift sling under the resident, and the resident slid off the bed. The IDT note showed they recommended two-person assistance with ADL care. Review of Resident 51's Fall Committee IDT note dated 10/2/24 at 1459 hours, showed Resident 51 sustained a fall on 9/30/24. The note showed a CNA was providing bedside care and the resident began to slide off the bed. On 11/14/24 at 1427 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for the fall on 9/30/24, the CNA was performing ADL care without assistance and should have two staff assistance with ADL care.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent UTI for one of two final sampled residents (Resident 30) reviewed for indwelling urinary catheter. * Resident 30's urinary drainage bag and tubing were positioned above the bladder. This failure posed the risk for Resident 30 to develop urinary tract infection and other complications from UTI. Findings: Review of the facility's P&P titled Nursing Clinical, Subject Catheter Drainage Bag Revised November 2019 showed under the Standard Drainage Bag procedures, to position the drainage bag below the level of the resident's bladder and the drainage bag should be kept off the floor. On 11/14/24 at 0839 hours, an observation for Resident 30 and concurrent interview was conducted with CNA 6. Resident 30's indwelling urinary catheter drainage bag was observed inside the dignity bag (a bag used to cover and hold the catheter drainage bag so it is not visible) but its position was higher than the bladder, CNA 6 stated the indwelling urinary catheter bag must be lower than the bladder. On 11/14/24 at 0844 hours, another observation for Resident 30 and concurrent interview was conducted with LVN 8. LVN 8 stated the indwelling urinary catheter drainage bag must be below the bladder. LVN 8 verified the catheter drainage bag and tubing were above the bladder. On 11/14/24 at 0912 hours, an interview was conducted with the SAU Manager. The SAU Manager verified the catheter drainage bag was higher than the urinary bladder. The SAU Manager stated it must be lower than the bladder at all times. The SAU Manager repositioned the urine bag to be lower than the bladder at the right side of Resident 30's bed. Medical record review for Resident 30 was initiated on 11/14/24. Medical Record showed Resident 30 was originally admitted on [DATE], and readmitted on [DATE]. On 11/14/24, review of Resident 30's care plan was conducted. Resident 30's care plan showed a care plan problem addressing the use of indwelling urinary catheter for neurogenic bladder initiated on 4/11/24, and revised on 5/17/24. The care plan interventions revised on 4/11/24, included to position the catheter drainage bag and tubing below the level of the bladder and away from the room entrance door.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the correct enteral formula was admini...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the correct enteral formula was administered to one of two final sampled residents (Resident 56) reviewed for tube feeding * Resident 56 had the incorrect strength of tube feeding administered. This failure resulted for a less than the ordered calories to be administered to the resident, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 56 was initiated on 11/12/24. Resident 56 was readmitted to the facility on [DATE]. Review of Resident 56's Order Summary Report dated 11/14/25, showed a physician order dated 10/21/24, for Vital 1.5, to provide 1900 ml daily at 95 ml/hr for 20 hours, and to start at 1500 hours, and run until the total volume delivered. On 11/13/24 at 1510 hours, an observation, interview, and medical record review was conducted with LVN 1. LVN 1 stated they held the resident's tube feeding due to vomiting and for approximately two hours their shift (0700-1900 hours shift). When asked how much formula the resident had received since yesterday's feeding was started at 1500 hours, LVN 6 went to Resident 56's feeding pump and stated the resident received 612 ml of formula since she hung the current 1000 ml bottle yesterday at 1500 hours. The LVN stated the bottle had approximately 500 ml of formula left. LVN was asked what type of formula was hanging, the LVN replied Vital 1.2 (1.2 calories per ounce), and verified the resident should be receiving Vital 1.5 (1.5 calories per ounce). Cross reference to F580, example #2.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for four of seven residents (two final sampled residents, Residents 65 and 83; and two nonsampled residents, Residents 725 and 726) reviewed for respiratory care. * The facility failed to ensure Residents 83, 725, and 726's oxygen tubing was dated. * The facility failed to ensure Resident 65 received oxygen as ordered by the physician. These failures had the potential to put the residents at risk for adverse effects of the inaccurate administration of oxygen and improper care of oxygen equipment. Findings: Review or the facility's P&P titled Oxygen Administration (mask, cannula, catheter, use of humidifier) revised 12/2023 showed it is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as emergency measure until the order can be obtained. Oxygen tubing is to be replaced every seven days. 1. On 11/12/24 at 0826 hours, an observation for Resident 725 and concurrent interview was conducted with LVN 14. Resident 725 was observed asleep in bed receiving 2.5 liters per minute of oxygen via tracheostomy. LVN 14 verified Resident 725's oxygen tubing was undated. Medical record review for Resident 725 was initiated on 11/12/24. Resident 725 was admitted to the facility on [DATE]. Review of Resident 725's Order Summary Report dated 11/13/24, showed a physician's order dated 11/9/24, to administer humidified oxygen via T-bar/T-mask at two liters per minute to keep oxygen saturation level greater or equal to 92% every shift. On 11/14/24 at 1435 hours, an interview was conducted with the DON. The DON stated the subacute unit's RT had their own weekly schedule. The DON stated the oxygen tubing and humidifier should be dated. 2. On 11/12/24 at 0828 hours, an observation for Resident 726 and concurrent interview was conducted with LVN 14. Resident 726 was observed asleep in bed with oxygen administered via tracheostomy at three liters per minute. LVN 14 verified there was no date observed on Resident 726's oxygen tubing. Medical record review for Resident 726 was initiated on 11/12/24. Resident 726 was admitted to the facility on [DATE]. Review of Resident 726's Order Summary Report dated 11/13/24, showed a physician's order dated 11/12/24, to administer humidified oxygen via T-bar/T-mask at one liter per minute every day and night shift as tolerated, and to place on A/C (assist-control ventilation) if not tolerated. On 11/14/24 at 1435 hours, an interview was conducted with the DON. The DON stated the subacute unit's RT had their own weekly schedule. The DON stated the oxygen tubing and humidifier should be dated. 3. On 11/12/24 at 0826 hours, an observation for Resident 83 and concurrent interview was conducted with LVN 14. Resident 83 was observed asleep in bed receiving two liters per minute of oxygen via tracheostomy. LVN 14 verified Resident 83's oxygen tubing was undated. Medical record review for Resident 83 was initiated on 11/12/24. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's Order Summary Report dated 11/13/24, showed a physician's order dated 9/13/24, to administer humidified oxygen via T-bar/T-mask at two liters per minute to keep oxygen saturation level greater or equal to 92% every shift. On 11/12/24 at 0936 hours, an interview was conducted with RRT 1. RRT 1 stated the oxygen tubing was supposed to be dated during the night shift every Saturdays and if needed. RRT 1 stated the humidifier should be changed and dated, and oxygen should be dated if there was no date. On 11/13/24 at 1028 hours, an interview was conducted with LVN 11. LVN 11 stated the RT usually took care of the oxygen tubing. LVN 11 stated she would change the oxygen tubing and put the date if there was no date on the oxygen tubing. On 11/13/24 at 1259 hours, an interview was conducted with LVN 15. LVN 15 stated the RT changed the humidifier and oxygen tubing on the night shift every Saturday. LVN 15 stated according to the policy and the RT director, the humidifier and oxygen tubing should be replaced and dated if there was no date. On 11/14/24 at 1435 hours, an interview was conducted with the DON. The DON stated the subacute unit's RT had their own weekly schedule. The DON stated the oxygen tubing and humidifier should be dated. On 11/15/24 at 1451 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Policy/ Procedure- Nursing Clinical, Subject-Oxygen Administration ( Mask, Cannula, Catheter, use of Humidifier) revised 12/2023, showed it is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. Procedure showed obtain appropriate physician's order. Medical record review for Resident 65 was initiated on 11/14/24. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65's Order Summary Report showed an order dated 3/7/24, for humidified oxygen via T-bar/ T-mask at 3 liters per minute to keep oxygen saturation level greater or equal to 92% every day and night shift. Review of Resident 65's care plan date revised 3/5/24, showed the resident had tracheostomy related to impaired breathing mechanics. The interventions dated 3/5/24, showed to administer oxygen as ordered and give humidified oxygen as prescribed. On 11/14/24 at 0930 hours, an observation was conducted of Resident 65. Resident 65 had a tracheostomy with T-bar connected to oxygen being administered at 4 liters per minute. On 11/14/24 at 1347 hours, a concurrent observation of Resident 65 and interview was conducted with LVN 8. LVN 8 verified Resident 65's oxygen was at 4 liters per minute and did not match the physician's order.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Bedrail assessment dated 8/2017 showed it is the policy of this facility to use appropria...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Bedrail assessment dated 8/2017 showed it is the policy of this facility to use appropriate alternatives prior to installing a side or bed rail. The facility should maintain evidence of the alternatives attempted that failed to meet the resident's needs and the alternatives considered but not attempted because they were inappropriate for the resident. Medical record review for Resident 41 was initiated on 11/12/24. Resident 41 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 41's Order Summary Report dated 11/13/24, showed the physician's order dated 10/2/24, for the use of 1/4 side rails for positioning and ease in mobility as an enabler. Review of Resident 41's LN-Restraint/Enabling Device/Safety Device Evaluation- V2 dated 10/2/24, showed Resident 41 had an unsteady gait which contributed to her risk for fall and/or need for a safety/enabling device. The evaluation showed Resident 41 requested the side rails to enhance bed mobility. The evaluation failed to show documented evidence of the least restrictive alternatives implemented before side rails use. On 11/12/24 at 0803 hours, an interview was conducted with Resident 41. Resident 41 was observed lying in bed with the bilateral 1/4 side rails elevated. Resident 41 stated she used the side rails to change positions in the bed. On 11/13/24 at 0937 hours, Resident 41 was observed lying in the bed with the bilateral 1/4 side rails elevated. On 11/13/24 at 1159 hours, a follow-up interview and concurrent observation was conducted with Resident 41. Resident 41 stated she requested the side rails to assist her with position changes while in the bed. Resident 41 stated the side rails on the bed were always elevated. Resident 41 stated the facility did not offer her alternatives for the use of the side rails. On 11/13/24 at 1500 hours, an interview, concurrent medical record review, and facility document review was conducted with the DON and ADON. The DON verified Resident 41's side rail use as per the resident's request. The DON stated the facility would recommend the least restrictive alternatives for the residents prior to the use of the side rails. The DON stated the least restrictive alternatives were documented on the LN-Restraint/Enabling Device/Safety Device Evaluation- V2. However, Resident 41's LN-Restraint/Enabling Device/Safety Device Evaluation- V2 dated 10/2/24, failed to show documented evidence of the least restrictive alternatives implemented before initiating the side rail use. On 11/13/24 at 1621 hours, a follow-up interview and concurrent medical record review was conducted with the DON. The DON verified Resident 41's LN-Restraint/Enabling Device/Safety Device Evaluation- V2 dated 10/2/24, failed to show the least restrictive alternatives implemented before the side rail use. The DON stated the interventions on the evaluation form were not appropriate for Resident 41, and the facility did not implement the least restrictive alternatives before initiating the side rail use. The DON verified the least restrictive alternatives should have been implemented for Resident 41 before initiating side rail use. On 11/13/24 at 1643 hours, a follow-up interview was conducted with the DON. The DON verified the facility should have documented the least restrictive alternatives implemented before initiating side rail use for Resident 41 and/or documented the alternatives were inappropriate for Resident 41 in the LN-Restraint/Enabling Device/Safety Device Evaluation. When asked for documentation of the least restrictive alternatives were implemented prior to Resident 41's use of the side rails, the DON provided Resident 41's Physical Therapy Treatment Encounter Note(s) dated 10/10/24. The Encounter Note for Resident 41 showed the PTA's recommendations included training in rolling, scooting, and partial bridging to facilitate independence in bed mobility. However, the DON verified the side rails were already in use for Resident 41 on the date of the PTA's note and therefore, would not be considered a recommendation for the least restrictive alternatives before initiating the side rail use. On 11/15/24 an interview was conducted with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 18, 41, and 56) reviewed for side rail use remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to ensure the accurate and complete assessments and evaluations for the side rails use for Resident 18. * The facility failed to ensure documented evidence of the least restrictive measures attempted prior to the side rail use for Resident 41. * Resident 56's siderail order was for an inappropriate use. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Bed Rail Assessment revised on 8/2017 showed the facility to attempt to use appropriate alternatives prior to installing a side rail or bed rail. If a bed rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. 1. On 11/13/24 at 0745 hours, Resident 18 was observed lying in bed with ¼ (quarter) side rails elevated. Resident 18 was lying in bed and watching the television. Resident 18 stated he used the side rails for positioning. Medical record review for Resident 18 was initiated on 11/12/24. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's Order Summary Report showed a physician's order dated 9/9/24, for bilateral ¼ side rails up for mobility and positioning. Review of Resident 18's MDS dated [DATE], showed Resident 18's cognition was intact. Review of Resident 18's LN-Restraint/Enabling Device/Safety Device Evaluation-V2 dated 9/16/24, did not show the measures or interventions attempted before implementing the side rails. Further review of Resident 18's medical record failed to show the least restrictive measures were evaluated if effective. On 11/14/24 at 0855 hours, an observation and concurrent interview was conducted with CNA 8. CNA 8 verified Resident 18's had the bilateral ¼ side rails. CNA 8 stated Resident 18 was able to use the ¼ side rails for turning and positioning. On 11/14/24 at 0939 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified Resident 18's LN-Restraint/Enabling Device/Safety Device Evaluation-V2 did not show the measures attempted before implementing the side rails and the least restrictive measure was not done. The ADON further stated the licensed nurse would try everything prior to applying the side rails. The ADON stated the licensed nurse forgot to check the box on the measures attempted before implementing the side rails. On 11/15/24 at 1531 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 3. Medical record review for Resident 56 was initiated on 11/12/24. Resident 56 was readmitted to the facility on [DATE]. Review of Resident 56's Order Summary Report dated 11/14/25, showed a physician order dated 9/1/24, for use of the bilateral 1/4 side rails for positioning and ease in mobility. Review of Resident 56's plan of care showed a care plan problem addressing the resident at risk for falls with an intervention for the use of 1/4 side rails for positioning and ease in mobility as an enabler. On 11/12/24 at 1613 hours, Resident 56 was observed lying in bed with the bilateral padded 1/4 side rails up. The resident did not respond to verbal stimulation and was not observed with purposeful movement. On 11/14/24 at 1510 hours, an interview and concurrent observation was conducted with LVN 1 at Resident 56's bedside. LVN 1 verified Resident 56 had the bilateral padded 1/4 side rails, and stated the resident did not use the side rails for repositioning and had no purposeful movement. On 11/14/24 at 1328 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated Resident 56 did not have purposeful movement and was unable to self-position. The DON reviewed the resident's physician's order and verified the order for the bilateral padded 1/4 side rails was an inappropriate use.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure all controll...

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure all controlled medications were accounted for and documented for one of three inspected medication carts (Medication Cart A) with controlled medications. * The facility failed to ensure accurate and complete documentation of controlled medication administration for two nonsampled residents (Residents 22 and 94). These failures had the potential for the medications to be administered in errors and opportunities for drug diversion. Findings: Review of the facility's P&P titled Controlled Medications revised 12/2019 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: - Date and time of the administration. - The amount administered. - Signature of the nurse administering the dose (completed after the medication is administered). At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on a controlled drug count audit record. 1. On 11/15/24 at 1056 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 3. The form titled Narcotic Count Sheet dated 11/1/24 to 11/15/24, showed the following entries were crossed out with a single line for 11/7/24. - 7 am on column: signature for oncoming 7 am nurse -7 pm off column: signature for off going 7 pm nurse - Count correct column: a check mark - Key exchange column: a check mark When LVN 3 was asked why the above entries were crossed out, LVN 3 stated she filled out the row for 11/7/24 in error and crossed out the entries. LVN 3 verified the Narcotic Count Sheet did not show documentation licensed staff performed the controlled substances count for Medication Cart A on 11/7/24. 2. On 11/15/24 at 1113 hours, an inspection of Medication Cart A and concurrent count of the controlled medications, medical record review, and interview was conducted with LVN 3. a. A bubble pack (type of pre-formed, plastic packaging that seal individual tablets until they are taken) of Resident 94's hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg tablets showed a total of 21 tablets remaining. However, the Medication Count Sheet for Resident 94 showed an incomplete entry on row 20. The entry for row 20 showed a date of 11/15/24, and LVN 3's initials. The column titled time for row 20 was blank. LVN 3 stated Resident 94 received the hydrocodone-acetaminophen medication around the clock and she started to fill out the rows for tablet 20 in anticipation of Resident 94's next dose. In addition, LVN 3 stated the Medication Count Sheet should be completed only at the time of the medication administration to ensure correct counts of controlled medications. b. A bubble pack of Resident 22's lorazepam (antianxiety medication) 0.5 mg tablets showed a total of 15 tablets remaining. However, the Medication Count Sheet for Resident 22 showed there were 16 tablets remaining. LVN 3 verified the number of remaining hydrocodone-acetaminophen tablets on the Medication Count Sheet for Resident 22 did not match the number of tablets remaining in the bubble pack. LVN 3 stated the count sheet was incorrect due to the lorazepam 0.5 mg tablet being administered to Resident 22 at 0815 hours on 11/15/24, but not documented on the Medication Count Sheet. Review of Resident 22's MAR for November 2024 showed documentation the lorazepam 0.5 mg was administered at 0815 on 11/15/24. LVN 3 verified the Medication Count Sheet documentation was not done for Resident 22's lorazepam 0.5 mg given at 0815 on 11/15/24, and documentation should be completed at the time the medication was given. LVN 3 stated documenting on the count sheet at the time when the medication was given ensured the correct counts of the controlled substances. LVN 3 verified all the above findings. On 11/15/24 at 1504 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. The DON verified the documentation on the Medication Count Sheet must be completed at the time when the medications were given. The DON verified documentation of controlled substance administration should not be filled out prior to the medication administration to prevent drug diversion. Furthermore, the DON verified the Narcotic Count Sheet for Medication Cart A failed to show documentation a controlled substance count was performed on 11/7/24.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the orthostatic blood pressure...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the orthostatic blood pressure was monitored accurately as ordered by the physician related to the use of an antipsychotic medication for one of five final sampled residents (Resident 42) reviewed for unnecessary medications. This failure had the potential for Resident 42 to have adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dose of the psychotropic medication for Resident 42. Findings: Review of the facility's P&P titled Unnecessary Drugs revised 5/2007 showed it is the policy of the facility that each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: 1. In excessive dose (including duplicate therapy); 2. For excessive duration; 3. Without adequate monitoring; 4. Without adequate indications for its use; 5. In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or 6. Any combinations of the reasons above. Under the Procedures section, the facility must monitor and track progress towards the therapeutic goal(s) and detect the emergence or presence of any significant adverse consequences for them to be minimized. Review of the facility's P&P titled Postural Hypotension, assessment dated [DATE], showed it is the policy of this facility to assess for postural hypotension if ordered by the physician. Note changes in blood pressure while the resident is lying and either sitting or standing. Allow 5 to 8 minutes between position changes before obtaining blood pressure. Medical record review for Resident 42 was initiated on 11/12/24. Resident 42 was admitted to the facility on [DATE]. Review of Resident 42's Order Summary Report dated 11/14/24, showed the following physician's orders: - dated 5/28/24, to administer Zyprexa (antipsychotic medication) 2.5 mg one tablet by mouth in the morning for schizophrenia (chronic mental disorder that affects how people think, perceive reality, and interact with others). - dated 5/28/24, to administer Zyprexa 5 mg one tablet by mouth at bedtime for schizophrenia. - dated 4/14/23, to monitor orthostatic BP while lying one time a day every Monday. - dated 4/14/23, to monitor orthostatic BP while sitting one time a day every Monday. Review of Resident 42's MAR for August through November 2024 showed the following medication was administered to Resident 42: - Zyprexa 2.5 mg tablet daily at 0900 hours, from 8/1 to 11/14/24; and - Zyprexa 5 mg tablet daily at 2100 hours, from 8/1 to 11/14/24. Further review of Resident 42's MAR for August through November 2024 showed the orthostatic BP (lying and sitting) were scheduled to be monitored every Monday. However, the blood pressure readings for both positions were the same as follows: - On 8/5/24, the blood pressure readings were 145/79 mmHg for the lying position and 145/79 mmHg for the sitting position. - On 8/19/24, the blood pressure readings were 137/74 mmHg for the lying position and 137/74 mmHg for the sitting position. - On 9/2/24, the blood pressure readings were 139/73 mmHg for the lying position and 139/73 mmHg for the sitting position. - On 11/11/24, the blood pressure readings were 125/78 mmHg for the lying position and 125/78 mmHg for the sitting position. On 11/14/24 at 1557 hours, an interview and concurrent medical record review for Resident 42 was conducted with the DON. The DON was informed and verified the above findings. The DON verified Resident 42's orthostatic BP was not accurately monitored and stated there should be a difference of the resident's BP readings when the resident was lying and sitting. The DON stated the orthostatic BP readings should not be the same for the sitting and lying position if the procedure for taking the orthostatic BP readings was followed. On 11/15/24 at 0940 hours, an interview and concurrent medical record review for Resident 42 was conducted with LVN 16. When asked about the procedure for taking orthostatic blood pressure readings, LVN 16 stated the BP was taken with the resident lying down. A second BP was taken as soon as the resident was sitting up. LVN 16 stated the orthostatic BPs readings should not be the same for the sitting and lying position. LVN 16 verified the orthostatic BP readings for Resident 42 were the same for the above dates. On 11/15/24 at 1504 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 25% for n...

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Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 25% for nine medication errors out of 36 medication administration observations. One nurse (LVN 2) observed administering the medications was found to have errors while administering the medications to one of 27 final sampled residents (Resident 43) and one nonsampled resident (Resident 35). This failure created the risk of the resident developing complications and ineffective therapeutic effects of the medications. Findings: 1. On 11/14/24 at 0800 hours, a medication pass observation was conducted with LVN 2 for Resident 51. LVN 2 was observed administering eight medications to Resident 43. LVN 2 was observed crushing each medication and mixing them with applesauce in the individual cups. After administering the medications to the resident, the LVN went to discard the used medications cups. An observation of all eight medicine cups showed a residual of medication in each cup. LVN 2 verified the findings, resulting in eight medication errors. 2. On 11/14/24 at 0824 hours, a medication pass observation was conducted with LVN 2 for Resident 35. LVN 2 was observed administering dorzolamide (an eye drop medication for glaucoma) 2% drops into the resident's right eye. Review of the pharmacy label showed to administer to both eyes. After the medication administration, LVN 2 stated the order was revised for it only to be administered in the right eye. LVN 2 reviewed Resident 35's physician's orders and verified the order was for both eyes, but stated the resident only liked the drops in the right eye. On 11/14/24 at 0844 hours, an interview was conducted with Resident 35. Resident 35 stated they would like their eye drops in both eyes. This resulted in an additional medication error.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medication and disposal of biologicals. * The facil...

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Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medication and disposal of biologicals. * The facility failed ensure one single-use medication was discarded after use in Medication Cart E. * The facility failed to ensure the sublingual medication was not stored with externally administered medications in Medication Cart D. * The facility failed to ensure the contents of the sharp disposal container remained below the full line for Medication Cart A. In addition, the facility failed to ensure oral medications, topical medications, ophthalmic medications (medication to treat conditions of the eye), nasal medications, inhaled medications, and suppositories (a solid, cone-shaped or round object that contains medication and is inserted into a body cavity) were stored separately in Medication Cart A. *T he facility failed to ensure the subcutaneously administered medications (inserted beneath the skin either by injection or infusion) were not stored with the topical medications, and the orally administered medications were not stored with the externally administered medications in Medication Cart C. In addition, the facility failed to ensure the container for the orally administered medication in Medication Cart C was kept in clean condition. * The facility failed to ensure the ophthalmic medication, subcutaneously medications, GT (Gastrostomy tube - a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) medications, transdermal medications (medication that is absorbed through the skin), inhalant medications, and topical medications were stored separately in Medication Cart B. These failures had the potential to result in unsafe medication administration, cross contamination of medications, and put staff and residents at risk for needlesticks. Findings: Review of the facility's P&P titled Medication Access and Storage revised 2/2019 showed the following: - All drugs and biologicals are stored in locked compartments under the proper temperature controls. -Orally administered medications are kept separately from externally used medications e.g., suppositories, liquids, lotions, and tablets. - Eye medications are kept separate from ear medications. - Contaminated containers, or those that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. The OSHA (Occupation Safety and Health Administration - a division of the Department of Labor which ensures workers have safe and healthful working conditions) document titled Protecting Yourself When Handling Contaminated Sharps dated 1/2011 defined a needlestick as a cut from a contaminated sharp that can result in a worker being infected with bloodborne pathogens. The document further showed the sharps containers must be emptied or replaced routinely and not be overfilled. 1. On 11/15/24 at 0951 hours, a medication cart inspection for Medication Cart E was conducted with RN 1. The following was observed: - One used 10 ml syringe of 0.9% sodium chloride (saline) was stored with unopened Ultrasite Needle-Free injection sites (a device used to prevent backflow of blood when injecting or infusing fluids or medications). - One tube of hydrocortisone (medication used to treat skin conditions that cause swelling, redness, itching and rashes) cream 1% stored with the 25-gauge safety needles (needle engineered to reduce the risk of accidental needlestick injuries by retracting or shielding the needle after use). RN 1 verified the above findings and stated the 10 ml syringe of 0.9% sodium chloride should have been discarded after use and the hydrocortisone 1% cream should not have been stored with the 25-gauge needles. 2. On 11/15/14 at 1022 hours, a medication cart inspection for Medication Cart D was conducted with RN 1. One bottle of nitroglycerin (medication used to treat chest pain) 0.4 mg sublingual tablets was observed stored with the lubricant jelly. RN 1 stated the nitroglycerin medication should not be stored in Medication Cart D and it should not be stored with the lubricant jelly. RN 1 verified the finding and removed the bottle of the nitroglycerin medication from Medication Cart D. 3. On 11/15/24 at 1056 hours, a medication cart inspection for Medication Cart A was conducted with LVN 3. The following was observed: - The contents of the sharp disposal container were above the full line. - One box of Refresh Celluvisc (eye drops to soothe and treat symptoms of dry eyes) 1% eye gel was stored with one box of orally administered throat lozenges. - One box of Gericare artificial tears (lubricant eye drops) was stored with one bottle of docusate sodium (stool softeners) 250 mg capsules, 30 packets of pantoprazole sodium (medication released in the body slowly over time to treat heartburn symptom) 40 mg delayed release oral suspension, and 60 single-use containers of dorzolamide hydrochloride 2% and timolol maleate (used to treat increased pressure in the eye caused by glaucoma) 0.5% ophthalmic solution. - One box of Polyvinyl alcohol (lubricating eye drops) 1.4% was stored with one tube of Procto-Med HC (used to treat pain, itching, swelling, and discomfort caused by hemorrhoids) 2.5% hydrocortisone cream and one bottle of Pertzye DR (used to treat eye conditions like glaucoma) 8,000 unit capsules. - One box of biscodyl (medication to treat constipation) 10 mg suppositories was stored in the bottom drawer with the BP (blood pressure) cuff and stethoscope. -Three boxes of ipratropium bromide and albuterol sulfate (medication to control symptoms of lung disease and treat air flow blockage) inhalation solution 0.5-3 mg per 3 ml was stored with one bottle of Saline Mist (used to treat sinus congestion) 0.65% nasal spray, one bottle of fluticasone propionate used to treat hay fever, nasal polyps, and other allergic and non-allergic nasal symptoms) 50 mcg nasal spray, 12 tablets of rizatriptan benzoate (used to treat acute migraine headaches) 10 mg oral tablets, one fluticasone furoate/vilanterol (medication to treat and prevent breathing difficulties caused by lung disease) inhalation powder 100 mcg/25 mcg inhaler, three boxes of lidocaine 5% transdermal patches (medication applied to the skin to treat pain), and two vials of intramuscular methylprednisone (given via injection into the muscle to prevent and treat inflammatory conditions such as asthma, allergic reactions, and arthritis) 40 mg. LVN 3 verified the above findings and stated the medications with different routes of administration should not be stored together to prevent cross-contamination. 4. On 11/15/24 at 1141 hours, a medication cart inspection for Medication Cart C was conducted with LVN 5. The following was observed: - One tube of diclofen sodium (medication put on the skin to treat the inflammation and swelling of joints) topical gel 3% was stored with two boxes of pre-filled single dose enoxaparin sodium (medication to prevent blood clots) syringes, and one box of heparin sodium (medication to prevent blood clots) 5,000 units per ml vials. - Lidocaine 5% transdermal patches and scopolamine 1 mg transdermal patches were stored with one bottle of oral liquid Prostat (protein supplement) and fiber protein powder (dietary supplement). The Prostat bottle was observed with sticky beige colored liquid on the top of the container and covered the bottle's label. - One box of biscodyl 10 mg suppositories was stored with orally administered liquid vitamin C 500 mg per 5 ml (supplement) and orally administered docusate sodium (stool softener) 50 mg per ml. LVN 5 verified the findings. 5. On 11/15/24 at 1408 hours, a medication cart inspection of Medication Cart B was conducted with LVN 6 and the ADON. The following was observed: - One unopened box of Refresh Celluvisc lubricant eye gel stored with four boxes of heparin sodium 5,000 units per ml vials. - Testosterone 1.62% topical gel (applied to the skin to increase the levels of testosterone) was stored with one bottle of cephalexin (antibiotic medication) 250 mg per 5 ml suspension liquid was stored with morphine sulfate (pain medication) oral solution 100 mg per 5 ml, one bottle of docusate sodium 100 mg oral capsules. - Two boxes of lidocaine 5% pain patches were stored with albuterol sulfate inhalation solution 0.083%. - Diclofen sodium topical gel 1% was stored with one bottle of Delsym cough syrup, ipratropium bromide and albuterol sulfate inhalation solution, and Pradaxa (blood thinner) 110 mg oral capsules. LVN 6 and the ADON verified the above findings. On 11/15/24 at 1504 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to follow-up with the physician for the abnormal laboratory re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to follow-up with the physician for the abnormal laboratory results for one of five final sampled residents (Resident 70) reviewed for unnecessary medication. This failure had the potential for the resident to have undesirable outcomes. Findings: Medical record review for Resident 70 was initiated on 11/12/24. Resident 70 was readmitted to the facility on [DATE]. Review of Resident 70's Skilled Nursing H&P examination dated 9/9/24, showed the resident had intractable epilepsy (a seizure disorder). Review of Resident 70's Order Summary Report dated 11/14/24, showed a physician's order for divalproex sodium (a compound containing valproic acid and sodium valproate) 500 mg daily for seizure activity. Review of the Consultant Pharmacist's Medication Regimen Review for August 2024 showed a recommendation for Resident 70. The recommendation showed to clarify if the valproic acid was for seizures, and if it was, to obtain a valproic acid level. Review of Resident 70's Laboratory Results Report for the valproic acid dated 9/7/24, showed the resident's valproic acid level was 37 mcg/ml, with a reference range of 50-100 mcg/ml. The report showed a flag code of L. Review of Resident 70's Progress Note showed a nursing note dated 9/7/24 at 1257 hours, the nurse communicated with the physician regarding the valproic acid level results and a recommendation to increase the dose. The note showed they were awaiting a response. Review of Resident 70's medical record failed to show the facility made repeated attempt to notify the resident's physician of the low laboratory results. On 11/15/24 at 1055 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for an abnormal laboratory values, the expectation was to make two to three attempts to notify the physician and if unable to get a hold of the physician, then staff should contact the medical director.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's document review titled Hospice Service Agreement dated 11/5/20, showed the SNFs shall also document ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's document review titled Hospice Service Agreement dated 11/5/20, showed the SNFs shall also document accurately in the patient chart in the SNF record, according to the policy for the particular SNF. Documentation of services provided shall include copies of any instructions delivered to the patient. All required documentation shall be submitted within 5 days of providing any specific services. Medical record review for Resident 105 was initiated on 11/12/24. Resident 105 was admitted to the facility on [DATE]. Review of Resident 105's Certification Statement with Plan of Care Effective date of 10/8/24, showed Resident 105 was to be visited by skilled nurse to visit one time a week and a Hospice Aide two times a week. Review of Resident 105's Order Summary Report showed a physician's order dated 11/11/24, to admit the resident to hospice care under a hospice provider with diagnosis of COPD (Chronic Obstructive Pulmonary Disease). Review of the hospice provider Flow Sheet sign-in log showed the following: - on 10/24/24, showed one visitation from a skilled nurse and one visitation from a Hospice Aid (missing signature of one visitation from a Hospice Aid). - on11/5/24 -11/9/24 showed one visitation from a skilled nurse and one visitation from a Hospice Aid (missing signature of one visitation from a Hospice Aid). On 11/13/24 at 1454 hours, an interview and concurrent facility documents and medical record review was conducted with the DSD. The DSD was asked if the hospice provider Flow Sheet sign-in log was accurately filled out for the months of October 2024 through November 2024. She verified the sign-in log was missing signatures and dates of when services were provided for Resident 105 by the hospice staff. The DSD stated she contacted the hospice provider to remind them that Resident 105's hospice provider Flow Sheet sign-in log needed to be completed with each visit. 4. Review of facility's P&P titled Record Systems, Organization and Maintenance -Designated Record Set undated showed the facility shall maintain a health record for each resident, which shall include: - Consent forms - Licensed nurse's notes Review of the facility's P&P titled Immunizations-Residents revised 7/2023 showed information related to education provided regarding the benefits and risks of each immunization and the administration or refusal of or medical contraindication to the vaccines will be documented in the resident's medical records. - Document that the resident either received the influenza and/ or pneumococcal and/ or Covid 19 immunization or did not receive the influenza and/ or immunization due to medical contraindications or declination. Medical record review for Resident 41 was initiated on 11/12/24. Resident 41 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 41's Order Summary showed a physician's order dated 10/24/24, for influenza vaccine 0.5 ml injection IM (intramuscular) annually as prophylaxis for influenza, unless contraindicated one time only for influenza prevention for one day. Further review of Resident 41's medical record did not show a signed consent form for influenza Vaccine. On 11/13/24 at 1557 hours, an interview and concurrent medical record review was conducted with the IP regarding Resident 41. The IP was asked where Resident 41's consent was kept for the Influenza vccine. The IP stated the consent for Resident 41 was stored in her own facility binder for record keeping and not in the resident's medical records. When asked if the consent was a medical record belonging to Resident 41, the IP stated yes. When asked what the proper area for Resident 41's consent to be stored, the IP stated it should have been in the Resident's medical record. On 11/13/24 at 1628 hours, an interview and concurrent medical record review was conducted with the DON regarding Resident 41. The DON was asked where signed consent was kept for the Influenza vaccine given to the residents. The DON stated the signed consent forms for all vaccines were kept in the residents' medical records. When asked if Resident 41's influenza consent should have been stored in the resident's medical record, the DON stated yes, that was where all the records were stored. On 11/15/24 at 1503 hours, an interview with the DON and Administrator was conducted. The DON and Administrator were informed and acknowledged the above findings. Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurately maintained for four of 27 residents (three final sampled residents, Residents 33, 41, and 105; and one nonsampled resident, Resident 49) reviewed for medical records. * The facility failed to ensure Resident 33's intravenous fluid intake was documented. * The facility failed to ensure the RNA documented Resident 33's refusal to be weighed. * The facility failed to ensure Resident 49's MAR was completed. * The facility failed to ensure Resident 105's hospice visitation log was completed. * The facility failed to ensure Resident 41's updated flu vaccination consent was filed in the appropriate medical records folder. These failures had the potential for the residents' care needs not being met as the medical record was incomplete. Findings: Review of the facility's P&P titled Nutrition Status Management revised 12/2024 showed the following: - Evaluations will include determining ideal body weight range, usual body weight, current diet order, percentage of food eaten, possible dental problems, current illness, resident likes and dislikes, psychosocial needs, and any other change in medical condition that may impact weight gain or loss. - Nutritional assessment may include: weighing and weight changes, oral intakes of food and fluid, IV therapy . Review of the facility's P&P titled Nutrition revised 1/24/24, showed any resident meeting the criteria for weight loss and any resident at risk will be weighed weekly if ordered by the physician with the weight entered into POC (Point of Care)/PCC (PointClickCare). Medical record review for Resident 33 was initiated on 11/12/24. Resident 33 was admitted to the facility on [DATE]. Review of Resident 33's MDS dated [DATE], showed Resident 33 had severe cognitive impairment. 1.a. Review of Resident 33's Order Summary Report showed the following: - dated 10/18/24, to monitor the resident's Intake and Output every shift for new admit with the indwelling urinary catheter for 30 days. - dated 11/2/24, to administer sodium chloride intravenous solution, use 75 ml/hr intravenously every shift for hydration for 2 liters (0.45% Normal Saline). - dated 11/4/24, to administer sodium chloride intravenous solution, use 100 ml/hr intravenously every shift for hydration for 3 liters until 11/6/24 23:59 (D5 1/2 NS). Further review of Resident 33's medical record failed to show documentation of Resident 33's IV fluid intake every shift. On 11/14/24 at 1001 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 verified there was no documentation of the IV fluids given to Resident 33 every shift on the fluid intake record. RN 3 stated the IV fluids given should have been documented by the licensed nurses. On 11/15/24 at 1134 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no documentation of the IV fluids given on the fluid intake record for Resident 33. The DON stated the licensed nurse should have assessed the patient for an adequate hydration if the IV fluid intake was not documented. b. Review of Resident 33's Order Summary Report dated 10/16/24, showed for weekly weights for four weeks: every seven days for four weeks. On 11/14/24 at 1629 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified Resident 33 was not weighed on 11/11/24. The ADON further stated the RNA was the one who should have weighed the resident and input the weight in PCC. The ADON stated the weight should have been documented to monitor weight gain or weight loss. On 11/15/24 at 0848 hours, an interview and concurrent medical record review was conducted with RNA 1. RNA 1 verified there was no documentation of Resident 33's weight on 11/11/24. RNA 1 stated she weighed the residents and input the residents' weight in PCC. RNA 1 further stated she was taught how to use the PCC but did not knew how to document Resident 33's refusal in PCC. RNA 1 stated she tried to weigh the resident again but the LVN told her the resident was on comfort care and Resident 33 did not want to be weighed. 2. Review of the facility's P&P titled Medication Administration revised 8/2021 showed it is the policy of this facility that medications shall be administered as prescribed by the attending physician. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR) and treatment administration record (TAR) as appropriate. Medical record review for Resident 49 was initiated on 11/12/24. Resident 49 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 49's Skilled Nursing H&P examination dated 9/5/23, showed Resident 49 was unable to make decisions. Review of Resident 49's MAR dated 11/12/24, showed missing documentations for the following if administered or performed as ordered: - Insulin Lispro (fast acting insulin) Solution Inject subcutaneously in the morning for DM as per sliding scale as follows: If BS 0 - 69 mg/dl = 0 units give 8 oz of OJ (orange juice) then recheck in 15 minutes. If BS remains <70 mg/dl or unresponsive give glucagon, call MD (Doctor of Medicine). BS 70 - 150 mg/dl - 0 units no action; BS 151 - 200 mg/dl = 1 unit BS 201 - 250 mg/dl = 2 units; BS 251 - 300 mg/dl = 3 units; BS 301 - 350 mg/dl = 4 units; BS 351 - 400 mg/dl = 5 units; BS 401+ mg/dl = 6 units, recheck BS In 30 minutes and if BS >400 mg/dl, call MD, - Prevacid (reduces the amount of acid in the stomach) Capsule Delayed Release 30 mg (lansoprazole) one capsule via GT one time a day for GERD (gastroesophageal reflux disease). - Vital signs every shift. - Artificial Tears ophthalmic solution (artificial tear solution) one drop in both eyes four times a day for dry eyes. - Equipment: Use of left-hand mitten to prevent injury from pulling tubes. 1. Remove every two hours to check for skin condition (swelling, ROM (range of motion), circulation) and re-apply. Y = with issues. N = without issues. 2. Monitor for episodes of pulling on vital tubes every shift. Yes = patient pulling tubes. No = patient not pulling tubes. Review of Resident 49's MAR on 11/13/24 showed missing documentations for the following if administered or performed as ordered: - Insulin Lispro Solution Inject subcutaneously in the morning for DM as per sliding scale - Prevacid Capsule Delayed Release 30 mg (lansoprazole) one capsule via G-tube one time a day for GERD. - Artificial Tears Ophthalmic solution (artificial tear solution) one drop in both eyes four times a day for dry eyes. - Equipment: Use of left-hand mitten to prevent injury from pulling tubes. 1. Remove every two hours to check for skin condition (swelling, ROM, circulation) and re-apply. Y = with issues. N = without issues. 2. Monitor for episodes of pulling on vital tubes every shift. Yes = patient pulling tubes. No = patient not pulling tubes. On 11/15/24 at 1111 hours, an interview and concurrent medical record review was conducted with LVN 15. LVN 15 verified the missing documentations on Resident 49's MAR for 11/12 and 11/13/24. LVN 15 stated the staff were supposed to document in the MAR. On 11/15/24 at 1451 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the process of the medication administration included the five rights, pouring the medication, giving the medication, and signing the document. The DON stated the medical records did daily audits to capture any missing documentation and she would be notified if there was recurrent missing documentation. The DON stated the charge nurse had 72 hours to complete their audit. On 11/15/24 at 1451 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infection were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for January 2024 through September 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to implement their infection control surveillance program for July 2024 through September 2024. * The facility failed to ensure infection control practices were implemented for one final sampled resident (Resident 775) * The facility failed to ensure tracheostomy supplies in the respiratory carts were stored properly for use. * The facility failed to ensure one final sampled resident (Resident 43's) urinal was labeled. * The facility failed to ensure the blood glucose meter in Medication Cart A was cleaned after use. These failures posed the risk for not identifying infections and controlling the transmission of communicable disease to other resident through the facility. Findings: Review of the facility's P&P titled Infection Prevention and Control Program undated showed the resident infection cases are monitored by the IP. The IP completes an Infection Surveillance from monthly and reports on a routine basis. Review of the facility's P&P titled Infection Prevention and Control Program - Infection Control dated 6/2021 showed the facility had goals to: - decrease the risk of infection to residents and personal. - Recognize infection control practices while providing care. 1.a. Review of the facility's monthly Infection Prevention and Control Surveillance Log from January 2024 through September 2024 Showed the following surveillance data: - January 2024, total of 45 cases including 16 CAI and 29 HAI, - February 2024, total of 48 cases including 11 CAI and 37 HAI, - March 2024, total of 41 cases including 10 CAI and 31 HAI, - April 2024, total of 47 cases including 13 CAI and 34 HAI, - May 2024, total of 44 cases including 14 CAI and 30 HAI, - June 2024, total of 49 cases including 16 CAI and 33 HAI, - July 2024, total of 55 cases including 24 CAI and 32 HAI, - August 2024, total of 38 cases including 11 CAI and 27 HAI, and - September 2024, total of 44 cases including 9 CAI and 35 HAI. Review of the facility's monthly Prevention and Control Surveillance log from January 2024 through August 2024 showed documentation of the residents having an HAI or CAI and prescribed with antimicrobial medications. Further review of the facility's monthly Prevention and Control Surveillance Log from January 2024 through September 2024 showed the facility failed to conduct surveillance for all the residents' infections, specific to the residents who had signs and symptoms of infection, met the McGeer's criteria (method used to retrospectively counting true infection), and were not prescribed antimicrobial medications. On 11/12/24, at 1442 hours, an interview was conduction with the IP. When asked if she included the residents with signs and symptoms of infection who met the McGeer's criteria, but were not prescribed antimicrobial medication on the monthly Prevention and Control Surveillance log, the IP stated the residents who developed signs and symptoms, and who were not prescribed antibiotics were not a part of the monthly Prevention and Control Surveillance log. b. Review of the facility's monthly Infection Prevention and Control Surveillance Log and Surveillance Data Collection Forms for July 2024 showed the following residents with antibiotic were not included in the monthly surveillance log, the IP stated she did not include the residents without antibiotics in the log. - dated 7/3/24, Resident 528's Zosyn (antibiotic) 3.375 grams - dated 7/8/24, Resident 80's Doxycycline (antibiotic) 100 mg - dated 7/30/24, Resident 78's Zerbaxa (antibiotic) 3 grams Review of the facility's monthly Infection Prevention and Control Surveillance Log and Surveillance Data Collection Forms for August 2024 showed the following residents with antibiotic were not included in the monthly surveillance log. - dated 8/7/24, Resident 527's Amoxicillin (antibiotic) 875-125 mg - dated 8/7/24, Resident 45's Ceftriaxone (antibiotic) 1 gram Review of the facility's monthly Infection Prevention and Control Surveillance Log and Surveillance Data Collection Forms for August 2024 showed the following residents with antibiotic were not included in the monthly surveillance log. -dated 9/6/24, Resident 528's Ceftriaxone (antibiotic) 2 grams -dated 9/5/24, Resident 14's Azithromycin (antibiotic) 500 mg -dated 9/7/24, Resident 100's Zosyn (antibiotic) 3.375 grams -dated 9/27/24, Resident 9's Doxycycline (antibiotic) -dated 9/28/24, Resident 529's Ertapenem (antibiotic) 2. Medical record review for Resident 775 was initiated on 11/12/24. Resident 775 was admitted to the facility on [DATE]. On 11/13/24 at 124 hours, an observation of Resident 775's room including signage of enhanced barrier precautions. On 11/13/24 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. When the DON was asked if Resident 775 had the physician's order for the enhanced barrier precautions, she stated she did not see one. When the DON was asked if Resident 775 had a care plan for the enhanced barrier precautions, she verified the resident did not have any. The DON verified both order and care plan should have been completed for Resident 775 due to his wounds. 3. Review of the facility's P&P titled Medication Access and storage revised on 2/2019 showed that contaminated, or those in containers that are cracked, solid, or without secure closures are immediately removed from stock, disposed of according to procedures for medications destruction and reordered from the pharmacy if a current order exists. On 11/15/24 at 1115 hours, a respiratory cart inspection for Cart 6 in Station one was conducted with the Administrator. The following was observed: - One Spring-loaded T Adapter was found without a secure closure package in the first drawer. - Closed Suction Tracheostomy Catheter parts were found without a secure closure package in the first drawer. On 11/15/24 at 1123 hours, the Administrator was asked if the tracheostomy adaptors should be in the cart without a closure package. The Administrator stated it should not be used and should have been discarded. When asked if parts of the tracheostomy catheter should be stored in the cart without a secure closure package, the Administrator stated it should have been thrown away. On 11/15/24 at 1503 hours, during an interview with the DON and Administrator, the DON and Administrator were informed and acknowledged the above findings. 5. Review of the facility's P&P titled Glucometer Calibration showed the glucometer (blood glucose meter) will be cleaned and disinfected per the manufacturer's guidelines. Review of the Evencare G2 blood glucose meter user's guide published in 2018 showed the instructions to disinfect the glucose meter include the following: 1. The blood glucose meter should be inspected for blood, debris, dust, or lint. 2. Clean the blood glucose meter with one of the validated disinfecting wipes listed below: - Dispatch Hospital Cleaner Disinfectant Towels with Bleach - Medline Micro-Kill+ Disinfecting, Deodorizing, Cleaning Wipes with Alcohol - Chlorox Healthcare Bleach and Germicidal and Disinfectant Wipes - Medline Micro-Kill Bleach Germicidal Bleach Wipes Wipe all external areas of the blood glucose meter, including the front and back surfaces, until visibly clean. Allow the surface of the blood glucose meter to remain wet at room temperature for the contact time listed on the wipe's directions before use. Wipe blood glucose meter dry or allow to air dry. On 11/15/24 at 1056 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 3. The back side of the Evencare G2 blood glucose meter in Medication Cart A was observed with a red/brown smear. LVN 3 verified the findings and stated the blood glucose meter should be cleaned after use and should not be soiled. LVN 3 was observed to clean the blood glucose meter with Medline Micro-Kill Bleach Germicidal Bleach Wipes (ready to use wipes with a bleach solution, used to clean and disinfect hard and nonporous surfaces). On 11/15/24 at 1504 hours, an interview was conducted with the Administrator and DON. The DON stated the blood glucose meter should be disinfected before and after use and should not be visibly soiled. The Administrator and DON were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Disposable Equipments revised 8/2019 showed it is the policy of this facility to allow multiple usage of disposable equipment for residents' ADL care such as bed bath basins, urinals, and emesis basins. These items will be clearly labelled when initially used and changed. On 11/12/24 at 1138 hours, a urinal inside a urinal holder on the left side of Resident 43's bed was observed unlabeled. Medical record review for Resident 43 was initiated on 11/12/24. Resident 43 was admitted to the facility on [DATE], and readmitted on [DATE] . Review of Resident 43's MDS dated [DATE], showed Resident 43's cognition was intact. On 11/12/24 at 1158 hours, an observation and concurrent interview was conducted with RN 4. RN 4 verified the urinal inside a urinal holder on the left side of Resident 43's bed was unlabeled. RN 4 stated whoever gave the urinal to Resident 43 should have labeled the urinal. On 11/15/24 at 1531 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

Based on interview, facility document review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program (ASP) when: * The facility failed to conduct an assessment ...

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Based on interview, facility document review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program (ASP) when: * The facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for one nonsampled resident (Resident 525). * The facility failed to use the correct Surveillance Data Collection Form for two final sampled residents (Residents 96 and 108) and four nonsampled residents (Residents 4, 8, 86, and 531). * The facility failed to properly use the Surveillance Data Collection Form criteria to indicate a true infection for one final sampled resident (Resident 83) and three nonsampled residents (Residents 2, 19, and 80). These failures had the potential for inaccurately identifying for true infections and potentially inhibited residents from receiving proper treatment and care. Findings: Review of the facility's P&P titled Infection Prevention- Surveillance of Infection and Reporting undated showed the IP/DNS (Director of Nursing Services)/Designee will trend all validated infections using McGeer's criteria on monthly basis. Action Plans will be written for any identified problems and implemented as soon as possible. 1. On 11/12/24 at 1457 hours, an interview and concurrent facility document reviews were conducted with the IP. When asked to review Residents 525's Surveillance Data Collection Form since Resident 525 was on the Infection Prevention and Control Surveillance Log for July 2024, the IP stated she did not have a Surveillance Data Collection (McGeer's criteria) Form filled out for the resident. When the IP was asked if Resident 525 should have had a Surveillance Collection Form, she stated the resident should have had a form to validate a true infection. 2.a. Review of the facility's monthly Surveillance Data Collection Form for July 2024 showed the following residents did not have the correct IP Surveillance Data Collection Form: - Surveillance Data Collection Form- Other Infections was used for Resident 86 rather than Surveillance Data Collection Form- Respiratory Tract Infections - Surveillance Data Collection Form- Other Infections was used for Resident 108 rather than Surveillance Data Collection Form- Skin/ Soft Tissue, and Mucosal Infection. - Surveillance Data Collection Form- Other Infections was used for Resident 8 rather than Surveillance Data Collection Form- Skin/ Soft Tissue, and Mucosal Infection. b. Review of the facility's monthly Surveillance Data Collection Form for August 2024 showed the following resident did not have the correct IP Surveillance Data Collection Form: - Surveillance Data Collection Form- Other Infections was used for Resident 96 rather than Surveillance Data Collection Form- Respiratory Tract Infections. c. Review of the facility's monthly Surveillance Data Collection Form for September 2024 showed the following residents did not have the correct IP Surveillance Data Collection Form: - Surveillance Data Collection Form- Other Infections was used for Resident 4 rather than Surveillance Data Collection Form-Urinary Tract Infections. - Surveillance Data Collection Form- Other Infections was used for Resident 531 rather than Surveillance Data Collection Form- Skin/ Soft Tissue, and Mucosal Infection. On 11/12/24 at 1501 hours an interview and concurrent facility document review were conducted with the IP. When asked about if she should have used a more precise Surveillance Data Collection Form based McGeer's criteria for each resident, the IP verified a more precise Surveillance Data Collection Form should have been used. 3.a. Review of the facility's monthly Surveillance Data Collection Forms for July 2024 showed the following resident did not meet the criteria McGeer's for HAI on the Surveillance Data Collection Form: - Resident 83 was prescribed Bactrim DS (antibiotic) initiated on 7/6/24; however, the Surveillance Data Collection Form- Urinary Tract Infections showed the HAI was checked and not the did not meet two of the McGeer's criteria b. Review of the facility's monthly Surveillance Data Collection Forms for September 2024 showed the following residents did not meet the criteria McGeer's for HAI on the Surveillance Data Collection Form. - Resident 2 was prescribed Bactrim DS (antibiotic) initiated on 9/6/24; however, the Surveillance Data Collection Form- Urinary Tract Infections showed the HAI was checked and not the did not meet two of the McGeer's criteria - Resident 19 was prescribed Ciprofloxacin (antibiotic) 250 mg initiated on 9/19/24; however, the Surveillance Data Collection Form- Urinary Tract Infections for residents with indwelling urinary catheter showed the HAI was checked and not the did not meet two of the McGeer's criteria - Resident 80 was prescribed ertapenem (antibiotic) 1 gram and linezolid (antibiotic) 600 mg initiated on 9/30/24; however, the Surveillance Data Collection Form- Respiratory Tract Infection showed the HAI was checked and not the did not meet two of the McGeer's criteria On 11/12/24 at 1512 hours, an interview and concurrent facility document review of the monthly Surveillance Data Collection logs were conducted with the IP. The IP verified Residents 2, 19, 80, and 83 did not meet the McGeer's criteria on their Surveillance Data Collection Forms and should have been checked. On 11/15/24 at 1503, an interview with the DON and Administrator. The DON and Administrator were informed and acknowledged the above findings.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility fai...

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 11/15/24, showed 88 of 137 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 11/12/24 at 0804 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. The following were observed and verified by the Dietary Manager: - Two white rubber spatulas with red handles were chipped at the edges and discolored. The Dietary Manager stated it should not be used because it can harbor bacteria inside the groves. - One stainless whisk was observed dirty with dry, crusted orange residue resembles a rust. - Two stainless slotted scoops with black handles were dirty, discolored and had dry paper sticking to it. One of the black handles was partially melted and worn off which resembled burnt mark. 2. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 11/12/24 at 0804 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. The following was observed and verified by the Dietary Manager: - Two stainless slotted scoops with black handles were dirty, discolored and had dry paper sticking to it. - Two stainless spatulas with cream handles were stored wet and dirty. - One stainless scoop with blue handle was dirty, fuzzy with cloudy film. - Two cutting knives with black handle were dirty with dry green residue, fuzzy with cloudy film. 3. Review of the facility's P&P titled Sanitation dated 2023 showed plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 11/12/24 at 0804 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. One green cutting board was observed fuzzy, heavily marred, discolored, and peeling. 4. Review of the facility's P&P titled Dishwashing dated 2023 showed dishes are to be air dried in racks before stacking and storing. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 11/12/24 at 0804 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. One heavy-duty blender stored on the counter shelf was still wet with visible water inside. 5. Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 11/12/24 at 0804 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. The microwave at a countertop table was observed dirty with dry, crusted, clear to pale yellow food residue inside the microwave's glass plate. The Dietary Manager verified the findings and stated he was not sure if the microwave was used to warm food for the residents or staff, he had not seen anyone used the microwave. 6. Review of the facility's P&P titled Hoods, Filters, and Vents dated 2023 showed hoods must be cleaned every two weeks and must be free of dust and grease. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention. The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 11/12/24 at 1458 hours, during the kitchen tour, a concurrent observation and interview was conducted with the Dietary Manager. The kitchen hood had black, grease residue. The Dietary Manager acknowledged the findings and stated the dietary staff cleaned the hood once a week and an outside company performed the service every three months for the kitchen hood and was last maintained or serviced on 9/19/24. 7. Review of the facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. The Maintenance Supervisor can keep this record, or it can be posted on the ice machine. According to the USDA Food Code 2017, Section 4-601.11, the equipment food-contact surfaces and utensils shall be clean to sight and touch. On 11/12/24 at 0847 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Maintenance Supervisor. The ice machine's interior top portion to the water curtain located directly above the ice bin, was observed with ice buildup. The Maintenance Supervisor acknowledged the findings and stated the ice machine was under the warranty and could not be touch but he will call the outside company for maintenance services. On 11/14/24 at 1619 hours, a follow up interview was conducted with the Dietary Manager. The Dietary Manager acknowledged the above findings and stated the following: - The microwave should be cleaned to ensure it will not harbor any bacteria. - The spatulas should have a smooth surface because it had to be cleanable. - The utensil/kitchenware with greasy residue should be cleaned, washed properly, and air dried. - The utensil/ kitchenware with dents, scratches, and damaged should be discarded. - The cutting board heavily marred was discarded. - The blender should have been placed upside down and properly air dried. - The ice machine should not have an ice buildup because it can damage the ice machine and harbor bacteria. - The hood over the stove should not have a black, greasy residue because it can be a potential fire hazard. On 11/15/24 at 1519 hours, the DON and RD were informed and acknowledged the above findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Resident Rights (Tag F0550)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the resident rights were ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the resident rights were respected for one nonsampled resident (Resident 35). * CNA 3 was using his personal cell phone while feeding Resident 35. This failure had the potential for Resident 35 to be treated without dignity and respect. Findings: Review of the facility's employee Handbook Section Two: Good to Great signed by CNA 3 on 11/5/24, showed any form of personal electronic communication is prohibited during work hours. This includes the use of personal electronic devices. Medical record review for Resident 325 was initiated on 11/12/24. Resident 325 was readmitted to the facility on [DATE]. Review of Resident 325's IDT-BIMS dated 11/12/24, showed the resident was cognitively intact. On 11/14/24 at 0912 hours, an interview was conducted with Resident 325 at their bedside. Resident 325 stated CNA 3 was feeding Resident 35 and on his cell phone the other day. Resident 325 stated Resident 35 was legally blind and not aware of what the CNA was doing, but it was very disrespectful to be on the personal cell phone while providing care to a resident. Medical record review for Resident 35 was initiated on 11/12/24. Resident 35 was readmitted to the facility on [DATE]. Review of Resident 35's H&P examination dated 9/22/24, showed the resident was legally blind. Review of Resident 35's IDT-BIMS dated 11/6/24, showed the resident was cognitively intact. On 11/14/24 at 1350 hours, an interview was conducted with the DON. The DON stated the staff should not use their personal cell phones while performing resident care and on the unit. On 11/15/24 at 0847 hours, a telephone interview was conducted with CNA 3. CNA 3 stated he had used his cell phone three to four times while feeding Resident 35, and he verified the facility's policy was for no cell phones allowed while working.

Aug 2024 1 deficiency

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Infection Control (Tag F0880)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff followe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff followed the infection control practices during the wound care dressing change for one of two sampled residents (Resident 3). * The licensed nurse did not change gloves and perform hand hygiene in between the wound care dressing change for Resident 3. This failure had the potential for spread of infections in the facility. Findings: Review of the facility's P&P titled Hand Hygiene revised 10/2022 showed all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. The P&P also showed to wash hands with soap and water for the following situations: - When hands are visibly soiled (e.g., blood, body fluids) - After caring for a resident with known or suspected Clostridioides Difficile or Norovirus infection during an outbreak, or if infection rates of C. Difficile Infection (CDI) are high use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: - Before handling clean or soiled dressings, gauze pads, etc. - Before moving from a contaminated body site to a clean body site during resident care; - After handling used dressings, contaminated equipment, etc. - After removing gloves Medical Record review for Resident 3 was initiated on 7/30/24. Resident 3 was admitted on [DATE]. Review of Resident 3's skin assessment dated [DATE], showed Resident 3 had a Stage 4 sacral coccyx wound (an open wound from the break of the skin that appears along the lower back near the bottom of the spine above the coccyx), measuring 1.1 cm (length) x 1.9 cm (width) x 1.9 cm (depth). On 7/31/24 at 1432 hours, a wound care observation for Resident 3 and concurrent interview was conducted with LVN 8. LVN 8 donned new gloves and entered Resident 3's room to greet Resident 3 and CNA 7. CNA 7 repositioned Resident 3 to her left side. LVN 8 cleaned Resident 3's stool with a gauze dressing. LVN 8 had stool on his gloves. LVN 8then pulled back the sacral coccyx wound dressing. LVN 8 did not change his gloves and perform hand hygiene prior to removing the sacral coccyx wound dressing from Resident 3. After removing the wound dressing, LVN 8 removed his gloves, did not perform hand hygiene, and left the room to get supplies from the treatment cart in the hallway outside Resident 3's door. LVN 8 put on new gloves and placed clean supplies on the bedside table without sanitizing the table. LVN 8 cleaned the resident's sacral coccyx wound with a clean gauze with saline. LVN 8 proceeded to cover the sacral coccyx wound with a new dressing. When LVN 8 was asked about the process for changing gloves and performing hand hygiene during wound care, LVN 8 verified he should have changed his gloves and performed hand hygiene during the wound dressing change. On 7/31/24 at 1530 hours, an interview was conducted with the DON. The DON stated LVN 8 did not follow infection control practices by changing gloves and performing hand hygiene in between steps for changing a wound dressing.

May 2024 1 deficiency

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0558 (Tag F0558)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for one of three final sampled residents (Resident 1). * The facility failed to ensure the call light for Resident 1 was within the resident's reach. This failure had the potential for the resident to not be able to call for assistance when needed. Findings: Review of the facility's P&P titled Call Light/Bell revised May 2007 showed to place the call device within the residents' reach before leaving the room. On 5/24/24 at 1520 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed awake and lying in her bed on her left side. The call light cord was observed wrapped around the elevated right bedrail with the call light button hanging down halfway to the floor and not within Resident 1's reach. Resident 1 stated she would use the call light when she needed assistance from the staff. Resident 1 further stated she did not know where her call light was at this time. Medical record review for Resident 1 was initiated on 5/24/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 1/7/24, showed Resident 1 had impaired speech but was able to verbalize needs and answer simple questions. On 5/24/24 at 1607 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 1's call light was not within reach. CNA 1 stated Resident 1's call light should have been within the resident's reach. On 5/30/24 at 1200 hours, a follow-up observation and concurrent interview was conducted with Resident 1. Resident 1 was observed in her bed eating her lunch meal and crying. When Resident 1 was asked why she was crying, Resident 1 stated she wanted to be changed because she felt she was wet. Resident 1's call light was observed wrapped around the elevated right bedrail with the call light button hanging down halfway to the floor and not within Resident 1's reach. Resident 1 stated she could not reach the call light when she was informed where it was. On 5/30/24 at 1215 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified the call light was not within Resident 1's reach. CNA 2 stated the call light should not be hanging down the bed and it should be clipped within Resident 1's reach. On 5/30/24 at 1220 hours, an interview was conducted with the ADON. The ADON stated the call device should always be within the resident's reach. The ADON was informed and acknowledged the above findings.

Mar 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan to address the individual care needs for one of six sampled residents (Resident 1). * The facility failed to implement Resident 1's plan of care to monitor and document output as per the facility's protocol. This failure had potential for not providing appropriate, consistent, and individualized care. Findings: According to the facility's P&P titled Care plan and Care Plan Update last revised 2/2023, it is the policy of the facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. According to the facility's P&P titled Intake and Output Policy revised 10/2020, under the documentation section, licensed nurse will document resident's intake and output at the end of each shift in the Intake and Output Record sheet. Intake and output record will be reviewed by a designated licensed nurse on a weekly basis to determine adequate hydration and fluid balance. After 30 days of continued intake and output monitoring, the IDT shall re-evaluate the intake and output for residents on indwelling catheter, to determine further need for recording intake and output. Medical record review for Resident 1 was conducted on 3/20/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1'scomprehensive care plan revised 12/2023 showed a care plan problem addressing the indwelling urinary catheter (drains urine from the bladder into a bag outside of the body) for neurogenic bladder (lacks bladder control due to brain, spinal cord or nerve problems). The interventions included to monitor and document intake and output as per thefacility's policy. On 3/20/24 at 1418 hours, an interview and concurrent medical record review was conducted with RN 1. The comprehensive care plan and interventions were reviewed. Resident 1's fluid intake was documented under the task section in the PCC (the facility's software); however, the output was blank. The output binder was reviewed and showed the following: - On 2/19/24 for the AM shift, urine output of 1000 cc; and - On 3/20/24 for the AM shift, urine output of 1000 cc. RN 1 confirmed the documentation of output was not done as per the care plan. On 3/21/24 at 1450 hours, an interview was conducted with the DON. The DON confirmed fluid output was not documented in the facility's software and was done inconsistently on the paper record.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered Norco oral tablet 10-325 mg (medication to manage pain) when Resident's A pain level was below the parameters to administer the ordered medication. This failure had the potential for Resident 1 to receive unnecessary medication and experience adverse effects from the medication. Findings: According to Lexicomp, an online reference for clinical drug information, the warnings/precautions and concerns related to the adverse effects of Norco included sedation, confusion, and constipation. According to the facility's P&P titled Medication Administration-General Guidelines, undated, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Under Procedure – Administration, medications are administered in accordance with written orders of the attending physician. Review of Resident 1'smedical record was initiated on 3/20/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1'sOrder Summary Report showed a physician's order dated 11/1/23, to administer Norco oral tablet 10-325 mg one tablet by mouth every fourhours as needed for severe pain levels of 7-10. Review of Resident 1's MAR for March 2024 showed Resident 1 was administered Norco 10-325 mg on the following dates and pain levels: - On 3/1/24 at 0856 hours, with apain level of 5 - On 3/5/24 at 0930 hours, with apain level of 4 - On 3/6/24 at 1107 and 1727 hours, with apain level of 6 - On 3/9/24 at 0901 and 1651 hours, with apain level of 5 - On 3/10/24 at 0823 and 1632 hours, with apain level of 5 On 3/20/24 at 1418 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 stated Norco 10-325 was prescribed for Resident 1's pain levels of 7-10, indicating severe pain and to be administered as needed. RN 1 verified Norco 10-325 was administered to Resident 1 for a pain level below 7-10. On 3/21/24 at 1450 hours, an interview was conducted with the DON. The DON verified the above findings and stated the nurses should have read and followed the physician's order.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for one of six sampled residents (Resident 1). * Resident 1 had three personal clothing itemshanging in a bathroom shared with another resident. * A food cart containing the lunch trays to be passed to the residents was in the hallway next to a dirty linen bin. These failures had the potential to cause the transmission and development of disease and infection. Findings: 1. According to the CDC, under Environmental Infection Control Guidelines, contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately. Medical record review for Resident 1 was initiated on 3/20/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's focused care plan showed Resident 1 was non-compliant with the laundry services provided by the facility. On 3/20/24 at 0815 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1's bathroom was shared with another resident. Resident 1 had three personal clothing items hanging on the shared shower curtain rod. Resident 1 stated they asked CNA 1 to hang the clothes in the bathroom because Resident 1 preferred to wash their own clothes. When asked how clothes were washed, Resident 1 stated clothes were washed in the basin with their own stain remover and soap. On 3/20/24 at 0906 hours, an interview was conducted with CNA 1. CNA 1 verified Resident 1 washed clothes in the basin and used their own soap. CNA 1 stated Resident 1 asked to hang clothes after rinsing. 2. Review of the facility's P&P titled Infection Prevention and Control Program last revised 10/2022 showed goals to decrease the risk of infection to residents and personnel and recognize infection control practices while providing care. On 3/20/24 at 1222 hours, an observation and concurrent interview with CNA 2 and RN 1 was conducted in the skilled nursing side hallway. A food cart containing the lunch trays to be passed to the residents was in the hallway next to a dirty linen bin. CNA 2 and RN 1 verified the observation and stated the dirty linen container should not be near the food cart. On 3/21/24 at 1450 hours, an interview was conducted with the DON. The DON stated hanging of clothes in the shared bathroom was an infection control issue. The DON additionally verified the dirty linen bin should not be placed next to the food carts containing resident lunches.

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to prevent falls for one of four sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with two persons assist during the transfers on 2/28/24, as per the MDS assessment and sustained a fall during this transfer. The fall care plan was not revised to include two persons assist as per the PT's recommendation. In addition, Resident 2 was no not monitored every shift for 72 hours after the fall. * CNA 1's competency for using the gait belt was incomplete and a gait belt was not issued to CNA 1 as per the facility's P&P. These failures had the potential for not providing adequate supervision and assistance to prevent accidents or falls for the resident. Findings: 1. Review of the facility's P&P titled Significant Change in Condition, Monitoring revised 2/2023 showed if any time, it is recognized by any one of the team members that the care needs of the resident have changed, the Nurse Supervisor should be made aware of, and he/ she will monitor. The resident will be placed on the 24-hour report and the nursing staff will provide no less than three days of documentation. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior/acceptance of increased need of assistance will be monitored. During assessment period, the care plan needs to be updated to reflect the change. Review of the facility's P&P titled Falls Prevention dated 8/2020 showed the Falls IDT will meet to complete the Post Fall Assessments, identify contributing factors, and make recommendations and care plan changes for all residents who have experienced a fall during the prior week. Discussion topics may include, but are not limited to the following: A. Apparent trigger of the fall B. Pattern of the fall (time, place, activity) C. Recent medication changes D. Nutritional status if indicated. E. Review of neuro check documentation. F. Lab studies if indicated. G. Medical status. H. Mental status. I. Orthopedic and/ or neuromuscular condition. J. Changes in condition. Care plans will be revised and/or updated to reflect changes in intervention. Review of the facility's P&P titled Gait Belt Policy (undated) showed to help ensure the physical safety of our employees and our residents, gait belts must be worn by all CNAs while on duty. Gait Belts must be used when transferring and ambulating residents. Medical record review for Resident 2 was initiated on 3/6/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 7/31/23, showed the resident had decision making capacity. Review of the plan of care showed a care plan problem addressing the ADL care was initiated on 8/1/23. The ADL care plan problem showed the resident required 1-2 staff assist with the transfers. Review of Resident 2's MDS Annual assessment dated [DATE], under Section C, showed BIMS of 13 (score of 13-15 suggests cognitive intact). Section GG showed Resident 2 was dependent with the transfers from the chair to bed or from the bed to chair and required the assistance of two or more persons for the resident to complete the activity. However, there was no documented evidence of the care plan revision to reflect the assistance of two or more staff with the transfers as per the above MDS assessment. Review of the nurses' progress notes dated 2/28/24, showed the resident had a fall. Review of the care plan problem initiated on 2/28/24, addressing an actual witnessed fall, failed to show an intervention to transfer the resident with two or more persons assist. Review of the PT note dated 2/29/24, showed the PT's recommendation for two persons assist with transfers. Further review of the medical record showed no documented evidence of the neurological assessments and monitoring completed every shift for 72 hours after the fall on 2/28/24. In addition, the fall care plan was not revised to include the PT's recommendation. On 3/6/24 at 1130 hours, a telephone interview was conducted with CNA 1. CNA 1 stated Resident 2 fell during the transfer from the wheelchair to bed. CNA 1 stated she transferred Resident 2 by herself. CNA 1 stated she did not used a gait belt during the transfer. CNA 1 further stated she was hired on 2/13/24, and had watched orientation videos; however, she had not completed the skills competency and was not observed by the DSD. On 3/6/24 at 1153 hours, a telephone interview was conducted with LVN 2. LVN 2 stated CNA 1 transferred Resident 2 alone without the use of gait belt. LVN 2 stated she did not initiate the neurological assessment for Resident 1 after the fall. On 3/6/24 at 1325 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 stated the neurological assessments and every shift observation and documentation on the progress notes must be conducted for 72 hours after a resident fall. RN 1 verified the findings. On 3/6/24 at 1330 hours, a telephone interview was conducted with LVN 1. LVN 1 stated Resident 2 was a two-person assist with the transfers. LVN 1 stated Resident 2 complained of headache after the fall and verified she did not initiate a neurological assessment after the fall. LVN 1 further stated the neurological assessment was supposed to be initiated by the medication nurse. On 3/6/24 at 1420 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated the neurological assessments, observations, and progress notes documentation for every shift should have been conducted for 72 hours after the incident of fall. The DON verified the findings. On 3/6/24 at 1430 hours, a concurrent interview and medical record review was conducted with the MDS nurse. The MDS nurse verified Resident 2 required two or more persons assist with the transfers. The MDS nurse verified the care plan problem addressing the actual fall was initiated on 2/28/24, was not revised to include two persons assist as recommended by the PT on 2/29/24. On 3/7/24 at 1600 hours, a concurrent interview and medical record review of Resident 2's care plan was conducted with the DON. The DON stated the care plan should be updated to include the current interventions for change of condition or incident of fall. The DON verified the care plan addressing the actual fall initiated on 2/28/24, failed to show an intervention to transfer the resident with two persons transfers. 2. Review of the facility's P&P titled Gait Belt Policy (undated) showed to help ensure the physical safety of our employees and our residents, the gait belts must be worn by all CNAs while on duty. Each CNA and NA will be issued a Gait Belt at the time of hire. Each CNA and NA will be provided training on the proper use of a Gait Belt during new employee orientation. Gait Belts must be used when transferring and ambulating residents. Review of CNA 1's CNA Comprehensive Clinical Competency Review - Skills Checklist with the date of hire 2/13/24, showed the competency for transfer activities were not completed. The document failed to show date and signature of the observer. On 3/6/24 at 1130 hours, a telephone interview was conducted with CNA 1. CNA 1 stated she was hired on 2/13/24, and had watched orientation videos; however, she had not completed skills competency and was not observed by the DSD. On 3/6/24 at 1530 hours, a concurrent interview and facility document review was conducted with the DSD. The DSD verified the CNAs had to watch videos during their orientation and complete the trainings online as required by the company. The DSD stated the CNAs were provided the orientation and skills competency which were conducted during orientation and annually thereafter. The DSD stated she asked the CNAs to call her to complete the skills competency during their training. The DSD verified the transfer was not completed, the completion date was not signed and dated. The DSD stated the gait belt was not issued to CNA 1 upon orientation.

Jan 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. * The facility failed to monitor Resident 1 after a change of condition. This failure posed the risk of the resident not receiving the necessary care and services. Findings: Review of the facility's P&P titled Significant Change in Condition, Monitoring- revised 2/2023 showed the following: 1. If, at any time, it is recognized by any one of the team members that the care needs of the resident have changed, the Nurse Supervisor should be made aware of, and he/she will monitor. Example would be the following (but not limited to): - change in ability to ambulate or propel wheelchair; - change in ability to transfer or position self; - change in ability to feed or drink; - change in ability to groom or dress; - change in behavior or increased problems that may cause injuries or incidents to self or others; - changes and/or initiation of psychotropic drug intervention; and - changes in weight and/or intake; signs and symptoms of dehydration and/or decreased fluid intake. 2. The resident will then be placed on the 24-Hour Report and Nursing will provide no less than three days of documentation. An attempt to identify the cause for decline, when it occurs, needed assist and resident behavior/acceptance of increased need of assistance will be monitored. Medical record review for Resident 1 was initiated on 1/16/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1 ' s Progress Notes dated 12/14/23, showed Resident 1 was alert and oriented to person, place, time, and event. Review of Resident 1 ' s SBARCommunication Form dated 12/24/23, showed Resident 1 had noticeable swelling around the eyes and on the face, and had shortness of breath. The document also showed Resident 1 ' s physician was notified and ordered a dose of furosemide 40 mg (a medication used to treat fluid retention and swelling due to certain medical conditions). Review of Resident 1 ' s Progress Notes showed the following: - On 12/24/23 at 1800 hours, Resident 1 had shortness of breath and swelling in face; - On 12/24/23 at 1817 hours, Resident 1 was administered furosemide 40 mg; - On 12/25/23 at 0045 hours, Resident 1 was administered Norco 5-325 mg (pain medication) for moderate pain; - On 12/25/23 at 0634 hours, Resident 1 had abnormal vital signs; and - On 12/25/23 at 0650 hours, Resident 1 was found unresponsive by the nurse at 0625 hours. Further review of Resident 1 ' s medical record failed to show documentation Resident 1 was continually monitored after the initial change in his condition when he was found with shortness of breath and facial swelling on 12/24/23 at 1800 hours. On 1/17/24 at 1010 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified the above findings and acknowledged the staff should continually assess and monitor the residents every eight hours for three days when the residents had a change of condition. On 1/22/24 at 1255 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 1 received his pain medication, Norco 5-325 mg on 12/25/23 at 0045 hours,per Resident 1 ' s request. LVN 3 further stated Resident 1 was observed sleeping when LVN 3 walked in Resident 1 ' s room on 12/25/23 between 0230 and 0300 hours. When asked if LVN 3 assessed Resident 1 due to the change in his condition on 12/24/23, LVN 3 acknowledged she did not perform a focused assessment on Resident 1 in relation to the changes in his respiratory needs or facial swelling. LVN 3 stated at around 0635 hours on 12/25/23, LVN 3 found Resident 1 unresponsive with no respirations.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were administered for one of the three sampled residents (Resident 3) as ordered by the physician. This failure posed the risk to negatively impact Resident 3's medical condition. Findings: Review of the facility's P&P titled Medication Administration - General Guidelines (undated) showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so and administered in accordance with the written orders of the attending physician. Review of the facility's document titled Plan for Medication administration as prescribed by physician and in accordance with the written/prescribed orders showed the acceptable medication pass time is one hour before and one hour after the scheduled time and for most medications. Medical record review for Resident 3 was initiated on 1/22/24. Resident 3 was admitted to the facility on [DATE]. On 1/22/24 at 1025 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 stated he had not administered Resident 3's medications yet because he was training a new employee. LVN 5 acknowledge Resident 3's medications were late and needed to be given an hour before or after 0900 hours. Review of Resident 3's MAR for January 2024 showed the following medications were scheduled to be administered at 0900 hours, however, were not administered within an hour of the scheduled time: - ascorbic acid (supplement) 500 mg; - cyanocobalamin (vit B12 supplement) 1000 mcg; - enoxaparin (to prevent deep vein clot) 40 mg; - folic Acid (iron supplement) 1 mg; - multi vitamin (supplement) 1 tablet; - oxymetazoline (nasal congestion) 2 sprays each nose; - thiamine (supplement) 100 mg; - amantadine (Parkinson's disease) 100 mg; - nasal iodophor 10% (antiseptic) to each nose; - baclofen (muscle spasm) 20 mg; - florastor (supplement) 1 capsule; - lactulose (laxative) 30 ml; - Lyrica (pain medication) 50 mg; - Nasonex (nasal congestion) 2 sprays in each nose; - povidone-Iodine 1 swab in both nostrils; - docusate sodium (stool softener) 100 mg; and - simethicone (gas relief) 80 mg. On 1/22/24 at 1045 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON stated the nursing staff could administer the medications from 0800 to 1000 hours for the medications scheduled to be given at 0900 hours. The ADON verified the above findings. When asked what the nursing staff should do if the medications were administered late, the ADON stated LVN 5 should have notified the physician that Resident 3's medications were administered late.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to document the administered medications in the MAR for one of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to document the administered medications in the MAR for one of three sampled residents (Resident 1). This failure posed the risk of errors in medical care as the documentation was incomplete. Findings: Medical record review for Resident 1 was initiated on 1/16/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MAR for December 2023 showed a physician's order to administer the following medications at 0600 hours: - famotidine (medication for acid reflux) 20 mg; - glipizide (medication for diabetes) 5 mg; - gabapentin (medication for nerve pain) 300 mg; and - ipratropium-albuterol solution (breathing treatment) 0.5-2.5 mg per 3 ml. Further review of Resident 1's MAR for December 2023 showed a physician's order to administer insulin lispro (medication for diabetes) per the sliding scale (the dose of insulin based on blood sugar levels) at 0630 hours. Review of Resident 1's MAR for December 2023 showed the blank documentation on the medications to be given on 12/24/23 at 0600 and 0630 hours. On 1/22/24 at 1255, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 1's medications were administered on 12/24/23 at 0600 and 0630 hours; however, LVN 3 acknowledged the medications given to Resident 1 were not documented in Resident 1's MAR for December 2023.

Dec 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of six sample...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 2) remained free from the accidents hazards. * The facility failed to implement the safety interventions as ordered by the physician and care planed for Resident 2 who was at high risk for falls. This failure had the potential to place Resident 2 at risk for serious injury. Findings: Review of the facility ' s P&P titled Fall Management System revised June 2018 showed each resident is assisted in attaining or maintaining their highest level of function through proving the resident adequate supervision, assistive devices, and functional program as appropriate to prevent accidents. It is the policy of the facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Medical record review for Resident 2 was initiated on 12/13/23. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2 ' s History and Physical Note dated 3/15/23, showed Resident 2 was not able to make her own decisions. Review of Resident 2 ' s LN- Fall Risk Evaluation dated 9/26/23, showed Resident 2 was at high risk for falls. Review of Resident 2 ' s Order Summary Report showed two physician ' s orders dated 6/8/22, for bilateral landing mats (protective mat designed to reduce impact when falling out of bed) and pressure pad alarm (used to alert caregivers when a resident is getting out of bed) while in bed due to poor safety awareness related to diagnosis of dementia with psychosis. Review of Resident 2 ' s plan of care showed a care plan problem dated 4/10/23, addressing Resident 2 ' s risk for falls related to confusion, incontinence, unaware of safety needs, and diagnosis of convulsions (sudden, violent, irregular movement of a limb or body). The interventions included to implement the floor mats at the bedside. The plan of care also showed a care plan problem dated 5/19/23, addressing Resident 2 ' s use of the pressure pad alarm and bilateral landing mats. On 12/13/23 at 0815 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed lying in bed. Resident 2 stated she had fallen in the past at home and in the facility. On 12/13/23 at 1232 hours, an observation was conducted with Resident 2. Resident 2 was observed lying in bed with no bilateral landing mats and/or pressure pad alarm. On 12/23/23 at 1235 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 2 did not have bilateral landing mats on the floor and/or pressure pad alarm underneath the resident. CNA 1 stated he had not seen Resident 2 with bilateral landing mats and/or pressure pad alarm during the previous shifts when he was assigned to care for the resident. On 12/13/23 at 1248 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 2 ' s fall risk assessment showed she was high risk for fall and did not have bilateral landing mats on the floor and/or pressure pad alarm underneath the resident. RN 1 verified the facility did not implement bilateral landing mats and/or pressure pad alarm as ordered by the physician and Resident 2 ' s plan of care. On 12/13/23 at 1630 hours, an interview was conducted with the Administrator and Facility Clinical Resource. The Administrator and Facility Clinical Resource were informed and acknowledged the above finding.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to provide the pharmac...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to provide the pharmaceutical services to meet the resident ' s needs for one of six sampled residents (Resident 1). * The facility failed to ensure Resident 1 ' s oxycodone HCL (narcotic pain medication) was accurately reconciled. The oxycodone HCL tablets taken out of the bubble pack (a packaged used to dispense medications) documented on the Medication Count Sheet did not match the electronic MAR as administered to Resident 1. This failure had the potential for exposing the resident to ineffective treatment, medication errors, and the potential for diversion of controlled medications. Findings: Medical record review for Resident 1 was initiated on 11/30/23. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on [DATE]. Review of the MDS dated [DATE], showed Resident 1 was cognitively intact. Review of the Order Summary Report dated 11/30/23, showed two physician ' s orders dated 11/15/23, to administer oxycodone HCL 5 mg one tablet by mouth every four hours as needed for moderate pain and oxycodone HCL 5 mg two tablets by mouth every four hours as needed for severe pain. Review of Resident 1 ' s Medication Count Sheet showed oxycodone HCL was removed from the bubble pack on the following dates and times: - 11/16/23 at 2100 hours; - 11/17/23 at 2100 hours; - 11/17/23 at 2100 hours; - 11/18/23 at 0100 hours; - 11/18/23 at 0100 hours; - 11/18/23 at 2100 hours; - 11/18/23 at 2100 hours; and, - 11/19/23 at 2130 hours. Resident 1 ' s medication bubble pack for oxycodone HCL showed 45 tablets remaining, which matched with the number of oxycodone HCL tablets in the Medication Count Sheet. However, review of Resident 1 ' s electronic MAR for November 2023 failed to show documented evidence oxycodone HCL was documented as administered to Resident 1 for the following dates and times when the medication tablets were removed from the bubble pack: - 11/16/23 at 2100 hours; - 11/17/23 at 2100 hours; - 11/17/23 at 2100 hours; - 11/18/23 at 0100 hours; - 11/18/23 at 0100 hours; - 11/18/23 at 2100 hours; - 11/18/23 at 2100 hours; and, - 11/19/23 at 2130 hours. On 11/30/23 at 1240 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified the above findings. The ADON stated the licensed nurses should document the removal of controlled medications on the Medication Count Sheet and administration of controlled medications on the electronic MAR. On 11/30/23 at 1429 hours, a telephone interview was conducted with LVN 1. LVN 1 verified she worked at the facility from 11/16/23 at 1900 hours to 11/17/23 at 0700 hours. LVN 1 stated she was aware of the facility ' s process to document on the electronic MAR after administering controlled medications to the residents. However, LVN 1 stated she might have just forgotten to sign the electronic MAR after she administered Resident 1 ' s oxycodone on 11/16/23. On 11/30/22 at 1457 hours, a telephone interview was conducted with LVN 2. LVN 2 verified she worked at the facility on the following dates and times: - 11/17/23 at 2100 hours, - 11/17/23 at 2100 hours, - 11/18/23 at 0100 hours, - 11/18/23 at 0100 hours, - 11/18/23 at 2100 hours, - 11/18/23 at 2100 hours, and - 11/19/23 at 2130 hours. When asked about the process when administering controlled medications, LVN 2 stated she would first remove the controlled medication from the bubble pack, then sign the Medication Count Sheet with the date and time she removed the controlled medication. Then, she would administer the medication to the resident, and lastly sign the electronic MAR right after administering the controlled medication. However, LVN 2 stated she was not consistent when she signed the electronic MAR after administering controlled medications to the residents. LVN 2 stated she kept a list of the residents who she administered controlled medications to during her shift, along with their pain level. LVN 2 stated her list also included the time she administered the controlled medication. LVN 2 stated she would then go back and sign the electronic MAR for the residents on her list who had received controlled medications before her shift ended. On 11/30/23 at 1516 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered amiodarone HCl (medication for heart rhythm problems), carvedilol (medication to treat high blood pressure), spironolactone (medication to treat high blood pressure and fluid retention), and sacubitril-valsartan (medication to treat patient with chronic heart failure) when Resident 1's blood pressures were below the parameters to administer these ordered medications. * The facility failed to notify the physician when amiodarone HCl, carvedilol, spironolactone, and sacubitril-valsartan were held for two consecutive times as ordered by the physician. These failures had the potential for Resident 1 to receive unnecessary medication and develop symptoms such as bradycardia (slower than normal heart rate) and hypotension (low blood pressure). Findings: According to Lexicomp, an online reference for clinical drug information, the warnings/precautions and concerns related to the adverse effects of amiodarone HCl, carvedilol, spironolactone, and sacubitril-valsartan included bradycardia and hypotension. According to the facility's P&P titled Medication Administration-General Guidelines stated, medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Review of Resident 1's closed medical record was initiated on 11/2/23. Resident 1 was admitted to the facility on [DATE], and discharged home on [DATE]. Review of Resident 1's Order Summery Report for October 2023 showed the following physician's orders dated: - 10/18/23, to administer amiodarone HCL 200 mg by mouth one time a day for CHF, and hold for SBP less than 110 mmHg or HR (heart rate) 60 beats per minute, and notify MD if held for two consecutive days; - 10/23/23, to administer carvedilol 3.125 mg by mouth two times a day for hypertension, hold for SBP than 110 mmHg or HR 60 beats per minute, and notify MD if held for two consecutive days; - 10/23/23, to administer spironolactone 50 mg by mouth one time a day for CHF, hold for SBP less than 110 mmHg or HR 60 beats per minute, and notify MD if held for two consecutive days; and - 10/23/23, to administer sacubitril-valsartan 24-25 mg by mouth two times a day for CHF, hold for SBP less than 100 mmHg or HR 60 beats per minute, and notify MD if held for two consecutive times. a. Review of Resident 1's Medication Administration Record for October 2023 showed the following: - Resident 1 was administered amiodarone HCl on 10/23/23 at 0900 hours, while Resident 1's BP was 89/56 mmHg. - Resident 1 was administered carvedilol HCL on 10/6/23 at 0900 hours, while the resident's BP was 98/62 mmHg; and on 10/13/23 at 0900 and 1700 hours, while the resident's BP was 96/54 mmHg and 97/57 mmHg, respectively. Further review of the October 2023 Medication Administration Record showed carvedilol was administered on 10/25/23 at 0900 hours, when the resident's BP was 106/59 mmHg. On 11/17/23 at 0858 hours, an interview with LVN 1 was conducted. LVN 1 stated she administered Resident 1's blood pressure medications despite of Resident 1's low blood pressures because Resident 1 was insistent on taking her medications. LVN 1 stated she should not have administered the medications. LVN 1 further stated she did not document anything about Resident 1's insistence or notified the physician the above medications were administered despite of the resident's low blood pressures. On 11/2/23 at 1410 hours, an interview with the ADON was conducted. The ADON verified amiodarone and carvedilol were administered to Resident 1 when Resident 1's blood pressures were below the parameters set by the physician and should have been held. b. Review of Resident 1's Medication Administration Record for October 2023 showed the following medications were held due to not meeting the parameters for administration: - Resident 1 was not administered amiodarone from 10/20 through 10/22/23, and 10/24 through 10/26/23; however, there was no documentation to show Resident 1's physician was notified of not administering amiodarone to Resident 1 for two consecutive days. - Resident 1 was not administered carvedilol on 10/24 and 10/25/23; however, there was no documentation to show Resident 1's physician was notified of not administering carvedilol to Resident 1 for two consecutive days. - Resident 1 was not administered sacubitril-valsartan from 10/24 through 10/25 for 0900 and 1700 doses, and 10/26/23 for 0900 hours dose; however, there was no documentation to show Resident 1's physician was notified of not administering sacubitril-valsartan to Resident 1 for two consecutive times. - Resident 1's spironolactone was not administered from 10/24 through 10/26; however, there was no documentation to show Resident 1's physician was notified of not administering spironolactone to Resident 1 for two consecutive days. On 11/17/23 at 0858 hours, an interview with LVN 1 was conducted. LVN 1 verified the above finding and stated Resident 1's physician was not notified of Resident 1's medications being held. On 11/2/23 at 1410 hours, an interview with the ADON was conducted. The ADON verified amiodarone, carvedilol, sacubitril-valsartan, and spironolactone were held but no documentation to show the physician was notified. The ADON stated Resident 1 might have experienced lower blood pressures and the physician might not be aware of this symptom.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the reconciliation of medicati...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the reconciliation of medications was thoroughly performed and documented in the medical record whenthe one of two sampled residents (Resident 1) was discharged from the facility. * The facility failed to ensure Resident 1's medical record contained a list of reconciled pre-discharge and post discharge medications when Resident 1 was discharged home in accordance with the facility's P&P. This posed the risk for not identifying discrepancies or differences in Resident 1's pre-discharge and post discharge medication orders, which had the potential to negatively impact the Resident 1's wellbeing. * The facility failed to document information in Resident 1's medical record specific to the release of controlled medications to Resident 1's family. This posed the risk for diversion of controlled medications. * The facility failed to document the amount/number of non-controlled medications provided to Resident 1 when he was discharged from the facility. This posed the risk for Resident 1 not possessing documentation specific to the amount of medication he was provided, to allow for compliance with his physician ordered medication regimen, which posed the risk for negative health outcomes. Findings: Review of the facility's P&P titled Discharge/Transfer of Resident dated 1/2013 showedthe policy of the facility is to effectuate an orderly transfer or discharge. Discharge procedure (Includes): - Complete a (resident) discharge summary and post discharge plan of care form. - Include a list of (resident) medications with instructions in simple terms. - Have resident and/or representative sign the discharge summary and post discharge care form(s). - Give a copy of the form to the resident and/or representative responsible for care. - Place the signed original form in the medical record. 1. Medical record review for Resident 1 was initiated on 10/16/23. Resident 1 was admitted to the facility on [DATE], and discharged home on [DATE]. On 10/17/23 at 1154 hours, an interview and concurrent facility P&P review was conducted with the ADON. The ADON was asked to describe the facility's process for resident medication reconciliation when a resident discharged home from the facility. The ADON stated in accordance with the facility's P&P titled Discharge/Transfer of Resident dated 1/2013, when a resident would be discharged home, the licensed nurse would review the physician's order, to determine if the resident would be discharged home with medications. If a resident would be discharged home with medications, the licensed nurse would then print a list of the resident's current reconciled medications (comparing ordered pre-discharge medications to post discharge mediations). The list of medications would include the medication name, dosage, frequency, route, and indication for use. Additionally, if ordered by the physician, the licensed nurse would provide the resident with the remaining medications from the resident's medication supply. The ADON stated the resident's medication reconciliation wasimportant to ensure the resident would receive a current and accurate list of active prescribed medications, to allow for the safe continuance of prescribed medications post discharge from the facility. The ADON stated providing a discharged resident with the remaining medications from the resident's medication supply, ensured the resident did not miss a required dose of medication prescribed by the physician, and allowed the resident to determine when to request refills of prescribed medication. The ADON stated upon discharge, the licensed nurse would document (on the resident's current reconciled medication list) the number of remaining medications from the resident's medication supply and give to the resident at the time of discharge from the facility. Review of Resident 1's physician's order dated 10/6/23, showed to discharge Resident 1 home on [DATE]. The physician's order showed to provide home health services which included a home health RN for medication management. The physician's order showed may discharge Resident 1 home with his remaining medication supply. Review of Resident 1's Discharge Summary and Post Discharge Plan of Care dated 10/6/23, showed the facility reconciled Resident 1's pre-discharge and post-discharge medications. A list of Resident 1's reconciled medications was provided to Resident 1 and Resident 1's family or care giver. Documentation showed the facility provided Resident 1 a paper-based reconciled medication list. Review of Resident 1's Discharge Note dated 10/7/23 at 1215 hours, (as documented by RN 1) showed Family Member 1 was at the facility and provided transportation for Resident 1's discharge. Resident 1's discharge medications and all care after going home were explained to Resident 1 and Family Member 1. Resident 1 was awake, alert and signed for his discharge instructions. However, review of Resident 1's medical record failed to show a copy of the list of the Resident 1's reconciled discharge medications (provided to Resident 1 and Family Member 1, when Resident 1 was discharged home on [DATE]) was maintained in Resident 1's medical record. On 10/17/23 at 1245 hours, an interview was conducted with RN 1 who discharged Resident 1 home on [DATE]. RN 1 stated Family Member 1 was present for Resident 1's discharge from the facility on 10/7/23. RN 1 stated Family Member 1 provided transportation for Resident 1 when Resident 1 was discharged home. RN 1 was asked what medications (and how many of each medication) Resident 1 was discharged home with. RN 1 stated due to an oversight, Resident 1 was discharged home without any of his medications. RN 1 stated Family Member 1 had to return to the facility and was then provided with Resident 1's remaining prescribed medications. RN 1 stated when Family Member 1 returned to the facility to retrieve Resident 1's medications, RN 1 printed out a list of Resident 1's active medications and provided the list to Family Member 1. However, RN 1 stated he did not keep a copy for Resident 1's medical record and was unsure how many (number of tablets/capsules) of each medication was provided to Family Member 1. RN 1 stated LVN 1 assisted with Resident 1's discharge home and had provided Family Member 1 with Resident 1's prescribed controlled medications. On 10/17/23 at 1314 hours, an interview was conducted with LVN 1. LVN 1 stated she assisted with Resident 1's discharge home on [DATE]. LVN 1 stated Resident 1 was self-responsible. LVN 1 stated after Resident 1 was discharged from the facility (without his medications),RN 1 called Resident 1 to advise Resident 1 his medications remained at the facility. LVN 1 stated she then received a call from Resident 1 who stated Family Member 1 would return to the facility to retrieve his medications. LVN 1 stated Family Member 1 then returned to the facility to obtain Resident 1's medications. LVN 1 stated when she provided Resident 1's medications to Family Member 1, she did not print a list of Resident 1's reconciled discharge medications and did not record the number of medications provided to Family Member 1 on a reconciled discharge medication list. LVN 1 stated however, specific to Resident 1's prescribed controlled medications, she had Family Member 1 verify the number of controlled medications obtained on behalf of Resident 1. LVN 1 stated she and Family Member 1 counted Resident 1's remaining controlled medications and LVN 1 recorded the number of each medication given to Family Member 1. LVN 1 stated she and Family Member 1 signed Resident 1's Medication Count Sheets &/or Narcotic Log for each controlled medication (indicating Family Member 1 received Resident 1's remaining controlled medications). LVN 1 stated consistent with the documentation on Resident 1's Medication Count Sheets and Narcotic Log, the following controlled medications were given to Family Member 1 by LVN 1. * 14 tablets of hydrocodone-acetaminophen (narcotic analgesic) 10-325 mg * 11 tablets of clonazepam (antianxiety medication) 0.5 mg * 35 capsules of pregabalin (anticonvulsant medication) 150 mg * 1 fentanyl patch (narcotic analgesic) 50 mcg/hour LVN 1 was then asked to locate documentation in Resident 1's medical record specific to Resident 1 being discharged home without his medications. LVN 1 verified Resident 1's medical record failed to show documentation for the communication between Resident 1 and RN 1 and between Resident 1 and LVN 1, specific to Family Member 1 returning to the facility to retrieve Resident 1's medications (on Resident 1's behalf). LVN 1 stated she should have documented Resident 1 having given his consent, for Family Member 1 to return to the facility to retrieve Resident 1's medications (which included controlled medications). Further review of Resident 1's medical record failed to show documentation as to the name of Family Member 1. LVN 1 was asked the name of Family Member 1. LVN 1 then reviewed Resident 1's medical record (including Resident 1's controlled Medication Count Sheets & Narcotic Log which did not contain Family Member 1's name, only Family Member 1's signature). LVN 1 was unable to provide the name of Family Member 1 and was unable to locate documentation in Resident 1's medical record as to Family Member 1's name. LVN 1 stated she should have documented the name of Family Member 1 in Resident 1's medial record to provide details specific to who obtained Resident 1's controlled medications.

Aug 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to conduct a thorough abuse investigatio...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to conduct a thorough abuse investigation for two of four sampled residents (Residents 1 and 2) as evidenced by: * The facility did not interview other residents receiving care by the alleged staff for their abuse investigation. This failure posed the risk of not identifying if other residents were affected by the reported abuse allegation. Findings: Review of the facility's P&P titled Abuse: Prevention of and Prohibition Against revised 11/17 showed the abuse investigation would include interviews with other residents to whom the accused employee provides care or services. 1. On 8/23/23 at 1324 hours, an interview was conducted with Resident 1's Family Member 1. Resident 1's Family Member 1 stated Resident 1 verbalized she (Resident 1) was raped by a male staff at the facility. Closed medical record review for Resident 1 was initiated on 8/23/23. Resident 1 was admitted to the facility 8/2/23, and left against medical advice on 8/14/23. Review of Resident 1's History & Physical Examination dated 8/3/23, showed Resident 1's diagnoses included anxiety and depression. Review of Resident 1's progress note dated 8/22/23, showed Resident 1 verbalized she left the facility against medical advice because she was afraid and raped at the facility. On 8/24/23, at 1129 hours, an interview was conducted with the DON. The was informed regarding the information provided by Resident 1's Family Member 1. Review of the facility's abuse conclusion dated 8/25/23, for Resident 1, showed no documented evidence other residents receiving care from the alleged staff were interviewed as per the facility's P&P. On 9/5/23 at 1618 hours, the Administrator and DON were informed and verified the above findings. 2. Medical record review for Resident 2 was initiated on 8/23/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's History and Physical examinationdated 5/28/23, showed Resident 2 had diagnoses including dementia. On 8/29/23 at 0834 hours, an interview was conducted with Resident 2's RP. Resident2's RP stated about two weeks ago, Resident 2 verbalized she was hit in the back by a CNA. Review of Resident 2's abuse conclusion dated 9/2/23 for Resident 2, showed no documented evidence other residents receiving care from the alleged staff were interviewed as per the facility's P&P. On 9/5/23 at 1618 hours, the Administrator and DON were informed and verified the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) received quality of care as evidenced by: - The weekly skin assessments were not completed for Resident 1. This failure posed the risk of the resident not receiving appropriate care. Findings: Review of the facility's P&P titled Skin Care Policy/Procedure revised 2/22 showed in part, the following: * Assessment of wounds identified after admission: - A licensed nurse will assess/evaluate a resident's skin at least weekly. - Areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the nursing notes. * Weekly Skin Check: - The licensed nurse should document skin evaluations in accordance with this policy and document on the skin assessment/evaluation weekly /PRN form. On 8/23/23 at 0938 hours, Resident 2 was observed with red circular discoloration to her right shin. On 8/24/23 at 0951 hours, an interview was conducted with LVN 2. When asked about Resident 2's discolorations, LVN 2 stated she thought Resident 2 was admitted with bruising. Medical record review for Resident 2 was initiated on 8/23/23. Resident 2 was admitted to the facility on [DATE]. Further review of the medical record showed the most recent skin assessment was completed on 7/20/23. The skin assessment dated [DATE], showed no documented evidence related to Resident 2's bruising to her right shin. On 8/30/23, at 1512 hours, concurrent interview and medical record review was conducted with LVN 2. When asked how often LVN 2 conducted the residents' skin assessments, LVN 2 verbalized she completed them weekly. LVN 2 verified Resident 2's last skin assessment was completed on 7/20/23. LVN 2 acknowledged Resident 2's skin was not assessed weekly.

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 F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, and complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for 33 residents who used the side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety Inspection Clinical Guidance revised 2/2022 showed the Maintenance Personnel will check each bed rail for compatibility with the accompanied bed and mattress and will report safety checks to the Safety Committee for quality. Adopt the FDA approved measurement and guidance for the Seven Zones of Bed entrapment. Review of the Order Listing Report showed the facility had 33 residents with side rail use, including Residents 2, 3, and 4. A concurrent observation, medical record review, and facility document review for Residents 2, 3, and 4 showed the residents' bed entrapment assessments were not accurate or the bed inspection gap measurements were notrecorded from bed to side rails. For example: 1. On 8/29/23 at 1000 hours, and 8/30/23 at 0758 hours, Resident 2 was observed lying in bed with bilateral quarter side rails elevated. Medical record review for Resident 2 was initiated on 8/30/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's MDS dated [DATE], showed Resident 2 had severe cognitive impairment, required extensive assistance from one staff for bed mobility, and required total assistance from one staff for transfer. Review of Resident 2's Order Summary Report for August 2023 showed a physician's order dated 7/7/23, for Resident 2 may have bilateral half side rails to aid in the bed mobility as an enabler and for safety. Review of Resident 2's Bed Rail Safety Evaluation dated 5/27/23, showed under the IDT recommendation and justification, Resident 2 had a fall in the past per family and was deemed to be ahigh risk for falls. Review of Resident 2's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed Zones 1, 2, 3, and 4 as pass, and Zones 5, 6, and 7 as N/A or not applicable. The rail type showed Invacare half; however, the form did not indicate how many side rails or which side rails were being assessed. On 8/30/23 at 0945 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified Resident 2 had bilateral side rails up. CNA 2 stated Resident 2 was a fall risk and used the bed side rails to help with turning. On 8/30/23 at 1350 hours, an interview was conducted with RN 1. RN 1 stated Resident 2 used the side rails for repositioning in bed mobility. 2. On 8/29/23 at 0842 and 1005 hours, and 8/30/23 at 0745 hours, Resident 3 was observed lying in bed with bilateral padded quarter side rails elevated. Medical record review for Resident 3 was initiated on 8/29/23. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's MDS dated [DATE], showed Resident 3 had intact cognition, required total assistance from one staff for bed mobility, and required extensive assistance from one staff for transfer. Review of Resident 3's Order Summary Report for August 2023 showed a physician's order dated 8/23/23, for Resident 3 may have half side rails to use as an enabler in mobility and positioning. Review of Resident 3's Bed Rail Safety Evaluation dated 8/22/23, showed under the IDT recommendation and justification, the side rails were used as an enabler in mobility and repositioning. Review of Resident 3's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed Zones 1, 2, 3, and 4 as pass, and Zones 5, 6, and 7 as N/A or not applicable. The rail type showed Invacare half; however, the form did not indicate the rail type, nor which side rails were being assessed. On 8/29/23 at 1058 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 3 had bilateral padded side rails up. CNA 1 stated the side rails were used to help Resident 3 to turn easily and hold on to the rails. On 8/29/23 at 1110 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 3's padded side rails were to prevent falls. On 8/30/23 at 1004 hours, an interview with Resident 3 was conducted. Resident 3 stated she used the side rails to hold on to pull herself up. 3. On 8/29/23 at 1012 and 8/30 at 0805 hours, Resident 4 was observed lying in bed with bilateral quarter side rails elevated. Medical record review for Resident 4 was initiated on 8/30/23. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's MDS dated [DATE], showed Resident 4 had moderately impaired cognition, required extensive assistance from one staff for bed mobility, and required extensive assistance from two staff for transfer. Review of Resident 4's Order Summary Report for August 2023, showed a physician's order dated 7/31/23, for Resident 4 may have half side rails for positioning, safety, and ease in mobility. Review of Resident 4's Bed Rail Safety Evaluation dated 6/20/23, showed under the section for IDT recommendation and justification, Resident 4 may use half bed side rails for positioning and ease in mobility, safety, and as an enabler. Review of Resident 4's Bed Rail 7 Zones Entrapment assessment dated [DATE], showed Zones 1, 2, 3, and 4 as pass, and Zones 5, 6, and 7 as N/A or not applicable. The rail type showed DRIVE (bed manufacturer's name) half; however, the form did not indicate which side rail was being assessed. On 8/30/23 at 0805 hours, an interview was conducted with Resident 4. Resident 4 stated he used the side rails for turning. On 8/30/23 at 0819 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified Resident 4's bilateral quarter bed side rails were up. CNA 3 stated theside rails were used to aide in turning, repositioning, and safety. On 8/30/23 at 1350 hours, an interview was conducted with RN 1. RN 1 stated Resident 4's side rails were used for repositioning in bed. On 8/30/23 at 1420 hours, an interview was conducted with Maintenance Staff 1. Maintenance Staff 1 stated he was one of the staff responsible for installing the residents' bed side rails. Maintenance Staff 1 stated after installing the residents' bed side rail, an entrapment assessment was performed. Maintenance Staff 1 further stated in order to install side rails in the bed, a copy of the resident's side rail physician's order and consent must be obtained prior to side rail installation. Maintenance Staff 1 stated a measuring device was used to perform an entrapment assessment. Maintenance Staff 1 stated there were instructions of how to measure the different zones in the bed when the side rails were installed. On 8/30/23 at 1528 hours, an interview was conducted with the Maintenance Director. The Maintenance Director was asked his responsibilities regarding side rails and stated he received a work order to install or remove side rails when all documented requirements were completed with the side rails. The Maintenance Director further stated the maintenance personnel performed entrapment assessment after installation of the side rails. The Maintenance Director stated he only assessed for Zones 1, 2, 3, and 4 due to only using half side rails in the facility. The Maintenance Director stated for beds with side rails, they only tested for entrapment in Zone 7 every three months. The Maintenance Director stated they used a measuring device for the assessment of entrapment, where the top part of the measuring device measured 4 ¾ inches that resembled the size a person's head. The Maintenance Director did not measure and document specific measurements of the gap in between the bed and the side rail. The Maintenance Director stated there was a diagram of a bed, the seven different zones of entrapment, and direction of how to assess for entrapment. The Maintenance Director stated if the top part of the measuring device did not go through the gap, then it meant pass. If the top part of the measuring device went through the gap, then it meant fail. The Maintenance Director stated if the test failed for the entrapment assessment, then he changed the bed or the mattress. The Maintenance Director stated the facility used different types of bed. The Maintenance Director stated he only installed 2 side rails and never installed only one side rail. The Maintenance Director was asked how he knew how many side rails to install, and he stated by looking at the physician's order. The Maintenance Director verified Residents 3 and 4's physician's order did not indicate how many side rails to install. The Maintenance Director further stated they only had and used half side rails and grab bars in the facility. On 8/30/23 at 1635 hours, an observation and concurrent follow-up interview was conducted with the Maintenance Director. The Maintenance Director was asked how he defined a half side rail, and he stated half side rail was half the size the length of the resident's bed. The Maintenance Director measured Resident 3's bed length with a power lock tape measure showing the bed length of 83 inches and measured the side rail showing the length of 20.5 inches. The Maintenance Director stated the length of the side rail was a quarter in the total length of the bed. Then, the Maintenance Director measured Resident 2's bed length with a power lock tape measure showing the bed length of 80 inches and measured the side rail showing the length of 20 inches. The Maintenance Director stated Resident 4's bed and side rails were the same length and size as Resident 2's bed. The Maintenance Director verified Residents 2 and 4's bed siderails length were a quarter length of the total length of the bed. On 8/30/23 at 1700 hours, the DON was informed and acknowledged the above findings.

May 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to implement the interventions as outlined in th...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to implement the interventions as outlined in the plan of care related to falls for one of three sampled residents (Resident 1). * After Resident 1 experienced a fall in the facility, one intervention implemented was to place the bilateral floor mats at the bedside. The facility failed to implement the floor mats as documented in the plan of care. This failure put Resident 1 at risk of further injury due to falls. Findings: On 5/9/23 at 1244 hours, an observation and concurrent interview with Family Member 1 was conducted at Resident 1's bedside. Resident 1 was observed in bed with bilateral side rails elevated. There were no floor mats in place. Family Member 1 was asked about care and services received by Resident 1. Family Member 1 stated Resident 1 had experienced a fall while in the facility. On 5/9/23 at 1413 hours, Resident 1 was again observed in bed with no floor mats in place. On 5/9/23 at 1558 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1 at Resident 1's bedside. LVN 1 stated Resident 1 was at risk for falls due to his leaning when he coughs. LVN 1 stated Resident 1 had the side rails in place to prevent falls. LVN 1 reviewed Resident 1's plan of care and verified Resident 1 was supposed to have bilateral floor mats but did not have them in place. LVN 1 was not sure why Resident 1 did not have bilateral floor mats in place as documented in the plan of care. Medical record review for Resident 1 was initiated on 5/9/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's plan of care showed a care plan problem dated 4/24/23, addressing Resident 1 at risk of falls related to being unaware of the safety needs, anoxic brain damage, contracture of muscle, multiple sites, muscle weakness. One of the care plan interventions was to place the floor mats at the resident ' s bedsideevery shift and as needed.

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide care based on cu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide care based on current professional standards of practice for one of three sampled residents (Resident 1). * When Resident 1 was readmitted to the facility with an indwelling urinary catheter, the facility failed to obtain an order for its use and failed to show any documentation the catheter care was performedfor more than one week. This failure put Resident 1 at risk for infection and other catheter related complications. Findings: Review of the facility P&P titled Catheter Care, Urinary revised 9/2014 showed the following should be recorded in the resident's medical record: - The date and time that catheter care was given. - The name and title of the individual(s) giving catheter care. - All assessment data obtained when giving catheter care. - Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. - Any problems noted at the catheter-urethral junction during perineal care such as drainage, redness, bleeding, irritation, crusting, or pain. - Any problems or complaints made by the resident related to the procedure. - How the resident tolerated the procedure. - If the resident refused the procedure, the reason(s) why and the intervention taken. - The signature and title of the person recording the data. On 5/9/23 at 1244 hours, an observation and concurrent interview was conducted with Family Member 1 at Resident 1's bedside. Resident 1 was observed in bed with an indwelling urinary catheter draining to a bag hanging atthe side of the bed. Family Member 1 stated the indwelling urinary catheter was for Resident 1's skin breakdown. Medical record review for Resident 1 was initiated on 5/9/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Initial admission Record dated 4/20/23, showed Resident 1 was admitted with an indwelling urinary catheter in place. Review of Resident 1's Order Summary Report showed an order dated 5/6/23, for indwelling catheter to closed drainage system for an indication of neurogenic bladder for wound management. Further review of Resident 1's Order Summary Report failed to show an order for an indwelling urinary catheter prior to 5/6/23. Review of Resident 1's tasks for bladder incontinence showed Resident 1's continence was not rated since 4/30/23, due to the presence of an indwelling catheter. On 5/9/23 at 1434 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 1 was incontinent of urine and had an indwelling urinary catheter since his latest readmission. LVN 1 stated the assigned LVN was responsible for performing the catheter care on the daily basis. LVN 1 was asked to review the orders for the indwelling urinary catheter and verified there was no order in place until 5/6/23. LVN 1 was asked to show any documentation of catheter care being performed prior to 5/6/23, but was unable to do so. LVN 1 stated she did not know why there was not an order prior to 5/6/23, and stated there should have been. LVN 1 stated the indwelling urinary catheter care would be documented on the MAR and verified it was not.

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure pain management was provided a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure pain management was provided as ordered for one of three sampled residents (Resident 2). * Resident 2 had a physician's order for methocarbamol (a medication used to treat muscle pain) but did not receive the ordered medication until five days after it was ordered. This failure put Resident at risk for pain and discomfort. Findings: Review of the facility ' s P&P titled Recognition and Management of Pain dated 1/2021showed the policy of this facility to ensure 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. On 5/9/23 at 0950 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated Resident 2 had notified her that the resident did not receive all of his ordered pain medication. Family Member 2 stated she contacted the facility and was told by an RN that Resident 2 had not received his methocarbamol as of 4/17/23, and was not sure why. Closed medical record review for Resident 2 was initiated on 5/9/23. Resident 2 was admitted to the facility on [DATE], and discharged on 4/22/23. Review of Resident 2 ' s History and Physical examinationform dated 4/13/23, showed Resident 2 was admitted for left shoulder, knee, wrist, hip, and shoulder pain. Review of Resident 2 ' s Order Summary Report showed an order dated 4/13/23, for methocarbamol tablet 500 mg one tablet by mouth every eight hours for pain management. Review of Resident 2 ' s MAR showed Resident 2 received methocarbamol tablet 500 mg as ordered beginning 4/13/23 at 2300 hours. On 5/10/23 at 1015 hours, a telephone interview was conducted with the Pharmacy Technician. The Pharmacy Technician was asked when Resident 2 ' s methocarbamol 500 mg tablets were delivered to the facility. The Pharmacy Technician stated the methocarbamol 500 mg tablets were not delivered until 4/17/23. On 5/10/23 at 1020 hours, an interview and concurrent interview was conducted with the DON. The DON was asked about Resident 2 ' s methocarbamol order. The DON was asked if methocarbamol was available in the emergency kit, and she stated no. The DON verified the staff had documented the methocarbamol tablets were given as ordered prior to the medication being delivered by the pharmacy. The DON was unable to explain why.

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 F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the alternatives were attempted prior ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the alternatives were attempted prior to the implementation of side rails for two of three sampled residents (Residents 1 and 3). This failure put the residents at risk of entrapment and unnecessary side rail use. Findings: According to the FDA (United States Food and Drug Administration), deaths and serious injuries related to side rail entrapment have occurred with the use of side rails. 1. On 5/9/23 at 1244 hours, an observation and concurrent interview was conducted with Family Member 1 at Resident 1 ' s bedside. Resident 1 was observed in bed with bilateral side rails elevated. Family Member 1 stated Resident 1 had had the side rails since he suffered a fall in the facility. On 5/9/23 at 1413 hours, Resident 1 was again observed in bed with bilateral side rails elevated. Medical record review for Resident 1 was initiated on 5/9/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1 ' s Order Summary Report showed an order dated 4/24/23, may have ¼ side rails for comfort and safety. On 5/10/23 at 1117 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was asked about the process for the side rail use. RN 2 stated the nurses would ask the PT if a resident was appropriate to have side rails. If the PT agreed, the nurse would contact the physician for an order, then the maintenance staff would install the side rails. RN 2 was asked to show the assessment for the side rail use for Resident 1. RN 2 stated they did not document the assessment, but the alternatives attempted prior to the use of side rails would be documented in the progress notes. RN 2 was unable to show documentation the alternatives had been attempted prior to the implementation of side rails for Resident 1. 2. On 5/9/23 at 1300 hours, an observation was conducted at Resident 3 ' s bedside. Resident 3 was observed in bed with bilateral side rails elevated. Medical record review for Resident 3 was initiated on 5/9/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3 ' s Order Summary Report showed an order dated 10/8/21, may use adjustable bed with bilateral ¼ side rails up for safety and fall prevention. On 5/10/23 at 1213 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified Resident 3 had a physician ' s order for the side rail use. The ADON was asked to show documentation the alternatives had been attempted prior to the use of side rails for Resident 3. The ADON was unable to show such documentation.

Apr 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 F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan was dev...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan was developed to reflect the specific care needs for one of four sampled residents (Resident 1). The facility failed to ensure a baseline care plan problem was developed to address Resident 1's risk for falling. This had the potential for the resident's care needs not being met. Findings: Review of the facility's P&P titled Care Plans – Baseline (undated) showed a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Medical record review for Resident 1 was initiated on 4/4/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Hospitalist History and Physical from the acute care hospital dated 3/21/23, showed Resident 1 was admitted to the acute care hospital for a left hip fracture after suffering a ground level fall. Review of Resident 1's plan of care failed to show a baseline care plan problem was developed to address Resident 1's risk for falls. Review of Resident 1's Progress Notes dated 3/28/23 at 2349 hours, showed at about 2250 hours Resident 1 was found on the floor after the staff had responded to audible calls for help. The entry showed Resident 1 reported falling while attempting to get to his wheelchair and as a result, had sustained lacerations to his left eyebrow and left elbow. On 4/4/23 at 1214 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings and stated a baseline care plan should have been created within 48 hours of admission if the resident had a recent history of falling or was a moderate to high risk for falls on the Fall Risk Evaluation. Cross reference to F842.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one sampled resident (Residen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one sampled resident (Resident 1) was accurate. The facility failed to ensure Resident 1's Fall Risk Evaluation was completed accurately. This had the potential for the resident's care needs not being met as their medical information was inaccurate. Findings: Medical record review for Resident 1 was initiated on 4/4/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's medical record from the acute care hospital showed the following: - Review of Resident 1's Hospitalist History and Physical from the acute care hospital dated 3/21/23, showed Resident 1 was admitted to the acute care hospital for a left hip fracture after suffering a ground level fall on 3/20/23. - Review of Resident 1's Med Admin (2 Days) as of 3/24/23 1505 hours, from the acute care hospital showed Resident 1 was administered one tablet of Norco (narcotic pain medication) 5-325 mg on 3/23/23 at 1941 hours, for moderate pain. However, review of Resident 1's Fall Risk Evaluation dated 3/25/23, inaccurately showed the following: - Resident 1 had no falls in the past 3 months, - Resident 1 did not take a narcotic medication within the last seven days, and - Resident 1 did not have any predisposing diseases or conditions including fractures. As a result of the inaccurate assessment, Resident 1 was categorized as a low risk for falls. Review of Resident 1's Progress Notes dated 3/28/23 at 2349 hours, showed at about 2250 hours, Resident 1 was found on the floor after the staff had responded to audible calls for help. The entry showed Resident 1 reported falling while attempting to get to his wheelchair and as a result, had sustained lacerations to his left eyebrow and left elbow. On 4/4/23 at 1214 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings and stated had Resident 1's Fall Risk Evaluation dated 3/25/23, been completed accurately, it would have categorized Resident 1 as a high risk for falls and prompted the staff to develop and implement fall risk interventions upon admission. Cross reference to F655.

Jan 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to meet t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to meet the needs for one nonsampled resident (Resident E). * Resident E was not administered the medications as ordered by the physician due to the medications being unavailable. This failure had the potential to negatively impact resident's physical health. Findings: Medical record review for Resident E was initiated on 1/26/23. Resident E was admitted to the facility on [DATE]. Review of Resident E's Order Summary Report for January 2023 showed the following physician orders dated: - 01/24/23, to administer Pataday Ophthalmic Solution 0.2 % (Olopatadine HCI) instill one drop in both eyes one time a day, to be given at 0900 hours; and, - 05/05/21, to administer sertraline HCI Tablet 25 mg one tablet by mouth one time a day, to be given at 0900 hours. On 1/26/23 at 1220 hours, a medication administration observation for Resident E was conducted with LVN 3. LVN 3 was observed not administering the Pataday Ophthalmic solution (eye drop medication for dry eyes) and sertraline (a medication used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress syndrome, and social anxiety disorder) to Resident E due to the medications were not available. On 1/26/23 at 1345 hours, an interview was conducted with LVN 3. LVN 3 verified the above findings and stated Resident E was a long-term care resident and should have the cycle medications but was unable to explain why these medications were unavailable. LVN 3 further stated the steps when identified the unavailable medications were to look on other carts to see if Resident E's medication packs were misplaced, check the emergency kit for medication availability, or call the pharmacy to refill the supply of the medications. LVN 3 stated she would not call the physician if the unavailable medications were not given because the medications of Resident E were not significant. On 1/26/23 at 1515 hours, an interview was conducted with the DON. The DON was asked what the standard of practice for medications not given when the medication was unavailable. The DON stated they would check the emergency kit for the availability of the medication or call the pharmacy to refill the unavailable medication. On 1/26/23 at 1632 hours, a follow-upinterview was conducted with the DON. The DON added that the physician should be notified when the medications were not given, and the resident should be assessed for any complications.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical recor...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for one nonsampled resident (Resident E) were accurate. * Resident E's medications were documented as administered although the medications were omitted and unavailable. This had the potential for the resident care needs not being met as their medical information was inaccurate. Findings: Review of the facility's P&P titled Nursing Services Policy and Procedure for Long-Term Care Med-Pass dated April 2019 showed the individual administering for a medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next dose. Medical record review for Resident E was initiated on 1/26/23. Resident E was admitted to the facility on [DATE]. Review of Resident E's Medication Administration Record for January 2023 showed the Pataday Ophthalmic solution and Lido-lotion medications were documented as administered on 1/26/23 at 0900 hours. However, on 1/26/23 at 1220 hours, a medication administration observation for Resident E was conducted with LVN 3. LVN 3 was observed to have omitted administering Pataday Ophthalmic solution (eye drop medication for dry eyes). LVN 3 was also not observed administering Lido-lotion (medication indicated for the relief of pain to minor cuts, grazes, and irritation) to Resident E. On 1/26/23 at 1345 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. LVN 3 verified she documented that she administered the Pataday Ophthalmic solution and Lido-lotion even though she did not administer both medications to Resident E.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to maintain infection control practices to help ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to maintain infection control practices to help prevent the development and transmission of diseases and infections. * CNA 1 failed to don proper PPE upon entering a room (Room E) on contact precautions. * Family Member 1 did not wear the appropriate PPE when entering a room (Room A) on contact precautions. * CNA 3 failed to perform hand hygiene after providing care for residents. These failures had the potential to cause the transmission of disease-causing pathogens and infections. Findings: 1. According to the CDC (Centers of Disease Control and Prevention), under Transmission-Based Precautions, showed to use PPE appropriately, including gloves and gown for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. On 12/22/22 at 1141 hours, an observation and concurrent interview was conducted with CNA 1. Room E's doorway entrance was observed with a contact precaution sign. The sign showed anyone who enters Room E should wear gloves, an isolation gown, a faceshield and a surgical mask. CNA 1 was observed entering Room E donning theface shield and N95 respirator. CNA 1 was observed without gloves and isolation gown upon entrance to Room E. CNA 1 was observed changing Resident B's bed linens without wearing gloves or an isolation gown. CNA 1 verified the above findings and stated she did not put on any gloves or an isolation gown while providing care for the residents in Room E. CNA 1 further stated she did not know what type of isolation the residents (Residents B and G) in Room E were placed on. CNA 1 stated she should have worn the mask, gloves, isolationgown, and face shield when entering Room E. a. Medical record review for Resident B was initiated on 12/22/22. Resident B was admitted to the facility on [DATE]. Review of the facility's Isolation Room Listings dated 12/22/22,showed Resident B was on contact precaution for Candida Auris (also known as C. Auris, an emerging fungus that presents a serious global health threat). b. Medical record review for Resident G was initiated on 12/22/22. Resident G was admitted in the facility on 4/19/21, and readmitted on 8/30/21. Review of the facility's Isolation Room Listings dated 12/22/22,showed Resident G was on contact precaution for C. Auris. On 12/22/22 at 1536 hours, an interview was conducted with the IP. The IP stated the staff performed huddles in the morning and gave report of which residents were on isolation precautions. The IP stated he placed a list of residents, in each nursing station, who were placed in isolation precautions and the type of organisms the residents had. The IP further stated since the facility had positive COVID-19 residents, the staff were expected to wear the N95 masks, face shields, gowns, and gloves in rooms placed on contact precautions. 2. On 12/22/22 at 1151 hours, an observation of Room A was conducted. A sign was observed posted on Room A's doorway entrance that showed Room A was on contact precautions. The contact precaution sign showed everyone must clean their hands before entering and when leaving the room, to put on gloves and gown before room entry and discard gloves and gown before room exit. A visitor (Family Member 1) was observed inside Room A touching items in the room. Family Member 1 was observed not wearing an isolation gown or gloves. On 12/22/22 at 1200 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified Family Member1 was not wearing an isolation gown or gloves when he was in Room A. RN 1 verified the signage outside Room A had clear instructions on the necessary PPE for the staff and families to wear prior to entering the room. RN 1 verified Family Member1 had to don the isolation gown and gloves before entering Room A. On 12/22/22 at 1157 hours, an interview was conducted with the DON. The DON stated the visitors should see the signage posted and don proper PPE as directed to prevent the spread of infection. 3. According to the CDC, the clinical indications for hand hygiene includes immediately before touching a patient, before performing an aseptic task or handling medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. On 1/26/23 at 1153 hours, an observation was conducted for Room C. CNA 3 and LVN 4 were observed entering Room C to assist a resident transferring from the wheelchair to bed. CNA 3 was observed wearing gloves while assisting the resident. CNA 3 was then observed taking her gloves off; however, was not observed performing any hand hygiene after aiding the resident. CNA 3 then proceeded to go to a different resident room and was not observed to perform hand hygiene. On 1/26/23 at 1213 hours, CNA 3 was observed entering Room D with a water pitcher. CNA 3 was not observed performing hand hygiene prior to entering and leaving Room D. On 1/26/23 at 1237 hours, an interview was conducted with CNA 3. CNA 3 acknowledged the above findings and admitted she did not perform hand hygiene. CNA 3 stated she should perform hand hygiene to prevent contamination. On 1/26/23 at 1258 hours, an interview was conducted with the DON. The DON stated the staff and visitors should perform hand hygiene before entering and before exiting the room to prevent the spread of infection.

Jan 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of tw...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained and maintained their highest practicable physical well-being. The facility failed to administer Resident 1's medications as per the physician's orders. This had the potential of Resident 1 not receiving the appropriate care and services to treat their medical conditions. Findings: Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 1/4/23, showed Resident 1 alleged the facility did not administer her medications on time or as ordered by her physician. Medical record review for Resident 1 was initiated on 1/12/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 1 had no cognitive impairment. Review of the Progress Notes entry dated 12/4/22 at 0504 hours, showed Resident 1 complained that the charge nurse from the AM shift (on 12/3/22) never administered any of the resident's medications. Review of the Medication Administration Record dated December 2022 failed to show documented evidence the following medications were administered to Resident 1 on 12/4/22: - 30 ml of Active Liquid Protein (supplement) at 1000 hours, - 5 mg of amlodipine besylate (treats high blood pressure) at 0900 hours, - 500 mg of calcium carbonate (treats gastroesophageal reflux disease) at 0900 hours, - 1000 units of cholecalciferol (Vitamin D3, supplement) at 0900 hours, - 12 mg of ivermectin for dermatitis (general terms for skin inflammation) at 0900 hours, - 25 mg of losartan potassium (treats high blood pressure) at 0900 hours, - 17 grams of polyethylene glycol (laxative) for bowel management at 0900 hours, - 1000 units of Vitamin D3 (supplement) at 0900 hours, - 200 mg of amiodarone (treats arrythmias [an irregular heartbeat]) at 0900 hours, - 500-125 mg of amoxicillin-potassium clavulanate (antibiotic) at 0900 hours, - 325 mg of ferrous sulfate (iron supplement) at 0900 hours, - 250 mg of Florastor (probiotic) at 0900 hours, - 20 mg of prednisone (corticosteroid) for itching at 0900 and 1700 hours, - 25 mg of quetiapine (treats schizoaffective disorder) at 0900 hours, - 1 drop of Visine Dry Eye Relief Solution (treats dry eyes) in each eye at 0900 hours, - 800 mg of Renvela (used to control phosphorus levels in residents with chronic kidney disease) at 0900, 1300, and 1700 hours, and - insulin regular human Solution (treats diabetes) as per the sliding scale based on the resident's blood sugar levels at 1130 and 1630 hours. On 1/12/23 at 1212 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified administered medications were documented in the Medication Administration Record. The DON verified there was no documented evidence Resident 1's medications were administered to her during the morning shift of 12/4/22. The DON verified there was no physician's orders to hold Resident 1's medications on 12/4/22, and no documentation showingResident 1 had refused her medications. On 1/12/23 at 1257 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified she was assigned to Resident 1 on the morning shift of 12/4/22. LVN 2 verified administered medications were documented in the Medication Administration Record. LVN 2 stated Resident 1 was the type of resident that would complain if she did not receive her medications. LVN 2 stated she was pretty sure she administered Resident 1 her medications. LVN 2 verified there was no documented evidence Resident 1's medications were administered to her during the morning shift of 12/4/22, and no documentation showing the resident had refused the medications. Cross reference to F760.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from unnecessary drugs. Resident 1 had duplicate orders for cholecalciferol, also known as Vitamin D3 (supplement). This had the potential for Resident 1 to have adverse effects from the medication. Findings: Medical record review for Resident 1 was initiated on 1/12/23. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1's Order Summary Report with active orders as of 12/24/2022, showed duplicate orders for the administration of cholecalciferol, also known as Vitamin D3: - 1000 units of cholecalciferol one time a day for supplement and - 1000 units of Vitamin D3 one time a day for supplement. Review of the Medication Administration Record dated December 2022 showed both orders for the cholecalciferol and the Vitamin D3 were documented as administered at 0900 hours in December. On 1/24/23 at 1040 hours, a telephone interview and concurrent medical record review was conducted with the Pharmacist Consultant. The Pharmacist Consultant verified the findings and stated the cholecalciferol and Vitamin D3 were duplicate orders and showed up twice on the Medication Administration Record. The Pharmacist Consultant stated the usual dosage for Vitamin D3 as a supplement was 1000 units a day.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from significant medication errors. Doses of insulin regular human (treats diabetes), prednisone (corticosteroid, abrupt discontinuation may cause prednisone withdrawal), and amiodarone (treats irregular heartbeats) were not administered to Resident 1 as ordered. This had the potential for Resident 1 to have complications or symptoms from untreated high blood sugar; adrenal shock and inflammatory problems from missed doses of prednisone; and arrythmias (an irregular heartbeat). Findings: Review of Lexicomp (an online clinical drug information resource) showed do not abruptly discontinue prednisone treatment. Review of the SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 1/4/23, showed Resident 1 alleged the facility did not administer her medications on time or as ordered by her physician. Medical record review for Resident 1 was initiated on 1/12/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 1 had no cognitive impairment. Review of the Progress Notes entry dated 12/4/22 at 0504 hours, showed Resident 1 complained that the charge nurse from the AM shift (on 12/3/22) never administered any of the resident's medications. Review of the Medication Administration Record dated December 2022 failed to show documented evidence the following medications were administered to Resident 1 on 12/4/22: - insulin regular human Solution (treats diabetes) as per the sliding scale based on the resident's blood sugar levels at 1130 and 1630 hours, - 20 mg of prednisone (corticosteroid) for itching at 0900 and 1700 hours, and - 200 mg of amiodarone (treats arrythmias [an irregular heartbeat]) at 0900 hours. Further review of the Medication Administration Record dated December 2022 showed Resident 1's blood sugar level was 447 mg/dl at 2100 hours on 12/4/22. A fasting blood sugar level less than 100 mg/dl is normal; a blood sugar level of 70 to 150 mg/dl requires no insulin regular human administration as per the sliding scale. There was no documented evidence Resident 1's blood sugar levels were obtained at 1130 and 1630 hours on 12/4/22. On 1/12/23 at 1212 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above information. The DON verified administered medications were documented in the Medication Administration Record. The DON verified there was no documented evidence Resident 1's medications were administered to her during the morning shift of 12/4/22. The DON verified there was no physician's orders to hold Resident 1's medications on 12/4/22, and no documentation showing Resident 1 had refused her medications. Cross reference to F684.

Nov 2022 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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2's routine pain medication was administered as ordered. As a result, Resident 2 had 46 doses of routine pain medication documented as not administered between August 2022 through October 4, 2022. In addition, the facility failed to notify Resident 2's primary physician of the numerous missed pain medication doses. These failures had the potential for the resident to experience unmanaged and unnecessary pain. Findings: Review of the facility's P&P titled Ordering and Receiving Medications from Pharmacy (undated) showed the facility will reorder the medications three to four days in advance to assure an adequate supply is on hand. Medical record review for Resident 2 was initiated on 10/14/22. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 10/14/22, showed a physician's order dated 4/21/22, for morphine sulfate (a narcotic opioid medication used to treat moderate to severe pain) ER (extended release) 15 mg every eight hours for pain. On 10/14/22 at 0821 hours, an interview was conducted with Resident 2. Resident 2 stated the facility has missed providing multiple doses of routine morphine. 1. Review of Resident 2's MAR for August 2022 showed the administration code of 9 indicating the resident's morphine sulfate was not administered on the following dates and times for a total of 14 doses: - August 4th at 0600 and 2200 hours - August 5th at 0600 hours - August 26th at 0600, 1400, and 2200 hours - August 27th at 0600 hours - August 28th at 1400 and 2200 hours - August 29th at 0600, 1400, and 2200 hours - August 30th at 0600 and 2200 hours Review of Resident 2's MAR Chart Codes showed 9 stood for other/see progress notes. Review of Resident 2's Order-Administration Notes for August 2022 showed the linked medication administration progress notes for morphine sulfate ER. The linked medication progress notes for the morphine sulfate were not available to be administered at the above times. 2. Review of Resident 2's MAR for September 2022 showed the administration code of 9 indicating the resident's morphine sulfate was not administered on the following dates and times for a total of 26 doses: - September 4th at 1400 hours - September 5th at 0600 and 1400 hours - September 6th at 0600 and 2200 hours - September 7th at 0600 and 2200 hours - September 8th at 0600 and 2200 hours - September 9th at 0600, 1400 and 2200 hours - September 10th at 0600, 1400 and 2200 hours - September 11th at 0600 hours - September 12th at 2200 hours - September 18th at 0600 and 2200 hours - September 24th at 1400 and 2200 hours - September 25th at 1400 and 2200 hours - September 26th at 0600 and 2200 hours - September 27th at 0600 Review of Resident 2's MAR Chart Codes showed 9 stood for other/see progress notes. Review of Resident 2's Order-Administration Notes for September 2022 showed the linked medication administration progress notes for morphine sulfate ER. The linked medication progress notes for the morphine sulfate were not available to be administered at the above times. 3. Review of Resident 2's MAR for October 2022, showed the administration code of 9 indicating the resident's morphine sulfate was not administered on the following dates and times for a total of six doses: - October 2nd at 1400 and 2200 hours - October 3rd at 0600, 1400 and 2200 hours - October 4th at 0600 hours Review of Resident 2's MAR Chart Codes showed 9 stood for other/see progress notes. Review of Resident 2's Order-Administration Notes for October 2022 showed the linked medication administration progress notes for morphine sulfate ER. The linked medication progress notes for the morphine sulfate were not available to be administered at the above times. On 10/14/22 at 1139 hours, an observation and concurrent interview was conducted with RN 1. RN 1 retrieved the controlled medication e-kit (emergency medication kit) and stated the e-kit was supplied with four tablets of morphine sulfate ER 15 mg. The RN showed the medication stored in the kit and observed four tablets were currently in the e-kit. On 11/17/22 at 1506 hours, a telephone interview was conducted with Pharmacy Consultant 1. Pharmacy Consultant 1 stated the pharmacy provided the medications to the facility. Pharmacy Consultant 1 stated morphine sulfate was a controlled C-II level medication (drugs with an acceptable medical use with a high potential for abuse and dependence), so the prescription would expire after 60 days and a new prescription would be required by the ordering physician. Pharmacy Consultant 1 reviewed Resident 2's medical record and stated in the event they needed a new prescription from the physician, the pharmacy would dispense the five days' worth of medications while waiting for the new prescription. Pharmacy Consultant 1 also stated the controlled medications were not automatically refilled, and the facility must request a refill. Pharmacy Consultant 1 stated morphine sulfate was also located in the e-kit which was stored in the facility, and the facility may retrieve the medications from the supply after speaking to a Pharmacy Consultant and getting the approval. Pharmacy Consultant 1 stated their records showed the e-kit was authorized for Resident 2's morphine sulfate from August 2022 through 10/14/22, five times on the following dates and times: - On 8/31/22, for one dose. - On 9/12/22, for two doses. - On 9/18/22, for one dose. - On 10/7/22, for one dose. The Pharmacy Consultant also stated the pharmacy filled Resident 2's morphine sulfate ER on the following dates: - On 7/29/22, for 60 tabs (20 days supply) - On 9/12/22, for 15 doses (five days emergency supply) - On 9/18/22, for 15 doses (five days emergency supply) - On 9/26/22, for 15 doses (five days emergency supply) - On 10/3/22, for 30 pills (10 days supply) - On 10/14/22, for 60 pills (20 days supply) On 11/22/22 at 1018 hours, a concurrent telephone interview and medical record review was conducted with the DON. The DON reviewed Resident 2's medication administration notes and verified the notes showed Resident 2's routine morphine sulfate ER was not administered to the resident. During the interview, the DON stated there was a delay in the morphine sulfate ER being delivered by the pharmacy while waiting for the physician to sign a new prescription. On 11/22/22 at 1141 hours, a telephone interview was conducted with Pharmacy Consultant 2. Pharmacy Consultant 2 stated the pharmacy's protocol was to provide a five-day emergency refill for the controlled medications pending a new prescription. The Pharmacy Consultant stated usually, the pharmacy would dispense up to three five-day emergency supplies while waiting for a new prescription from the physician. When asked if Resident 2 reached the emergency supply limit, Pharmacy Consultant 2 replied no because the residents was receiving it routinely and they would not withhold routine medications from a resident. On 11/23/22 at 0832 hours, a telephone interview was conducted with the Resident 2's primary physician, Physician 1. Physician 1 stated Resident 2's pain regimen was handled though a pain management group who was responsible for handling the pain medication prescriptions. Physician 1 stated they were aware of some missed doses due to a lapse in the physician's orders and had written the prescriptions in the past for emergency use while waiting for the pain special group physicians to provide new prescriptions. The physician stated they were not aware so many doses had been missed between August 2022 to October 14, 2022, and stated it should not be that much.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the controlled medication records were maintained fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the controlled medication records were maintained for one of three sampled residents (Resident 2) when two Medication Count Sheets for morphine sulfate ER 15 mg were not able to be located by the facility. This had the potential to delay in identifying a potential diversion of controlled substances. Findings: Medical record review for Resident 2 was initiated on 10/14/22. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 10/14/22, showed a physician's order dated 4/21/22, for morphine sulfate ER 15 mg every eight hours for pain. On 10/14/22 at 0821 hours, an interview was conducted with Resident 2. Resident 2 stated the resident had missed multiple doses of the routine morphine medications. On 10/14/22 at 1128 hours, an interview, observation, and concurrent medical record review was conducted with LVN 1. LVN 1 was asked to show Resident 2's morphine sulfate supply on hand and the Medication Count Sheets. There were two morphine sulfate ER 15 mg tablets labeled for Resident 2's use. The Medication Count Sheet showed 30 tablets had been filled on 10/3/22, and the first tablet was removed on 10/4/22 at 1400 hours. The sheet also showed two remaining tablets were left in the supply. Review of Resident 2's medical records showed morphine sulfate ER 15mg Medication Count Sheets for the following: - A fill date of 7/10/22, for 60 tablets, signed out from 7/12/22 at 0600 through 8/3/22 at 2100 hours. - A fill date of 9/12/22, for 15 tablets, signed out from 9/12/22 at 1400 through 9/17/22 at 2100 hours. - A fill date of 9/26/22, for 15 tablets, signed out from 9/27/22 at 1400 through 10/2/22 at 0500 hours. There were no Medication Count Sheets for morphine administered between 8/4/22 through 9/11/22 and 9/18/22 through 9/26/22. On 10/14/22 at 1356 hours, an interview was conducted with the DON. The DON stated she was unable to locate any additional Medication Count Sheets for Resident 2's morphine sulfate. The DON also stated the old Medication Count Sheets should be placed in the resident's chart as part of their medical record. On 11/17/22 at 1506 hours, a telephone interview was conducted with Pharmacy Consultant 1. Pharmacy Consultant 1 stated the pharmacy filled Resident 2's morphine sulfate ER on the following dates: - On 7/29/22, for 60 tablets (20 days supply) - On 9/12/22, for 15 tablets (five days emergency supply) - On 9/18/22, for 15 tablets (five days emergency supply) - On 9/26/22, for 15 tablets (five days emergency supply) - On 10/3/22, for 30 tablets (10 days supply) - On 10/14/22, for 60 tablets (20 days supply) Therefore, the Medication Count Sheets were missing for the morphine sulfate ER delivered on 7/29/22, for 60 tabs (20 days supply) and on 9/18/22, for 15 tablets (five days emergency supply).

May 2022 13 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtained for the use of psychotropic medications (any drug prescribed to stabilize or improve mood, mental status, or behavior) for one of 25 final sampled residents (Resident 16). * The informed consent was not obtained from Resident 16 prior to administering mirtazapine (antidepressant medication). This failure had the potential for the resident to be unaware of the risks associated with the medications which may have adverse side effects detrimental to the resident's well-being or choice. Findings: Review of the facility's P&P titled Informed Consent - Psychotherapeutic Medications revised 12/14/17, showed the attending physician (healthcare practitioner) will be responsible for obtaining informed consent from the resident/ surrogate decision maker prior to receipt of the medication when a psychotherapeutic medication is ordered throughout the resident's stay in the facility, providing the facility with verification of informed consent and determining resident's decision-making capacity. The facility will be responsible for documenting verification of informed consent for all new orders or orders present on admission for chemical restraints. Review of Resident 16's medical record was initiated on 5/9/22. Resident 16 was initially admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the physician's History and Physical examination dated 2/3/22, showed Resident 16 had the capacity to understand and make decisions. Review of Resident 16's Order Summary Report showed a physician's order dated 2/1/22, for mirtazapine 7.5 mg one tablet by mouth at bedtime for depression. Review of Resident 16's MAR for April 2022 showed Resident 16 received mirtazapine medication on 4/1 to 4/3, and 4/5 to 4/30/22 at 2100 hours. Review of Resident 16's Medication Administration Record for May 2022 showed Resident 16 received mirtazapine medication on 5/1 to 5/12/22 at 2100 hours. Review of Resident 16's medical record did not show an informed consent for the mirtazapine medication was obtained from Resident 16 by the attending physician. Further review of Resident 16's medical records did not show the facility documented the verification of informed consent from Resident 16 for the mirtazapine medication. On 5/13/22 at 0919 hours, an interview and concurrent medical record review was conducted with the ADON. When asked about informed consents, the ADON stated the physician would obtain the informed consent from the resident's family or from the resident if the resident was self-responsible. The licensed nurses will have to verify the consent and fill out the Facility Verification of Informed Consent form. The ADON verified Resident 16 was able to make decisions and acknowledged there was no documentation to show an informed consent was obtained for the mirtazapine medication. On 5/13/22 at 1134 hours, an interview was conducted with Resident 16. When asked about her mirtazapine medication, Resident 16 stated she knew it was ordered by the physician, but she did not like this medication because it made her sleepy and weak. Resident 16 stated she was not informed of mirtazapine and did not know what it was for.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 56's medical record was initiated on 5/9/22. Resident 56 was admitted to the facility 2/17/21. Review of ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 56's medical record was initiated on 5/9/22. Resident 56 was admitted to the facility 2/17/21. Review of the MDS dated [DATE], showed Resident 56 had cognitive impairment and needed extensive assistance with her ADL care. Review of Resident 56's plan of care showed a care plan problem addressing a risk for fall or injury. An intervention included to place Resident 56's call light within reach. On 5/9/22 at 0831 hours, an observation of Resident 56 and a concurrent interview was conducted with the ADON. Resident 56's call light cord was observed clipped to the side of her pillow with the call light button placed under the pillow. Resident 56 was observed sitting on her wheelchair by the bedroom door. A floor mat was observed between the Resident 56's wheelchair and bed. The ADON stated Resident 56 was not able to get up out of her wheelchair or move independently. The ADON verified the call light was out of Resident 56's reach and should not have been. 3. Review of Resident 664's medical record was initiated on 5/9/22. Resident 664 was admitted to the facility 4/20/22. Review of the MDS dated [DATE], showed Resident 64 needed extensive assistance with her ADL care. Review of the plan of care showed a care plan problem developed to address Resident 664's actual fall incident on 5/8/22. An intervention was to encourage the use of call light and wait for assistance prior to getting up. On 5/9/22 at 0803 hours, an observation of Resident 664 and concurrent interview was conducted with LVN 1. Resident 664 was observed laying in bed with her eyes closed. Resident 664's call light was observed laying on the floor on the right side of her bed. LVN 1 stated Resident 664 was unable to move or turn by herself to reach the call light on the floor. LVN 1 verified the call light was not within Resident 664's reach and should have been. Based on observation, interview, and medical record review, the facility failed to ensure the call light was kept within reach for two of 25 final sampled residents (Residents 56 and 77) and one nonsampled resident (Resident 664). This failure posed the risk for the residents not being able to call for assistance should they require it. Findings: Review of the facility's P&P titled Call Light, Answering (undated) showed it is the policy of the facility to leave the call light within the reach of the resident, answer calls and respond to the resident's requests and needs as quickly as possible. 1. On 5/10/22 at 1043 and 1502 hours, Resident 77 was observed in bed. The call light was hanging over a mat propped against the wall behind Resident 77's bed. The call light was out of Resident 77's reach. Resident 77 stated he needed his incontinence briefs changed. When asked if he could reach the call light, Resident 77 stated no. On 5/10/22 at 1514 hours, an observation and concurrent interview were conducted with LVN 2. LVN 2 verified the call light was hanging on the mat behind Resident 77's bed and not within Resident 77's reach. LVN 2 stated Resident 77 was able to use the call light. LVN 2 asked Resident 77 if he wanted his call light and Resident 77 stated yes. LVN 2 stated Resident 77 was not able to ask for assistance when needed if the call light was not within reach. Medical record review for Resident 77 was initiated on 5/10/22. Resident 77 was readmitted to the facility on [DATE]. Review of Resident 77's MDS dated [DATE], showed Resident 77 was totally dependent on staff for all ADL care. On 5/12/22 at 1431 hours, an interview was conducted with the DON. The DON stated if a resident was not able to reach the call light, their needs would not be known and immediately met.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to develop a plan of care to reflect the individual care needs...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to develop a plan of care to reflect the individual care needs related to the deep tissue injury (DTI) for one of 25 final sampled residents (Resident 10). This posed the risk of not providing appropriate, consistent, and individualized care to Resident 10. Findings: The National Pressure Ulcer Advisory Panel's (NPUAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers dated 2014 defined DTIs as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Medical record review for Resident 10 was initiated on 5/10/22. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Admission/readmission Screener dated 1/26/22, showed the resident was admitted to the facility with the right heel DTI. Review of the MDS dated [DATE], showed Resident 108 was admitted to the facility with two unstageable pressure injuries presenting as DTIs. Review of Resident 10's plan of care failed to show a care plan problem was developed to address Resident 10's right heel DTI. On 5/11/22 at 1425 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified the above information. After reviewing Resident 10's comprehensive plan of care, the ADON verified there was no care plan problem (including all active and resolved care plan problems) developed to address Resident 10's right heel DTI that was present upon admission. Cross reference to F686, example #c.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility's P&P titled Wound Care last revised October 2010 showed in part, to mark the tape with initials, time...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility's P&P titled Wound Care last revised October 2010 showed in part, to mark the tape with initials, time and date and apply to dressing. Review of Resident 40's medical record was initiated on 5/10/22. Resident 40 was admitted to the facility on [DATE], and most recently readmitted on [DATE]. Review of Resident 40's MDS dated [DATE], showed Resident 40 needed assistance with his ADL care. Review of the physician's order showed Resident 40 was at risk for multiple open blisters to the bilateral lower extremities, to cleanse with NS (normal saline), pat dry, apply A&D Calcium Alginate (wound medication) as needed to open areas, cover with ACE wrap daily and as needed x 30 days, then reassess 5/21/22. On 5/10/22 at 0740 hours, during an initial tour, Resident 40 was observed awake, sitting in bed. Resident 40's both legs and feet were observed to be swollen. The bandage dressings on Resident 40's feet and legs were observed to be loose and touching the floor. On 5/10/22 at 0932 hours, Resident 40 was observed be lying in bed. Resident 40 's feet wee observed to be scaly and swollen. The bandage dressing on Resident 40's legs and feet were observed to be soiled. On 5/11/22 at 1553 hours, Resident 40's right lower extremity bandage was observed to be unraveling and touching the floor. On 5/11/22 at 1559 hours, an interview was conducted with LVN 3. When asked the process for wound dressing changes, LVN 3 stated the staff were supposed to initial and write the date of the dressing change on the dressing. When asked to describe why the process was important, LVN3 stated it was important, so the staff knew when the wound care dressing was last changed. When asked to describe the process if the dressing was unraveled and touched the floor, LVN 3 stated the dressing would need to be changed. On 5/11/22 at 1607 hours, an observation of Resident 40's dressing was conducted with LVN 3. LVN 3 verified Resident 40's dressing was loose and dragging on the floor. LVN 3 verified the bandage dressings on Resident 40's legs were not labeled to show when the dressing was last changed. 2. Review of the facility's P&P titled Administering Medications December 2012 showed medications must be administered in accordance with the orders including any required time frame. Medications must be administered within one hour of their prescribed time. Medical record review was initiated for Resident 84 on 5/12/22. Resident 84 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 84 had severe cognitive impairment. Review of Resident 84's Physician's Order Summary and the Medication Administration Audit Reports dated 5/12/22, showed the following medications were to be administered on 5/12/22 at 0900 hours: - Artificial Tears Solution 1-0.3% (medication to lubricate the eyes) one drop in both eyes two times a day for eye dryness. - Aspirin EC Tablet (medication to prevent clots) Delayed release 81 mg one tablet by mouth one time a day for cerebrovascular accident (CVA) prophylaxis. - Citalopram Hydrobromide (medication for depression) 10 mg one tablet by mouth one time a day for depression manifested by verbalization of sadness. - Donepezil HCI (medication to treat confusion) 10 mg one tablet by mouth one time a day for dementia. - FerrouSul (supplement) 325 mg by mouth two times a day for anemia. Review of the Medication Administration Audit Report dated 5/12/22, showed the above medications ordered for 0900 hours were given at 1048 hours. On 5/12/22 at 1050 hours, an observation and concurrent interview were conducted with LVN 7. LVN 7 was at the medication cart viewing the MAR for Resident 84. LVN 7 stated the MAR was blank with a pink/orange color showing the medications were late and had not been given. LVN 7 verified the medications due at 0900 hours were not given until 1048 hours. 3. Medical record review was initiated for Resident 93 on 5/12/22. Resident 93 was admitted to the facility on [DATE]. Review of the History and Physical examination dated 4/9/22, showed Resident 93 has the capacity to understand and make decisions. Review of the Physician's Order Summary Report and the MAR showed the following medications were ordered to be administered on 5/12/22 at 0900 hours: - Nasal Iodophor 10% antiseptic single swab to each nostril unless allergic, two times a day every two weeks on Mon, Tues, Wed, Thurs, Fri for decolonization. - Artificial Tears Solution (eye lubricant) 1% one drop in both eyes two times a day for dry eyes. - Gabapentin (medication to control pain and seizure) 300 mg one capsule by mouth one time a day for nerve pain and anticonvulsant. -Docusate Sodium (stool softener) 100 mg one capsule by mouth one time a day for constipation. - Aspirin EC (medication to prevent clot) delayed release tablet 81 mg one tablet by mouth one time a day for Cerebrovascular Accident (CVA) prophylaxis. - Breo Ellipta Aerosol Powder Breath Activated ( medication to decrease troubled breathing) 100-25 mcg per inhalation (INH) one puff inhale orally one time a day for Chronic Obstructive Pulmonary Disease (COPD). - Vitamin D3 (supplement) 2000 units by mouth one time a day for supplement. - Enalapril Maleate (medication for high blood pressure) 10 mg one tablet by mouth one time a day for hypertension (high blood pressure), hold if systolic blood pressure 100 mmHg, or heart rate 60 beats per minute. - Pramipexole Dihydrochloride (medication to treat muscle spasms) 0.125 mg one tablet by mouth one time a day for restless leg syndrome. - Prozac (antidepressant medication) 40 mg one capsule by mouth one time a day for depression manifested by feeling hopelessness and sadness. - Voltaren Gel (antiinflammatory medication) 1% apply to affected areas (joints) topically two times a day for chronic pain. - Lorazepam (antianxiety medication) 1 mg one tablet by mouth every six hours as needed for anxiety manifested by feeling agitated for 14 days. On 5/12/22 at 1040 hours, Resident 93 was observed with her call light on and asked CNA 9 to tell the nurse that she needed her morning medications. Resident 93's voice was loud and sounded upset. LVN 7 came into the room and acknowledged the medications were due at 0900 hours, and late. On 5/12/22 at 1045 hours, an observation and interview were conducted with Resident 93. Resident 93 had a mild wheeze (whistling sound) when talking, and an occasional cough. Resident 93 stated she was upset and nervous. Resident 93 stated she had asked for her nurse and requested her antianxiety medication all morning. Resident 93 stated she usually got her medications late and was not aware when she was supposed to get them. Resident 93 stated she had a hard time breathing if she did not receive her inhaled medication on time. Resident 93 stated she had a hard time breathing this morning and had not yet received her medications. On 5/12/22 between 1048 and 1101 hours, LVN 7 was observed administering the medications scheduled for 0900 hours to Resident 93. LVN 7 verified the medications were due to be given at 0900 hours, and were late. LVN 7 stated the facility's policy was for the medications to be given within one hour before or one hour after the time they were ordered to be given. LVN 7 stated she knew the medications were going to be administered late for Residents 84 and 93 and did not notify the charge nurse for assistance. When asked what could happen if the medications were given late, LVN 7 stated it would depend on the purpose of the medication being given. LVN 7 stated a late breathing treatment could cause breathing problems for Resident 93. On 5/12/22 at 1426 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the facility's policy was for the medications to be administered one hour before or one hour after the ordered and scheduled administration time. The DON stated the RN Supervisor should be notified if the nurse was behind in passing medications and assistance should be provided to ensure medications were given on time to the residents. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of the 25 final sampled residents (Residents 8 and 40) and two nonsampled residents (Residents 84 and 93) to maintain their highest physical well-being. * The facility failed to complete the CXR, CBC, BMP, and Mg laboratory tests for Resident 8 as per the physician's order. * Residents 84 and 93's medications were not administered in a timely manner. * Resident 40's wound dressing on both legs and feet were loose, soiled, and touching the floor. In addition, Resident 40's wound dressing were not dated to show when it was last changed. These failures had the potential to negatively impact the resident's' well-being. Findings: 1. Review of the facility's P&P titled Lab and Diagnostic Orders dated 11/2018 showed the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The staff will process the tests requisition and arrange for tests. Medical record review was initiated for Resident 8 on 5/11/22. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Physician Orders dated 4/18/22 and 5/2/22, showed an order to complete CXR diagnostic test, CBC, BMP, and Mg laboratory tests. However, further review of the medical record failed to show documented evidence the CXR, CBC, BMP, and Mg laboratory tests were completed as per the physician's order. On 5/12/22 at 0834 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified the above findings. RN 1 stated the laboratory tests should have been completed. On 5/12/22 at 0933 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings. The DON stated the laboratory tests should have been carried out and completed.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for one of 25 final sampled residents (Resident 10). * The facility failed to ensure Resident 10's heels were offloaded which contributed to Resident 10 developing a Stage 2 pressure ulcer on the right lateral (to the side of, or away from the middle of the body) heel. * The facility failed to ensure Resident 10 received wound care for the fluid filled blister (Stage 2 pressure ulcer) on the right medial (toward the middle or center of the body) heel from 5/7 to 5/10/22. * Resident 10 was admitted to the facility with a DTI (deep tissue injury) on the right heel. The facility failed to ensure Resident 10 received the necessary treatment and services for the DTI. These failures had the potential of Resident 10 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers. Findings: Review of the National Pressure Ulcer Advisory Panel's (NPUAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers dated 2014 showed maintaining skin integrity is essential in the prevention of pressure ulcers. The underlying cause and formation of pressure ulcers is multifaceted; however, by definition, pressure ulcers cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in ischemia and inevitable tissue damage. Repositioning involves a change in position of the lying or seated individual undertaken at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort. Individuals who cannot reposition themselves will require assistance. The recommendations included to reposition all individuals at risk of developing pressure ulcers or with existing pressure ulcers. Support surfaces are an important element in pressure ulcer treatment because they provide an environment that enhances perfusion of injured tissue. However, support surfaces alone neither prevent nor heal pressure ulcers. The NPUAP defines the pressure ulcer stages as follows: - Stage 2 pressure ulcer - partial thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. - DTI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. a. On 5/10/22 at 0953 hours, an interview was conducted with Family Member 1 at Resident 10's bedside. Family Member 1 stated Resident 10 developed several pressure ulcers while at the facility. Medical record review for Resident 10 was initiated on 5/10/22. Resident 10 was admitted to the facility on [DATE]. Review of the Braden Scale for Predicting Pressure Sore Risk dated 3/12/22, showed Resident 10 was at a very high risk of developing pressure ulcers. Review of the Progress Notes dated 4/6/22 at 2035 hours, showed Resident 10 had developed a fluid filled blister (Stage 2 pressure ulcer) to the right medial heel. Review of Resident 10's plan of care showed a care plan problem dated 5/3/22, addressing the right medial heel fluid filled blister. The interventions included to offload the heels at all times. Review of the wound care physician's note dated 5/5/22, showed the plan for Resident 10's wounds was to continue the offloading interventions. On 5/10/22 at 1447 hours, and 5/11/22 at 0808 and 0944 hours, Resident 10 was observed lying in bed with both heels resting directly on the mattress (not offloaded). On 5/11/22 at 1115 hours, a wound care observation of Resident 10 was conducted with LVNs 3 and 17. LVN 17 stated Resident 10 had a blister on the right medial heel. Prior to the wound care observation, Resident 10 was observed lying in bed with both heels resting directly on the mattress. After LVNs 3 and 17 removed the dressing on Resident 10's right heel, an intact fluid filled blister was observed on the right lateral heel, which was previously observed resting directly on the mattress. LVNs 3 and 17 verified this was a newly developed pressure ulcer. After completing wound care for Resident 10, LVNs 3 and 17 placed one pillow under the resident's legs, however, both of the resident's heels were still resting directly on the mattress. On 5/11/22 at 1151 hours, an observation of Resident 10 was conducted with the ADON. The ADON verified Resident 10's heels were not offloaded and were resting directly on the mattress. The ADON stated enough pillows had to be placed under the resident's legs to ensure the heels were offloaded and no pressure was placed on the heels. b. Review of the Treatment Administration Record dated May 2022 showed the following wound care orders for Resident 10's right medial heel fluid filled blister: - An order dated 4/22/22, and discontinued on 5/6/22, to cleanse the wound with normal saline, pat dry, apply Betadine (antiseptic), and cover the wound with a foam dressing. -An order dated 5/11/22, to cleanse the wound with normal saline, pat dry, apply Betadine, and cover the wound with a foam dressing. Medical record review for Resident 10 failed to show wound care was provided to Resident 10's right medial heel fluid filled blister on 5/7, 5/8, 5/9, and 5/10/22. On 5/11/22 at 1425 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified the above information. The ADON stated the nurses failed to contact the physician to renew the wound care order or to get a new treatment order for Resident 10's right medial heel fluid filled blister. The ADON verified there was no documented evidence wound care was provided to Resident 10 on 5/7 to 5/10/22. c. Review of Resident 10's Admission/readmission Screener dated 1/26/22, showed the resident was admitted to the facility with a DTI on the right heel. Review of the MDS dated [DATE], showed Resident 108 was admitted to the facility with two unstageable pressure injuries presenting as DTIs. Medical record review for Resident 10 failed to show the physician order and care plan problem were developed to address the right heel DTI and failed to show documented weekly wound assessments of the right heel DTI. On 5/11/22 at 1425 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified the above findings. The ADON verified Resident 10 was admitted with the DTI on the right heel, but there were no physician orders and care plan problems developed to address the right heel DTI and no documented weekly assessments of the wound as required. Cross reference to F656.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 25 final sampled residents (Res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 108) remained free from accident hazards. * The facility failed to ensure Resident 108's side rails were padded as care planned. This failure posed the risk for Resident 108 to become injured by the side rails. Findings: On 5/10/22 at 1433 hours, Resident 108 was observed lying in bed with one side rail elevated by the right side of the head of the bed. The side rail was not padded. Medical record review for Resident 108 was initiated on 5/10/22. Resident 108 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 4/18/22, to implement bilateral upper side rails for comfort and security. Review of Resident 108's History and Physical examination dated 4/18/22, showed Resident 108 had diagnoses, including seizure disorder (the physical manifestations, such as convulsions, sensory disturbances, or loss of consciousness, resulting from abnormal electrical discharges in the brain). Review of the Safety Assessment for Side Rail Usage dated 4/18/22, showed Resident 108's conditions that contributed to siderail safety hazards included poor safety awareness and poor trunk control. Review of Resident 108's plan of care showed a care plan problem dated 4/27/22, to provide bilateral padded side rails due to the seizure disorder. On 5/12/22 at 1103 hours, Resident 108 was observed lying in bed with bilateral side rails elevated by the head of the bed. The side rails were not observed padded. On 5/12/22 at 1105 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 verified the above information and stated Resident 108 required padded side rails to prevent her from injuring herself should she have a seizure. On 5/12/22 at 1119 hours, an observation of Resident 108 and conncurent interview was conducted with LVN 10. LVN 10 verified Resident 108's side rails were not padded as required.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary ca...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and serviced for one nonsampled resident (Resident 25). * Resident 25's indwelling urinary catheter tubing was observed to dragging on the ground as he self-propelled his wheelchair. This failure posed the risk for the resident to develop complications related to urinary catheter use. Findings: Review of the facility's P&P titled Urinary Catheter Care revised 9/2014, under the section for Infection Control, showed the urinary catheter tubing and drainage bag are kept off the floor. Medical record review for Resident 25 was initiatied on 5/9/22. Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 25 needed extesnive assistance with his ADL care. Resident 25 had an indwelling urinary catheter. Review of the plan of care showed a care plan problem addressing the risk for infection related to Resident 25's use of indwelling urinary catheter. On 5/9/22 at 1100 hour, a concurrent observation of Resident 25 and interview was conducted with LVN 6. Resident 25 was observed propelling his wheelchair down the hallways. Resident 25's urinary drainage bag placed inside a dignity bag and the indwelling urinary catheter tubing were observed to be touching the ground. Resident 25's urinary bag and urinary catheter tubing were dragging on the ground behind the wheelchair. LVN 6 verified the Resident 25's urinary catheter tubing was dragging on the ground and should have properly secured on the wheelchair. LVN 6 told Resident 25's indwelling urinary catheter tubings had to be replaced. On 5/12/22 at 0833 hours, an interview was conducted with Resident 25. When asked if his indwelling urinary catheter tubing were replaced, Resident 25 stated no one had changed his indwelling urinary catheter or tubing from 5/9/22 - 5/12/22. On 5/12/22 at 0833 hours, a concurrent interview and medical record review was conducted with LVN 6. When asked what interventions were done after Resident 25's urinary catheter tubing was observed dragging on the floor on 5/9/22, LVN 6 stated she was only able to replace the indwelling urinary catheter tubing on 5/12/22. LVN 6 acknowledged Resident 25's indwelling urinary catheter tubing should have have been replaced right away to prevent complications related to urinary catheter use such as urinary tract infection.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care for one of 25 final sampled resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care for one of 25 final sampled residents (Resident 16). * The facility failed to ensure Resident 16 was administered medications as ordered on the days the resident left the facility for dialysis treatment (a treatment to rid the blood of toxins and waste when the kidneys fail to function). This had the potential for Resident 16 not getting the appropriate doses of medications as ordered, resulting in possible medical complications. Findings: Review of Resident 16's medical record was initiated on 5/9/22. Resident 16 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Order Summary Report showed the following physician's orders: - dated 2/1/22, for Resident 16 to go to dialysis on Tuesdays, Thursdays, and Saturdays at 1400 hours; - dated 2/1/22, to administer amiodarone (antiarrhythmic medication, used to treat serious irregular heartbeat) 200 mg one tablet by mouth two times a day and to hold if heart rate less than 60 beats per minute; - dated 2/1/22, to administer Florastor (probiotic supplement) 250 mg by mouth two times a day; - dated 2/1/22, to administer quetiapine (antipsychotic medication, used to treat mental/ mood disorder) 25 mg one tablet every 12 hours; - dated 5/11/22, to administer sevelamer (phosphate binder medication, used to control high blood levels of phosphorus 800 mg by mouth with meals; and - dated 6/15/21, to administer regular insulin (short-acting form of insulin, used to treat high level of sugar in the blood) per sliding scale subcutaneously (innermost layer of skin) before meals and at bedtime. Further review of the Order Summary Report did not show an order to hold Resident 16's medications on her scheduled dialysis days. Review of the Medication Administration Record for April 2022 showed Resident 16 did not receive the ordered medications on her scheduled dialysis treatment on Tuesdays, Thursdays and Saturdays after 1400 hours. For example: - For the 1700 hours scheduled dose for amiodarone medication, an X or NA with code 9 (other-see progress notes) was recorded on 4/2, 4/7, 4/9, 4/12, 4/19, 4/23, 4/26, 4/28, and 4/30/22; an X or NA with code 1 (absent from home without meds) was recorded on 4/5 and 4/14/22; and none were recorded on 4/16 and 4/21/22. - For the 1700 hours scheduled dose for florastor medication, code 9 was recorded on 4/2, 4/7, 4/9, 4/12, 4/19, 4/23, 4/26, 4/28 and 4/30/22; code 1 was recorded on 4/5/22, and none was recorded 4/16 and 4/21/22. - For the 1630 hours scheduled time to administer regular insulin per sliding scale, code 9 was recorded on 4/2, 4/7, 4/9, 4/12, 4/19, 4/23, 4/26, 4/28 and 4/30/22, code 1 was recorded on 4/5 and 4/14/22, and none were recorded on 4/16 and 4/21/22. - For the 1800 hours scheduled dose for quetiapine, code 9 was recorded on 4/2, 4/7, 4/9, 4/12, 4/19, 4/23, 4/26, 4/28, and 4/30/22; code 1 was recorded on 4/5 and 4/14/22, and none was recorded on 4/16 and 4/21/22. - For the 1700 hours schedule dose for sevelamer, code 9 was recorded on 4/2, 4/7, 4/9, 4/12, 4/19, 4/26, 4/28, and 4/30/22; code 1 was recorded on 4/5 and 4/14/22, and none was recorded on 4/16 and 4/21/22. Review of the Medication Administration Record for May 2022 showed Resident 16 did not receive the ordered medications on her scheduled dialysis treatment on Tuesdays, Thursdays and Saturdays after 1400 hours. For example: - For the 1700 hours scheduled dose for amiodarone medication, an X or NA with code 9 was recorded on 5/3, 5/7, and 5/10/22; and an X with code 1 was recorded on 5/5/22. - For the 1700 hours scheduled dose for florastor medication, code 9 was recorded on 5/3, 5/7, and 5/10/22; and code 1 was recorded on 5/5/22. - For the 1630 hours scheduled time to administer regular insulin per sliding scale, code 9 was recorded on 5/3, 5/7, and 5/10/22; and code 1 was recorded on 5/5/22. - For the 1800 hours scheduled dose for quetiapine, code 9 was recorded on 5/3, 5/7, and 5/10/22; and code 1 was recorded on 5/5/22. - For the 1700 hours schedule dose for sevelamer, code 9 was recorded on 5/3, 5/7, and 5/10/22; and code 1 was recorded on 5/5/22. Review of the Progress Notes showed the following nurse's notes: -on 4/2/22 at 1329 hours, Resident 17 was picked up to go to dialysis; -on 4/9/22 at 1358 hours, Resident 17 went out for dialysis at 1356 hours; -on 4/14/22 at 1330 hours, Resident 17 left for dialysis; -on 4/23/22 at 1407 hours, Resident 17 was picked up for dialysis at 1300 hours; and -on 5/3/22 at 1400 hours, Resident 17 was picked up by private transportation to dialysis. On 5/13/22 at 0919 hours, an interview was conducted with the ADON. The ADON verified the amiodarone, florastor, quetiapine, sevelamer, and regular insulin medications were put on hold while Resident 16 was out to the dialysis center. The ADON acknowledged there was no documentation the licensed staff notified the physician when the medications were put on hold. The ADON verified there was no order to discontinue the medications on the days when Resident 16 was out to the dialysis center.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling and disposal of medications. * The facility failed to ensure the discontinued medication for one of 25 final sampled residents (Resident 40), and medications for seven nonsampled residents (Residents 38, 47, 62, 113, 114 115, and 366) who were transferred, discharged home or expired were removed from the medication cart. These failures had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure the prepared medications for Resident 463 were labeled when stored in the medication cart as the licensed staff await for the resident to be able to take the medications. This had the potential for the medications to be accidentally administered to another resident and/or diverted. * Medication Carts A and B were left unlocked and unattended. This had the potential for unauthorized persons to have access to the medications inside the medication cart * The facility failed to ensure the medications in the bubble packs (type of pre-formed, plastic packaging that seal individual tablets until they are taken) were secured, and the bubble packs were sealed and free from tears or damage. These failures posed the risk of affecting the potency of medication, and potential for medications to be diverted. * The facility failed to ensure the temperature of the medication refrigerator containing the vaccines was checked twice a day. This had the potential to affect the potency of the medications requiring storage at room temperature or refrigeration. * The facility failed to ensure the opened insulin pens and vials were labeled with opened dates, and unopened insulin vials were stored in the medication refrigerator. * The narcotic emergency kit stored in the IV medication cart was tagged as open and had not been replaced. This failure posed the risk for emergency drugs to be not immediately available when needed resulting in a delay in medication administration. Findings: Review of the facility's P&P titled Storage of Medication dated 09/2010 showed the following: - In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. - The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. - Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in refrigerator or at room temperature. Opened insulin pens must be stored at room temperature. - Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy. Review of the facility's P&P titled Emergency Kit (E-Kit) Use (undated) showed once the e-kit is opened, it is to be sealed with a black lock, which is supplied within the kit. The pharmacy is to be notified as soon as possible that the e-kit has been opened so that it can be replaced within 72 hours. Records will be completed according to Title 22 regulations, which includes documentation in the e-kit log, and the e-kit drug card inside the kit. According to the Centers for Disease Control and Prevention (CDC), if a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Review of the package insert for Tuberculin Purified Protein Derivative (Mantoux) Tubersol (undated) showed a vial of Tubersol which has been entered and in use for 30 days should be discarded. Review of the package insert for Humalog Kwikpen dated 4/2021 showed once opened, Humalog vials, prefilled pens and cartridges should be thrown away after 28 days. Review of the information for the physician for Humulin Regular dated 4/2011 showed when not in use (unopened), Humulin R U-100 bottles should be stored in a refrigerator, but not in the freezer. When in-use (opened), in-use bottles must be used within 31 days or be thrown out, even if they still contain Humulin R U-100. 1. On [DATE] at 1417 hours, an inspection of Medication Room A, concurrent interview, and medical record review was conducted with the ADON and RN 3. The following was observed: - a bottle of antacid tablets was opened with no open date. - a bubble pack containing dronabinol (a psychoactive substance used to treat nausea and vomiting caused by chemotherapy) medications for Resident 114. Review of the medical record for Resident 114 showed a physician's order dated [DATE], to transfer Resident 114 to the acute care hospital. The ADON and RN 3 verified the above findings. 2. On [DATE] at 1440 hours, an inspection of the vaccine refrigerator and concurrent interview was conducted with the IP. The following was observed: - Two vials of influenza vaccines were opened with no open date. - Three vials of tuberculin PPD (purified protein derivative, used in a skin test to help diagnose tuberculosis infection) were opened with the dates of [DATE], [DATE], and [DATE], respectively. Review of the Temperature Log for March, April, and [DATE] showed the temperature of the refrigerator containing vaccines was only checked once a day, not twice daily. The IP verified the above findings. 3. On [DATE] at 1015 hours, Medication Cart A parked in the hallway was observed unlocked and unattended. The facility's staff were observed passing by. On [DATE] at 1020 hours, LVN 11 was observed coming out of the resident's room. LVN 11 verified she left the medication cart unlocked. LVN 11 stated she went to the resident's room and forgot to lock the medication cart. 4. On [DATE] at 1022 hours, Medication Cart B parked in the hallway was observed unlocked and unattended. the facility's staff were observed passing by. On [DATE] at 1025 hours, LVN 12 was observed coming out of the resident's room. LVN 12 verified she left Medication Cart B unlocked. LVN 12 stated she went to check on the resident. 5. On [DATE] at 1054 hours, an inspection of Medication Cart C, interview, and medical record review was conducted with LVN 13. The following medications were observed for Resident 62: - a bottle of valproic acid (anticonvulsant medication, used to treat seizures); - a bottle of lactulose solution (osmotic laxative medication, used to treat constipation); - a bottle of levetiracetam (anticonvulsant medication, used to treat seizures); and - a bottle of metoclopramide (antiemetic medication, used to treat nausea and vomiting) Review of Resident 62's medical record showed a physician's order dated [DATE], to transfer Resident 62 to the acute care hospital. LVN 13 verified the above findings. 6. On [DATE] at 1123 hours, an inspection of Medication Cart D, interview, and concurrent medical record review was conducted with LVN 2. The following was observed: a. An unlabeled cup containing nine tablets was observed inside the medication cart. LVN 2 stated the medications in the cups were for Resident 463. LVN 2 stated he prepared the medications from the bubble packs for Resident 463 at 1000 hours, but when he went to the room, Resident 463 was sleeping. Review of Resident 463's Order Summary Report showed the following physician's orders: - dated [DATE], to administer ascorbic acid (Vitamin C supplement) 500 mg one tablet by mouth daily; - dated [DATE], to administer clopidogrel bisulfate (antiplatelet medication, used to prevent blood clot) 75 mg one tablet by mouth daily; - dated [DATE], to administer colace (osmotic laxative medication, used to treat constipation) 100 mg every 12 hours; - dated [DATE], to administer cozaar (antihypertensive medication, used to treat high blood pressure) 50 mg one tablet by mouth daily; - dated [DATE], to administer ferrosol (iron supplement) 325 mg one tablet daily; - dated [DATE], to administer loratadine (antihistamine medication, used to treat symptoms of allergies) 10 mg one tablet by mouth; and - dated [DATE], to administer multiple vitamins-minerals (supplement) tablet one tablet daily. - dated [DATE], to administer cholecalciferol (Vitamin D supplement) 1000 unit one tablet by mouth daily; - dated [DATE], to administer citalopram hydrobomide (antidepressant medication)10 mg one tablet by mouth daily; b. The following medications were observed in a comfort pack for Resident 115: - a bottle of morphine sulfate liquid (narcotic analgesic medication, used to treat severe pain); - a bottle of lorazepam liquid (antianxiety medication); - four units of ipatropium (anticholinergic medication, used to open up airways in the lungs); - three bisacodyl (laxative medication) suppositories; - four acetaminophen (analgesic medication, used to treat mild to moderate pain) tablets; - four ondansetron (antiemetic medication) tablets; and - a bottle of Hyosyne (smooth muscle relaxant medication) oral drops. Review of Resident 115's medical record showed a physician's order dated [DATE], to release the resident's body to mortuary/cemetery on [DATE]. c. A Humalog kwikpen was observed open with no open date. LVN 2 verified the above findings. 7. On [DATE] at 1154 hours, an inspection of the IV (intravenous) medication cart, interview, and concurrent medical record review was conducted with RN 4. The following was observed: a. Six vials of ceftriaxone (antibiotic) for Resident 366. Review of Resident 366's medical record showed a physician's order dated [DATE], to transfer Resident 366 to the acute care hospital. b. 25 vials of ondansetron (antiemetic medication) for Resident 113. Review of Resident 113's medical record showed a physician's order dated [DATE], to discharge the resident home. c. 12 bags of 0.9 sodium chloride intravenous infusion (an isotonic solution) used for Resident 40's cefazolin (antibiotic) medication. Review of Resident 40's medical record showed a physician's order dated [DATE], for cefazolin two gram IV every 8 hours for the left leg cellulitis until [DATE]. d. One narcotic emergency kit was observed with a black zip tie. RN 4 stated the black zip tie meant the emergency kit was opened. When asked when the emergency kit was opened, RN 4 could not find the Emergency Drug Kit Slip. RN 4 stated the pharmacy should have been notified right away when the emergency kit was opened. RN 4 verified the above findings. 8. On [DATE] at 1410 hours, an inspection of Medication Cart E, interview, and concurrent medical record review was conducted with LVN 14. The following was observed: a. A bottle of carbamide peroxide (used to treat earwax buildup) eardrops for Resident 366. Review of Resident 366's medical record showed a physician's order dated [DATE], to transfer Resident 366 to the acute care hospital. b. A bubble pack of pantoprazole ( medication to decrease stomach acid) for Resident 363 was observed with a tear on one of the individual bubbles where a pantoprazole medication was individually stored. c. An opened vial of Humulin regular insulin with no open date. d. An unopened vial of Humulin regular insulin stored in the medication cart, and not refrigerated. LVN 14 verified the above findings. 9. On [DATE] at 1544 hours, an inspection of Medication Cart F, interview, and concurred medical record review was conducted with LVN 1. The following was observed: a. A bottle of nitroglycerin (vasodilator medication, used to treat episode of chest pain) for Resident 47. Review of Resident 47 's medical record showed a physician's order dated [DATE], to discharge Resident 47 home on [DATE]. b. A bubble pack of losartan (antihypertensive medication, used to treat high blood pressure ) for Resident 76 was observed with a tear on one of the individual bubbles where a losartan medication was individually stored. c. A bubble pack of metoprolol (antihypertensive medication) for Resident 83 was observed with a tear on two of the individual bubbles where metoprolol medications were individually stored. d. A bubble pack of midodrine (used to treat low blood pressure) for Resident 38. Review of the medical record for Resident 38 showed a physician's order dated [DATE], to discharge Resident 38 on [DATE]. LVN 1 verified the above findings.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * Open food containers had ...

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Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * Open food containers had no open dates. * Expired food was not discarded. These failures had the potential to cause food borne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Condition of Residents dated 5/9/22, showed 72 of 177 residents received food from the kitchen. Review of the facility's P&P titled Labeling and Dating of Food dated 2020 showed newly opened food items will need to be closed and labeled with an open date and used by date. On 5/9/22 at 0829 hours,during the initial kitchen tour with the Dietary Manager, the following was observed inside the walk in refrigerator: - an open container of mayonnaise with no open date, - an open container of dill pickles with no open date, - an open container of low fat cottage cheese with no open date, and - one head of lettuce which appeared dry, with brownish discolorations with a use by date of 5/2/22. The Dietary Manager verified the findings.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one of 25 final sampled residents (Resident 6). * Resident 6's medical record had two different physician orders to address his end of life choice. Resident 6 had physician's orders to administer Full code/full treatment and DNR. This failure posed the risk for the resident receiving emergency measures against his wishes. Findings: According to the facility's P&P titled Charting and Documentation revised on [DATE] showed documentation in the medical record would be objective, complete, and accurate. According to the facility's P&P titled Physician Order for Life Sustaining treatment (POLST) revised on [DATE], showed the POLST is an approach to end of life planning based on the conversations between the patients and their healthcare providers. The POLST form is a physician order and emergency medical personnel are required to adhere to its instruction regarding CPR and other emergency medical care. Review of Resident 6's medical record was initiated on [DATE]. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Order Summary Report for the active orders as of [DATE], showed an order dated [DATE], for Resident 6 to be on a Full code/full treatment. Another order dated [DATE] showed DNR. Review of the Physician's Orders for Life Sustaining Treatment (POLST) signed by Resident 6 dated [DATE], showed Resident 6 chose the Do Not Resuscitate option in the event when he became pulseless and not breathing and desired comfort-focused treatment only with the primary goal of maximizing comfort. During a concurrent interview and medical record review with LVN 6 on [DATE] at 1135 hours, LVN 6 was asked how the staff would respond to a resident found not breathing and non-responsive. LVN 6 stated they would check the resident's medical record. LVN 6 verified Resident 6's POLST dated [DATE], showed Resident 6 did not want CPR. LVN 6 verified Resident 6's active physician's order showed both DNR and full code. LVN 6 acknowledged the entries in Resident 6's physician orders were conflicting and added and may cause confusion. During a concurrent interview and medical record review with RN 3 on [DATE] at 1145 hours, RN 3 verified the physician orders for emergency treatment for Resident 6 were conflicting. RN 3 stated in case of emergency, she would review Resident 6's medical record to see what his preference was.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and facility document review, the facility failed to establish and maintain the infection control practices designed to provide a safe and sanitary environment and hel...

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Based on observation, interview, and facility document review, the facility failed to establish and maintain the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * CNA 8 failed to remove her gown and gloves and perform hand hygiene before exiting Resident 31's room which was an isolation room due to exposure to COVID 19. This failure had the potential for the spread of infectious diseases in the facility. Findings: Review of the CDC document titled Use of Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, and How to Safely Remove PPE (undated), showed safe work practices should be used to protect yourself and limit the spread of contamination. Gowns and masks worn in isolation rooms should be removed before exiting a patient room and hand hygiene should be performed immediately after removing all PPE. On 5/10/22 at 0953 hours, CNA 8 wearing an N95 mask, face shield, gown and gloves was observed standing at the doorway of Room A, an isolation room. Then, CNA 8 was observed leaving the room and walking across the hallway carrying dirty linen. CNA 8 placed the linen in the dirty linen bin on the other side of the hallway. On 5/10/22 at 1000 hours, CNA 8 was again observed exiting Room A wearing an N95 mask, face shield, gown and gloves, carrying dirty linen. CNA 8 was observed walking across the hallway carrying the linen and placed them in the dirty linen bin. CNA 8 was observed re-entering Room A. On 5/10/22 at 1005 hours, CNA 8 stated the PPE was required while caring for the residents in Room A because the room was on isolation and to prevent cross contamination of infection. CNA 8 stated she was aware that she was supposed to remove the PPE before exiting the room and perform hand hygiene. CNA 8 stated she walked across the hallway to place the dirty linens in the laundry bin because there was no laundry bin in the room. On 5/11/22 at 1649 hours, an interview was conducted with the IP. The IP stated the residents in Room A required Transmission Based Precautions isolation due to exposure to COVID-19. The IP verified CNA 8 should have removed the gown and gloves and performed hand hygiene immediately to prevent cross contamination to other residents and staff in the facility.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to maintain essential equipment in safe opera...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to maintain essential equipment in safe operating condition. The facility failed to ensure four glucometers (a device which measures the amount of sugar in the blood) currently used and stored in the medication carts were properly calibrated. The facility failed to ensure the glucometer monitoring log was completed and the quality control record matched the serial numbers of the glucometer and the lot numbers of the control solutions. This posed the risk for inaccurate blood glucose test results and inappropriate treatments, which posed the risk of inaccurate blood glucose readings used to determine the residents' insulin doses. Findings: Review of the users guide for EvenCare G2 Blood Glucose Monitoring System 2017, under Control Solution Testing, showed the purpose of the control solution testing is to make sure the EvenCare G2 meter and the EvenCare G2 test strips are working properly. Check the expiration date printed on the test strip bottle. Do not use expired test strips. Record the date opened on the bottle label. Discard the bottle and any remaining test strip after 6 months from date of opening. 1. On [DATE] at 1025 hours, an inspection of Medication Cart B, interview, and concurrent facility document review was conducted with LVN 12. Inspection of the medication cart showed the serial number of the glucometer currently in use was EG677107. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for [DATE] showed the serial number of the glucometer was EG677275 and did not match the serial number of the glucometer currently in use. Further review of the quality control record showed the daily quality control was not performed on 5/1, 5/4, and [DATE]. LVN 12 verified the findings. 2. On [DATE] at 1054 hours, an inspection of Medication Cart C, interview, and concurrent facility document review was conducted with LVN 13. The serial number of the glucometer currently in use was EG677265. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for [DATE] showed the serial number of the glucometer for Medication Cart C did not match the serial number of the glucometer currently in use. LVN 13 verified the findings. 3. On [DATE] at 1123 hours, an inspection of Medication Cart D, interview, and concurrent medical record review was conducted with LVN 2. Inspection of the medication cart showed the following: - a bottle of glucose test strips with lot number 16821092013 with an open date of [DATE]; - a bottle of glucose test strips with lot number 16821102004 with no open date; and - a bottle of glucose test strips with lot number 1621092002 with no open date. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for [DATE] showed the glucose test strip with the lot number 16821102004 was used for daily quality control, which was one of the opened bottles of glucose test strip with no open date. Further review of the quality control record showed the daily quality control was not performed on [DATE]. LVN 2 verified the findings. 4. On [DATE] at 1410 hours, an inspection of Medication Cart E, interview, and concurrent medical record review was conducted with LVN 14. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for [DATE] showed the record did not match the lot numbers of the control solutions. Further review of the quality control record showed the daily quality control was not performed on [DATE]. LVN 14 verified the above findings.

Feb 2020 21 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 2/18/2020 at 1505 hours, an interview was conducted with Resident 2. Resident 2's family member was at the bedside. Reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 2/18/2020 at 1505 hours, an interview was conducted with Resident 2. Resident 2's family member was at the bedside. Resident 2 stated it took the staff almost two hours to respond to their call light two weeks ago. Resident 2 stated he sat in a soiled diaper for almost two hours. Resident 2 stated the situation upset him. Resident 2 stated the facility was understaffed on the weekends. Medical record review for Resident 2 showed the resident was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the MDS dated [DATE], showed Resident 2 was cognitively intact. The MDS showed Resident 2 was always incontinent of bowel and required extensive assistance with personal hygiene. On 2/20/2020 at 1145 hours, an interview was conducted with LVN 12. When asked about a shortage of staff a couple of weeks ago, LVN 12 verified staffing was short two weeks ago. LVN 12 verified residents waited longer for care when the facility was short of staff. Cross reference to F725. 4. On 2/25/2020, an interview was conducted with Resident 522. Resident 522 stated almost every evening, it took about one and a half hours for staff to respond to her call light and address her pain. Resident 522 stated she took pain medication about three to four times a day. Medical record review for Resident 522 showed the resident was admitted to the facility on [DATE], with diagnoses including osteoarthritis and back pain. Review of Resident 522's MDS dated [DATE], showed the resident was cognitively intact. 5. On 2/25/2020 at 1412 hours, an interview was conducted with Resident 526. Resident 526 stated it frequently took at least 30 minutes for staff to respond to her call light and assist with tilting. Resident 526 stated, in the past, she had incontinence episodes in her bed after waiting so long for assistance. Resident 526 stated she was afraid of being incontinent in bed. The resident stated, since being readmitted , she pushed the call light button about 30 minutes before she really had to go to the restroom so she did not have any accidents. Medical record review for Resident 526 showed the resident was readmitted to the facility on [DATE]. Review of Resident 526's LTC (long term care) Skilled admission History & Physical dated 2/20/2020, showed the resident had the capacity to understand and make decisions. Based on observation, interview, and medical record review, the facility failed to ensure two of 25 final sampled residents (Residents 2 and 21) and five nonsampled residents (Residents 13, 38, 64, 522, and 526) were provided care in a manner that promoted dignity and respect. * The facility failed to ensure the staff responded to the call lights for Residents 2, 21, 13, 38, 64, 522, and 526 in a timely manner to meet the residents' care needs. These failures posed the potential of not maintaining or enhancing the residents' self-esteem and self-worth. Findings: 1. Review of the Resident Council Meeting Minutes showed reports including the following; - On 9/26/19, there was a long response time from the facility staff. - On 10/31/19, call light response time was worst on the weekends and at night time. - On 11/27/19, call light response was a little better. - On 12/26/19, call light response was a little better. - On 1/31/2020, call light response was the same and there was no improvement. a. On 2/19/2020 at 1328 hours, during the resident group interview, Resident 64 stated he waited for over two hours for a staff member to answer his call light. Medical record review for Resident 64 was initiated on 2/25/2020. Resident 64 was admitted to the facility on [DATE]. Review of Resident 64's MDS dated [DATE], showed the resident was cognitively intact, and the resident required extensive assistance for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. On 2/25/2020 at 1148 hours, a follow-up interview was conducted with Resident 64. Resident 64 was asked to describe the assistance he required from the facility staff. Resident 64 stated he needed assistance regularly with repositioning in bed; however, there were times he had to wait for a while for staff to respond to his call light. Resident 64 stated he kept track of the time using his virtual assistant device or his mobile phone. Resident 64 explained waiting for staff was frustrating and he was scared because he could potentially develop a pressure ulcer. On 2/25/2020 1334 hours, an interview was conducted with CNA 5. CNA 5 acknowledged she was familiar with the care required by Resident 64. When asked what care she provided to Resident 64, CNA 5 stated Resident 64 was dependent on staff for repositioning and transfers. When asked how she knew if Resident 64 needed assistance, CNA 5 stated Resident 64 used his call light when he needed assistance from staff. CNA 5 stated Resident 64 informed her his call light was not being answered in a timely manner. b. On 2/19/2020 at 1328 hours, during the resident group interview, Resident 13 stated he waited approximately 40 minutes for staff to answer his call light. Medical record review for Resident 13 was initiated on 2/25/2020. Resident 13 was readmitted to the facility on [DATE]. Review of Resident 13's MDS dated [DATE], showed the resident was cognitively intact, and the resident required extensive assistance for bed mobility, transfers, dressing, and toilet use. On 2/25/2020 at 0835 hours, a concurrent observation and follow-up interview was conducted with Resident 13. Resident 13 was asked to describe the assistance he required from staff. Resident 13 stated he needed assistance regularly with repositioning and he needed assistance for transferring in and out of the bed. Resident 13 explained he needed to be repositioned routinely to prevent his wound from getting worse. Resident 13 stated he had to wait approximately 40 minutes, especially on the weekends in the evening and night time. Resident 13 stated waiting for assistance from the made him frustrated. On 2/25/2020 at 1348 hours, an interview was conducted with CNA 6. When asked how much assistance Resident 13 required, CNA 6 stated Resident 13 needed assistance with ADLs, including repositioning in bed. CNA 6 explained Resident 13 could not move his lower extremities. c. On 2/19/2020 at 1328 hours, during the resident group interview, Resident 38 stated he waited approximately one hour for staff to answer his call light. Medical record review for Resident 38 was initiated on 2/25/2020. Resident 38 was readmitted to the facility on [DATE]. Review of Resident 38's MDS dated [DATE], showed the resident was cognitively intact, and required extensive assistance for bed mobility, transfers, dressing, and toilet use. On 2/25/2020 at 0844 hours, a concurrent observation and interview was conducted with Resident 38. Resident 38 was asked how he called the facility staff for assistance. Resident 38 stated he used his call light to call the facility staff for assistance. Resident 38 was asked to describe the assistance he needed from the staff. Resident 38 stated he needed his incontinence brief changed when his brief felt wet. Resident 38 stated sitting in a wet incontinence brief was frustrating and felt uncomfortable. On 2/25/2020 at 1348 hours, an interview was conducted with CNA 6. When asked what type of assistance Resident 38 required, CNA 6 stated Resident 38 needed assistance with ADLs, including toileting. CNA 6 stated the resident was incontinent of bowel and urine, and needed assistance to change his incontinence brief when the brief was soiled with urine or stool. 2. On 2/25/2020 at 1423 hours, during the initial tour of the facility, a concurrent observation and interview was conducted with Family Member 5 and Resident 21. Resident 21 was observed lying in bed with her eyes closed. Family Member 5 stated facility staff did not respond to Resident 21's call light in a timely manner. Family Member 5 stated a CNA stopped by and asked what Resident 21 needed; however, the CNA did not help Resident 21 because the CNA was not assigned to take care of Resident 21. Medical record review for Resident 21 was initiated on 2/18/2020. Resident 21 was readmitted to the facility on [DATE]. Review of Resident 21's MDS dated [DATE], showed the resident's cognition was mildly impaired, and the resident required extensive assistance with ADL care, including toileting and personal hygiene. On 2/19/2020 at 1542 hours, a concurrent observation and interview was conducted with Resident 21. When asked about the care she needed from the staff, Resident 21 stated the staff did not answer her call light in a timely manner. Resident 21 stated she needed assistance to change her incontinence brief. When asked how long she had to wait for the staff to respond to her call light, Resident 21 stated she had to wait for approximately 20 minutes. Resident 21 stated it was uncomfortable sitting in her wet incontinence brief. When asked how she kept track of the time, Resident 21 stated she looked at the clock on the wall. A clock was observed hanging on the wall across from her bed. On 2/20/2020 at 0952 hours, an interview was conducted with CNA 4. When asked what type of assistance Resident 21 required, CNA 4 stated Resident 21 needed assistance with ADLs. CNA 4 stated Resident 21 was able to tell if her incontinence brief was soiled with urine and stool. When asked how she knew if Resident 21 needed assistance, CNA 4 stated Resident 21 used the call light when she needed assistance from the staff.

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to verify the informed consent was obtained by the physician f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to verify the informed consent was obtained by the physician for the use of a psychotropic (used to control behavior) medication for one of 25 final sampled residents (Resident 68). This deficient practice had the potential to not allow the resident's responsible party the right to make an informed decision concerning the risks and benefits prior to receiving the psychotropic medication. Findings: Review of the facility's P&P titled Informed Consent Psychotherapeutic Medications and Restraint Devices updated 12/14/17, showed the healthcare practitioner ordering psychotherapeutic medication (physician ordering psychotropic or any mediation which is identified or used as a chemical restraint) or prolonged use of devices is responsible for: a. Obtaining the informed consent, providing risks and benefits and other related information from the resident and/or resident's representative for use of such medication/devices; b. Providing documentation for which informed consent is obtained, including the diagnosis and clinical indications for the mediation or physical restraint. On 2/20/2020, medical record review was initiated for Resident 68. Resident 68 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 68 had severe cognitive impairment. Review of the Order Summary Report showed an order dated 1/25/2020, for lorazepam 0.5 mg one tablet by mouth every six hours as needed for anxiety for 14 days manifested by constant yelling out. Review of the Facility Verification of Informed Consent dated 1/25/2020, showed the name of the staff member who received the order and the date it was received. However, the form did not contain the physician's signature or the responsible party's signature. Review of Resident 68's Medication Administration Record dated January 2020 showed lorazepam 0.5 mg was administered to the resident on 1/25, 1/26, 1/28, and 1/30/2020. On 2/20/2020 at 1520 hours, an interview was conducted with RN 3. RN 3 verified the informed consent, written or verbal, was not obtained from Resident 68's responsible party.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/18/2020 at 1409 hours, during the initial tour of the facility, Resident 55 was observed in bed with a tracheostomy tube...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/18/2020 at 1409 hours, during the initial tour of the facility, Resident 55 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator. Medical record review for Resident 55 was initiated on 2/18/2020. Resident 55 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 2/7/2020, for Resident 55's ventilator settings: AC (assist control) mode, respiratory rate of 12, tidal volume 500, and PEEP (positive end-expiratory pressure) of 5. Review of Resident 55's plan of care failed to show a care plan problem was developed to address Resident 55's ventilator dependence. On 2/20/2020 at 0958 hours, an interview and concurrent medical record review was conducted with MDS Coordinator 1. MDS Coordinator 1 verified there was no care plan problem developed to address Resident 55's ventilator dependence. Based on observation, interview, and medical record review, the facility failed to develop a plan of care to reflect the individual care needs for two of 25 final sampled residents (Residents 55 and 84). * The facility failed to ensure a care plan problem was developed to address Resident 84's use of a rectal tube. * The facility failed to ensure a care plan problem was developed to address Resident 55's mechanical ventilator dependence. These failures posed the risk of not providing appropriate, consistent, and individualized care to Residents 55 and 84. Findings: 1. On 2/18/2020 at 0817 hours, during an initial tour, an observation was conducted of Resident 84. A soft, clear tube draining a yellow-greenish colored liquid into a bag was observed on Resident 84's bed. Medical record review for Resident 84 was initiated on 1/18/2020. Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's Order Summary Report dated 2/19/2020, showed physician's orders dated 1/14/2020, for the use of a Flexiseal rectal tube (soft catheter inserted in the rectum and retained in the rectum with a balloon) for fecal management. Review of Resident 84's plan of care failed to show a care plan problem was developed to address the use of a rectal tube. On 11/7/19 at 1418 hours, an interview and concurrent medical record review was conducted with RN 4. RN 4 reviewed Resident 84's plan of care and verified there was no care plan problem developed to address Resident 84's rectal tube. Cross reference to F684.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. According to the CDC, orthostatic hypotension occurs when there is a drop in the upper reading of a blood pressure of at leas...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. According to the CDC, orthostatic hypotension occurs when there is a drop in the upper reading of a blood pressure of at least 20 mmHg (millimeters of mercury) or a drop in the lower reading of a blood pressure of at least 10 mmHg causing lightheadedness, dizziness, and a possible loss of consciousness. Orthostatic blood pressure is taken by having the resident laying down for five minutes, measuring the blood pressure, then taking another blood pressure after having the resident stand for one and three minutes. Medical record review for Resident 570 was initiated on 2/18/2020. Resident 570 was admitted to the facility on [DATE], with diagnoses including orthostatic hypotension. On 2/18/2020 at 1217 hours, an interview was conducted with Family Member 4. Family Member 4 stated Resident 570 had blood pressure problems and was worried about the resident. Family member 4 stated, even though the resident was admitted due to orthostatic hypotension, the nurses had not been taking the resident's orthostatic blood pressures. Family Member 4 stated only the PT took her mother's blood pressure but believed they did not do it enough. Review of Resident 570's Order Summary Report dated 2/20/2020, showed a physician's order dated 2/18/2020, to monitor the resident's orthostatic hypotension every shift. Review of Resident 570's care plan showed a care plan problem dated 2/14/2020, to address the potential of alteration in cardiac output related to hypotension and hyperlipidemia (high cholesterol). The interventions included to monitor the resident's vital signs as ordered. Review of Resident 570's Medication Administration Record for February 2020 showed an entry to monitor for orthostatic hypotension. On 2/19 and 2/20/2020, single blood pressure readings were recorded. Review of Resident 570's Weights and Vitals Summary dated 2/20/2020, failed to show orthostatic blood pressures were taken from 2/13 - 2/20/2020. On 2/20/2020 at 1423 hours, an interview was conducted with LVN 15. LVN 15 explained an orthostatic blood pressure is taken by starting the resident in a laying position, having them sit up, waiting five minutes, then taking the resident's blood pressure. LVN 15 stated the sitting blood pressure reading will be recorded as the orthostatic blood pressure. Review of Resident 570's Physical Therapy PT Evaluation & Plan of Treatment dated 2/13/2020, showed the following orthostatic blood pressure was taken: - a lying blood pressure of 151/78; - a sitting blood pressure of 119/68, with dizziness; - a standing blood pressure of 112/68, with increased dizziness. A blood pressure drop of 32 mmHg systolic (upper reading of a blood pressure) and 10 mmHg diastolic (lower reading of a blood pressure) was noted from lying to sitting. Under section Fall Risk Assessment, an entry showed Resident 570 was worried about falling. Review of Resident 570's Physical Therapy Treatment Encounter Note(s) for February 2020 showed an entry dated 2/14/2020, with the following orthostatic blood pressure recorded: - a lying blood pressure of 129/66; - a sitting blood pressure of 99/54. A note showed Resident 570 complained of dizziness which increased when transitioning into seated and into standing. A standing blood pressure was not able to be obtained. A blood pressure drop of 30 systolic and 12 diastolic was noted from lying to sitting. An entry dated 2/17/2020, showed the following orthostatic blood pressure was recorded: - a lying blood pressure of 161/82; - a sitting blood pressure of 133/76; - a standing blood pressure of 100/60. A blood pressure drop of 28 systolic was noted from lying to sitting. A blood pressure drop of 33 systolic was noted from sitting to standing. On 2/20/2020 at 1528 hours, an interview and concurrent medical record review was conducted with the Director of Rehabilitation. The Director of Rehabilitation verified the above. The Director of Rehabilitation stated the PT sometimes took orthostatic blood pressures of residents if they had a physician's order or if a resident started feeling dizzy during their session. The Director of Rehabilitation stated the PT and the nurses worked as a team in making sure orthostatic blood pressures were taken on a resident if ordered. The Director of Rehabilitation confirmed only three orthostatic blood pressures were taken by the PT during Resident 570's stay. On 2/20/2020 at 1539 hours, an interview and concurrent medical record review was conducted with LVN 14. LVN 14 stated Resident 570 did not have any orders to take orthostatic blood pressures. LVN 14 explained an orthostatic blood pressure was taken by taking the resident's blood pressure while they were laying down and looking at the number to see if they had orthostatic hypotension. LVN 14 was asked if there was anything else she would do, to which she stated no. On 2/20/2020 at 1557 hours, an interview was conducted with RN 3. RN 3 reviewed Resident 570's Weights and Vitals Summary forms dated February 2020 and verified no orthostatic blood pressures were taken during the resident's stay. RN 3 reviewed Resident 570's Medication Administration Record for February 2020 and verified under the area to monitor for orthostatic hypotension, a single blood pressure reading was recorded. 2. Medical record review for Resident 101 was initiated on 2/18/2020. Resident 101 was readmitted to the facility on [DATE]. Review of Resident 101's Order Summary Report dated 2/19/2020, showed an order dated 1/28/2020, to administer clonidine 0.1 mg by mouth every eight hours as needed for a systolic blood pressure greater than 160, and monitor the blood pressure every eight hours for the clonidine order. Review of Resident 101's Medication Administration Record for February 2020 showed the resident's systolic blood pressure was above 160 on the following dates: * On 2/8/2020 at 2200 hours, with a blood pressure of 168/81, * On 2/13/2020 at 2200 hours, with a blood pressure of 166/72, and * On 2/17/2020 at 0000 hours, with a blood pressure of 178/82. Review of Resident 101's Weights and Vitals Summary forms for January and February 2020 showed on 2/9/2020 at 0304 hours, the resident's blood pressure was 168/81. On 2/20/2020 at 1421 hours, and interview and concurrent medical record review was conducted with LVN 8. LVN 8 reviewed Resident 101's Medication Administration Record for February 2020 and the resident's Weights and Vitals Summary forms for January and February 2020. LVN 8 verified the resident's systolic blood pressure was above 160 on four occasions and stated the resident's PRN clonidine should have been administered per the physician's order. 4. On 2/18/2020 at 1130 hours, Resident 470 was observed in bed with a dressing on his right foot. Resident 470 stated he was supposed to have a wound vacuum attached to his right foot wound. Medical record review for Resident 470 was initiated on 2/28/2020. Resident 470 was admitted to the facility on [DATE]. Review of Resident 470's Admission/readmission Screener dated 2/6/2020, under skin integrity, failed to show any measurements of the right foot wound. Review of Resident 470's Order Summary Report showed a physician's order dated 2/10/2020, to change the wound vacuum dressing every Tuesday, Thursday, and Saturday and as needed for the right foot wound. Review of Resident 470's Skin Observation Tool dated 2/14/2020, showed Resident 470's right foot wound measured 16 cm (length) x 6 cm (width) x 0.6 cm (depth) with 80% granulation (healthy tissue) and 20% eschar (dead tissue). Review of Resident 470's Skin Observation Tools dated 2/7, 2/10, 2/19, and 2/24/2020, failed to show any wound measurements for Resident 470's right foot wound. In addition, the Skin Observation Tools dated 2/19 and 2/24/2020, showed Resident 470 had a left foot wound. Review of Resident 470's plan of care showed a care plan problem dated 2/20/2020, to address impaired skin integrity related to the right foot wound. The interventions/tasks included to perform weekly wound measurements and assessments. On 2/25/2020 at 1115 hours, an interview and concurrent medical record review for Resident 470 was conducted with LVN 6. LVN 6 stated the residents with skin conditions were assessed weekly. LVN 6 stated the weekly wound assessments were documented on the Skin Observation Tool. LVN 6 acknowledged she performed weekly assessments for Resident 470's right foot wound but did not include the wound measurements. 5. Review of Resident 90's medical record was initiated on 2/18/2020. Resident 90 was admitted to the facility on [DATE]. Review of Resident 90's physician's order form dated 2/3/2020, showed an order for a CBC (complete blood count) and BMP (basic metabolic panel) on 2/4/2020. Review of Resident 90's Progress Notes showed the following; - On 2/3/2020, a recommendation from the RD to check the resident's CBC and CMP (complete metabolic panel same as a BMP) levels, - On 2/10/2020, an entry by the RD showed there were no new laboratory results for the resident. On 2/21/2020, a concurrent interview and medical record review was conducted with RN 4. RN 4 verified the CBC and BMP laboratory tests for Resident 90 were not performed as ordered by the physician. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure five of 25 final sampled residents (Residents 84, 90, 101, 470, and 570) attained and/or maintained their highest practicable physical well-being. * The facility failed to ensure Resident 84, who had a rectal tube (soft catheter inserted in the rectum and retained in the rectum with a balloon), was appropriately monitored according to the manufacturer's specifications and failed to change the rectal tube as ordered by the physician. These failures posed a risk of injury to the resident related to the adverse effects with the use of a rectal tube. * The facility failed to follow a physician's order to order laboratory tests for Resident 90. This posed the risk of Resident 90 having abnormal laboratory results without appropriate treatment. * The facility failed to administer Resident 101's PRN (as needed) blood pressure medication as ordered by the physician. * The facility failed to ensure weekly wound measurements were completed for Resident 470's right foot wound. In addition, the facility failed to ensure the correct wound site was documented on the wound assessment record. These failures posed a potential risk for Resident 470's open wound to deteriorate without being noticed. * The facility failed to follow a physician's order to monitor Resident 570's orthostatic blood pressure (a blood pressure measurement when a person goes from a lying or sitting position to sitting or standing). This placed Resident 570 at an increased risk for falls due to a possible undetected rapid decrease in blood pressure. Findings: 1. Review of the Flexiseal (brand name of a rectal tube) package insert (document included in the package of the rectal tube that provides information about the tube and its use), showed warnings of using the rectal tube including the resident should be monitored daily for rectal pain, rectal bleeding, and abdominal symptoms such as distention and pain. On 2/18/2020 at 1618 hours, during the initial tour of the facility, Resident 84 was observed with a soft, clear tube on the resident's bed. There was a greenish-yellowish liquid substance draining in a collecting bag. Family Member 3 was at the bedside. Family Member 3 was asked about the tube on Resident 84's bed. Family Member 3 stated the tube was used to collect Resident 84's stool. Family Member 3 was asked how long Resident 84 had been using the tube. Family Member 3 stated Resident 84 had been using the tube for approximately one month. Medical record review for Resident 84 was initiated on 2/18/2020. Resident 84 was readmitted to the facility on [DATE]. Review of Resident 84's Order Summary Report dated 2/29/2020, showed the following orders for the Flexiseal rectal tube, for fecal management; - May reinsert the current (same) Flexiseal tube if it becomes dislodged within the 29-day period, - Change Flexiseal tube every 29 days, every day and night shift every 29 days, next change 2/6/2020, - Monitor every shift; however, the order did not show the signs and symptoms to be monitored by the facility staff. Review of Resident 84's Medication Administration Record dated 2/1 to 2/29/2020, showed the orders as described above. The Medication Administration Records dated 2/6/2020, on the 0700-1900 and 1900-0700 shifts were signed off by two licensed nurses. On the days 2/1 to 2/5/2020, and 2/7 to 2/29/2020, the Medication Administration Record was marked with an x. On 2/19/2020 at 1422 hours, a concurrent observation and interview was conducted with LVN 16. LVN 16 was asked to describe the care provided to Resident 84 with a rectal tube. LVN 16 stated she emptied the contents of the bag, recorded the amount of the contents in the bag on the Medication Administration Record, and changed the collection bag of the rectal tube every shift. LVN 16 explained she ensured the rectal tube was intact, checked if there were any kinks in the tube, and checked the consistency and color of the stool. LVN 16 was asked when the last time the rectal tube was changed. LVN 16 stated she did not know when the rectal tube was changed. LVN 16 stated she had to check with a supervisor when Resident 84's rectal tube was changed. LVN 16 verified there was no label on the rectal tube with a date to show when it was changed. On 2/19/2020 at 1440 hours, a concurrent interview and medical record review was conducted with RN 4. Resident 84's Medication Administration Record showed the order was signed by two licensed nurses on 2/6/2020, for the 0700-1900 and 1900 - 0700 shifts. RN 4 was asked if the rectal tube was changed on 2/6/2020. RN 4 stated she could not verify if Resident 84's rectal tube was changed on 2/6/2020. RN 4 acknowledged the order for the rectal tube was written incorrectly on the Medication Administration Record. On 2/21/2020 at 1555 hours, a concurrent interview, manufacturer's product package insert review, and medical record review was conducted with the DON. The DON verified Resident 84 was not monitored based on the manufacturer's specifications. On 2/25/2020 at 1324 hours, a concurrent interview and medical record review was conducted with LVN 18. LVN 18 acknowledged she did not change Resident 84's rectal tube on 2/6/2020, on the 0700 - 1900 shift. LVN 18 stated she did not see the physician's order to change the rectal tube on 2/6/2020. On 2/26/2020 at 1239 hours, a telephone interview was conducted with the DON. According to the DON, the LVN assigned to Resident 84 on 2/6/2020, on the 1900 - 0700 shift did not change Resident 84's rectal tube.

CONCERN (D)

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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide proper toenail care to one of 25 fina...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide proper toenail care to one of 25 final sampled residents (Resident 53). Resident 53's toenails were long and curled over her toes. This failure had the potential for injury and to place the resident at an increased risk of infection. Findings: According to the American Diabetes Association, toenails need care on a regular basis because long or thick nails can press on neighboring toes and cause open sores. Medical record review for Resident 53 was initiated on 2/18/2020. Resident 53 was admitted to the facility on [DATE], and was re-admitted to the facility on [DATE], with diagnoses including diabetes mellitus (a disease that causes high blood sugar which results in an increased risk for poor wound healing and infection). Review of Resident 53's MDS showed she was cognitively intact. On 2/18/2020 at 1506 hours, Resident 53 was observed lying in bed with both feet exposed. Resident 53's outermost pinky toenail and ring toenail on the right foot were observed to be curled over, and the remaining toenails on both feet appeared long. On 2/19/2020 at 1325 hours, an interview and concurrent medical record review were conducted with the SSD. The SSD stated the podiatrist came to see long-term care residents of the facility every three months, unless a resident requested him sooner. The SSD stated Resident 53 requested the podiatrist on 1/23/2020, because her toenails were too long and painful. The SSD stated she sent the request to the podiatrist' s office on 1/24/2020. The SSD stated the podiatrist came to visit Resident 53 that weekend but the resident had been sent out to the hospital. The SSD was asked if the podiatrist came back when the resident returned. The SSD stated the podiatrist was not recommended again. The SSD verified the next time she was seen by the podiatrist was on his routine visit to the facility on 2/17/2020. Review of Resident 53's Podiatry Worksheet dated 2/17/2020, showed Resident 53 was seen by the podiatrist on 2/17/2020, via request. Review of Resident 53's Podiatric Evaluation and Treatment sheet dated 2/17/2020, showed the resident's ten toenails were yellow, brittle, thickened, and with pain. Assessment included onychomycosis (nail fungus) and pain. The plan included examination and chart review and debridement (the removal of a diseased toenail bed or viable nail plate generally provided to residents presenting with onychomycosis) of all ten toenails. Procedure performed included debridement of all ten toenails. On 2/19/2020 at 1318 hours, an interview was conducted with Resident 53. Resident 53 stated the podiatrist had not come to see her recently. Resident 53 stated she wished the podiatrist had seen her because her toenails were very long. Resident 53 stated she wished she could cut her toenails herself but she was not allowed to. Resident 53 stated the last time she had her toenails cut was before she became a long-term resident of the facility. On 2/19/2020, a follow-up interview was conducted with the SSD. The SSD stated Resident 53 became a long-term resident on 12/31/2019. On 2/19/2020 at 1354 hours, an interview and observation of Resident 53's feet was conducted with RN 2. RN 2 stated the resident's ten toenails were really long and verified the resident's right pinky toenail and ring toenail were curling over. RN 2 stated the toenails really needed to be looked at and cut. On 2/26/2020 at 1400 hours, a telephone interview was conducted with the Podiatrist. The Podiatrist stated on the Podiatric Evaluation Treatment form, debridement of nails includes nail cleaning, removal of small in grown or scar tissue and trimming of nails. The Podiatrist stated when he fills out the form, he checks off debridement since that includes everything and does not check off trimming of nails. When the Podiatrist was asked if he remembered providing care to Resident 53, he stated he could not remember Resident 53. The Podiatrist explained the reason podiatrists do nail care on the diabetic population was due to loss of sensation to their feet. The Podiatrist stated if a resident with a diagnosis of diabetes had toenails so long they curled in, he would be able to trim them back. On 2/26/2020 at 1635 hours, the SSD provided documentation she witnessed the Podiatrist cutting Resident 53's toenails on 2/26/2020. Review of the Physician's Progress Notes dated 2/26/2020, showed the resident was complaining of painful, elongated, and dystrophic toenails. Elongated dystrophic toenails were observed with subungual debris. Mechanical debridement of toenails was performed by the Podiatrist on toenails one through ten.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent urinary tract infections for one of 25 final sampled residents (Resident 55) and one nonsampled resident (Resident 420) with indwelling urinary catheters. * The staff failed to ensure proper positioning of Resident 55 and 420's urinary drainage bags to prevent urine from flowing back into their bladders. This posed the risk for Residents 55 and 420 to develop catheter-associated urinary tract infections (CA-UTI). Findings: Review of the Centers for Disease Control and Prevention's (CDC) article (undated) titled Catheter-Associated Urinary Tract Infection showed a UTI is an infection in the urinary tract system (including the bladder and the kidneys). Germs can travel along the catheter, and if they enter the urinary tract, may cause an infection in the bladder or kidneys. Prevention of CA-UTIs include keeping the urinary drainage bag lower than the bladder to prevent urine from back-flowing to the bladder. 1. On 2/18/2020 at 1409 hours, during the initial tour of the facility, Resident 55 was observed in bed with an indwelling urinary catheter attached to a urinary drainage bag. The urinary drainage bag was attached to the resident's footboard, which caused the urinary drainage bag and the distal (situated away from the center of the body or from the point of attachment) end of the urinary catheter tubing to be above the level of the resident's bladder. The remainder of the urinary catheter tubing was resting on Resident 55's bed, below the urinary drainage bag. Stagnant cloudy yellow urine was observed in Resident 55's urinary catheter tubing. Medical record review for Resident 55 was initiated on 2/18/2020. Resident 55 was readmitted to the facility on [DATE]. Review of Resident 55's plan of care showed a care plan problem dated 2/8/2020, to address the risk for infection related to the use of the indwelling urinary catheter. The interventions included to position the urinary drainage bag below the level of the bladder. On 2/18/2020 at 1508 hours, and on 2/19/2020 at 0719 hours, Resident 55 was observed lying in bed. Resident 55's urinary drainage bag was attached to the resident's footboard, which caused the urinary drainage bag to be above the level of the resident's bladder. On 2/19/2020 at 0727 hours, an observation of Resident 55 was conducted with LVN 7. LVN 7 verified Resident 55's urinary drainage bag was not positioned below the level of the resident's bladder. LVN 7 verified the urinary drainage bag should be placed below the level of the bladder to prevent urine from flowing back into the bladder to prevent infections. 2. On 2/18/2020 at 1409 hours, during the initial tour of the facility, Resident 420 was observed in bed with an indwelling urinary catheter attached to a urinary drainage bag. The urinary drainage bag was attached to the resident's footboard, which caused the urinary drainage bag to be above the level of the resident's bladder. Amber-colored urine was observed in Resident 420's urinary catheter tubing. Medical record review for Resident 420 was initiated on 2/18/2020. Resident 420 was readmitted to the facility on [DATE]. Review of Resident 420's plan of care showed a care plan problem dated 2/17/2020, to address the risk for infection related to the use of the indwelling urinary catheter. The interventions included to position the urinary drainage bag below the level of the bladder. On 2/19/2020 at 0720 hours, Resident 420 was observed lying in bed. Resident 420's urinary drainage bag was attached to the resident's footboard, which caused the urinary drainage bag to be above the level of the resident's bladder. On 2/19/2020 at 0730 hours, an observation of Resident 420 was conducted with LVN 7. LVN 7 verified Resident 420's urinary drainage bag was not positioned below the level of the resident's bladder. LVN 7 verified the urinary drainage bag should be placed below the level of the bladder to prevent urine from flowing back into the bladder to prevent infections.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review and facility P&P review, the facility failed to adequately a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review and facility P&P review, the facility failed to adequately and timely manage the pain for one of 25 final sampled residents (Resident 520) and one nonsampled resident (Resident 100). * Resident 100 did not receive her scheduled narcotic pain medication as ordered to pre-medicate prior to physical therapy. * Resident 520 did not receive her scheduled pain medication as ordered by the physician. These failures had the potential to negatively impact the residents' comfort and well-being. findings: Review of the facility's P&P titled Preparation and General Guidelines: Medication Administration - General Guidelines updated January 2017 showed medications are administered within 60 minutes of the scheduled administration time. Review of the staff assignment log for Station 2 on 2/14/2020, showed LVNs 9 and 10 were assigned to Residents 100 and 520. 1. Closed medical record review for Resident 100 was initiated on 2/20/2020. Resident 100 was admitted to the facility on [DATE], and discharged on 2/17/2020. Review of Resident 100's Medication Administration Record for February 2020 showed the following: * Administer Percocet (an opioid pain medication) 10-325 mg, two tablets twice a day prior to physical therapy. The scheduled times showed at 1000 and 1400 hours. The record showed a blank (an indication it was not administered) on 2/14/2020, for the 1400 hours dose. * Administer Percocet 10-325 mg, one tablet every four hours as needed for pain. The Medication Administration Record showed on 2/14/2020, doses were administered at 0429 and 1850 hours. Review of Resident 100's Controlled Medication Count Sheets for Percocet 10-325 mg tablets showed two tablets of Percocet were signed out as removed from the supply on 2/14/2020 at 0935 hours for the 1000 hours dose. The next entry showed one tablet was removed on 2/14/2020 at 1547 hours. On 2/21/2020 at 1415 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 100's Controlled Medication Count Sheets for Percocet 10-325 mg tablets and Resident 100's Medication Administration Record for February 2020. The DON verified the records did not show resident 100 received two tablets of Percocet 10-325 mg at 1400 hours. The DON verified one PRN was signed out on 2/14/2020 at 1547 hours, and documented on the administration record as being administered on 2/14/2020 at 1850 hours. Review of Resident 100's Physical Therapy Treatment Encounter Note dated 2/14/2020, showed it was electronically signed by PTA 1 on 2/14/2020 at 1556 hours. On 2/21/2020 at 1449 hours, an interview was conducted with PTA 1. PTA 1 stated Resident 100 received split PT services, meaning her 75 minute session was divided into two smaller treatments, usually at 1000 and 1400 hours. PTA 1 was unable to recall if the resident was premedicated for pain prior to the afternoon treatment on 2/14/2020. When asked their process for when they document their treatment, PTA 1 stated they documented after completing both treatments. PTA 1 verified he signed the treatment note for 2/14/2020, the same day at 1556 hours. PTA 1 stated if pain medication was administered to resident 100 on 2/14/2020 at 1547 hours (nine minutes prior to him signing his treatment notes for the resident), the medication would not have been administered prior to the afternoon treatment being initiated. 2. Medical record review for Resident 520 was initiated on 2/18/2020. Resident 520 was admitted to the facility on [DATE]. On 2/18/2020 at 1139 hours, an interview and observation was conducted with Resident 520. Resident 520 stated they had an appointment on 2/14/2020, and believed she missed some of her medications. Resident 520 stated she was in a lot of pain when she returned to the facility. Review of Resident 520's Medication Administration Record for February 2020 showed the following: *gabapentin (a medication for nerve pain) 300 mg to be administered every eight hours. The record showed the scheduled dose on 2/14/2020 at 1400 hours was blank. Review of Resident 520's medical record showed a physician's order dated 2/13/2020. The order showed the resident had an appointment on 2/14/2020 at 1530 hours, at a medical facility 34 miles away from the facility. A handwritten note on the order showed the resident was scheduled to be picked up for the appointment at 1430 hours. On 2/21/2020 at 1358 hours, an interview was conducted with LVN 9. LVN 9 stated on 2/14/2020, they completed their assignment at 1300 hours, and did not administer any medications at 1400 hours. On 2/21/2020 at 1358 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above Medication Administration Record gaps for Residents 100 and 520 on 2/14/2020 at 1400 hours. On 2/21/2020 at 1407 hours, an interview was conducted with RN 3. RN 3 was asked if she administered any medications after LVN 9 left on 2/14/2020. RN 3 stated she could not recall if she had administered medications. RN 3 stated if she did administer any medications, she would have signed them as administered. On 2/25/2020 at 0912 hours, a telephone interview was conducted with LVN 10. LVN 10 stated on 2/14/2020, she assumed care of her assigned residents when she arrived at 1530 hours. LVN 10 stated she did not administer any medications scheduled at 1400 hours. Cross references to F755, example #1d and F842, example #1.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one nonsampled resident (Resident 30) ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one nonsampled resident (Resident 30) was free from a significant medication error. The doses of Keppra (seizure medication) were not administered to Resident 30 as ordered. This had the potential for Resident 30 to have seizures. Findings: Review of Lexicomp (an online clinical drug information resource) showed, do not stop taking Keppra all of a sudden without calling your doctor. You may have a greater risk of seizures. If you need to stop taking this drug, you will want to slowly stop it as ordered by your doctor. On 2/25/2020 at 1047 hours, an interview was conducted with Family Member 1. Family Member 1 stated Resident 30 had not been receiving the full doses of his seizure medication, Keppra. Family Member 1 stated she occasionally took Resident 30 home and was supplied with his medication bubble packs (a card where medications are placed in individual, clear, sealed compartments). Family Member 1 stated she noticed the Keppra tablets were not removed from the bubble pack on several days. Family Member 1 stated Resident 30 had two bubble packs for Keppra, one for the morning dose and one for the evening dose. Family Member 1 stated when she took Resident 30 home on Sunday, 2/23/2020, she noticed the evening doses of Keppra were omitted on 2/14, 2/16, and 2/20/2020. Medical record review for Resident 30 was initiated on 2/25/2020. Resident 30 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 7/11/19, to administer Keppra 500 mg by mouth in the morning (0630 hours) for convulsions. Another physician's order dated 7/11/19, showed to administer Keppra 1000 mg by mouth in the evening (1800 hours) for convulsions. On 2/25/2020 at 1100 hours, a concurrent interview, record review, and inspection of Station 2's Medication Cart 2 was conducted with LVN 14. Resident 30 had two bubble packs for Keppra: one bubble pack was labeled AM and one bubble pack was labeled PM. Each bubble pack had 29 sealed compartments containing the Keppra tablets and each compartment was numbered from 1 to 29. The PM bubble pack for Keppra showed the tablets in the compartments labeled 14, 16, and 20 were not removed. LVN 14 verified the findings. LVN 14 stated the nurses were supposed to remove the tablets of Keppra from the numbered compartment that corresponded to the calendar day (i.e. if the day was the 25th of the month, then the nurses would remove the tablet from the compartment labeled 25). LVN 14 verified Resident 30 did not have any other bubble packs or medication containers for Keppra. LVN 14 stated if the medication was not removed from the bubble pack, then it was not administered to the resident. Review of Resident 30's plan of care showed a care plan problem dated 12/9/19, to address the potential for seizure activity and injury related to seizure disorder. The interventions included to administer medications as ordered. Review of the Progress Notes dated 2/14 to 2/20/2020, failed to show documentation the physician was notified the Keppra was not administered to Resident 30. A nursing entry dated 2/20/2020 at 1615 hours, showed Resident 30 was out on pass, but returned to the facility around 1400 hours. Review of Resident 30's Release of Responsibility for Leave of Absence (a log showing the date and time the resident was out on pass and the date and time the resident returned to the facility) showed Resident 30 was not out on pass on 2/14 and 2/16/2020. LVN 14 verified the above findings. On 2/25/2020 at 1121 hours, an interview was conducted with the DON. The DON was informed of the above findings and verified the findings. The DON stated Keppra needed to be administered per the physician's orders to prevent seizures. (Cross reference to F867)

CONCERN (D)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure two nonsampled residents (Residents 39...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure two nonsampled residents (Residents 39 and 571) were provided the therapeutic diet ordered by the physician. This had the potential of the residents not having their nutritional needs met. Findings: 1. On 2/18/2020 at 1240 hours, Resident 571 was observed in her room sitting with her breakfast tray in front of her. The resident's tray included lasagna, broccoli, one full slice of bread and one glass of what appeared to be milk and one glass of what appeared to be juice. Review of Resident 571's meal ticket dated 2/18/2020, showed the resident was to receive a regular, CCHO (concentrated carbohydrate) diet for lunch. Review of the Cooks Spreadsheet Winter Menus sheet dated 2/18/2020, showed a regular CCHO diet was to receive half a slice of garlic bread for lunch. Medical record review for Resident 571 was initiated on 2/18/2020. Resident 571 was admitted to the facility on [DATE]. Review of Resident 571's Order Summary Report dated 2/19/2020, showed an order dated 2/17/2020, to administer a regular CCHO diet. On 2/18/2020 at 1252 hours, an interview and concurrent observation of Resident 571's meal tray was conducted with the RD. The RD verified Resident 571 received a full slice of garlic bread on her meal tray. On 2/18/2020 at 1421 hours, a follow-up interview was conducted with the RD. The RD stated Resident 571 should have received a half slice of garlic bread according to the menu. 2. Medical record review for Resident 39 was initiated on 2/20/2020. Resident 39 was admitted to the facility on [DATE]. Review of Resident 39's Order Summary Report dated 2/21/2020, showed an order dated 11/30/2017, to administer a regular CCHO diet. Review of the Cooks Spreadsheet Winter Menus sheet dated 2/20/2020, showed a regular CCHO diet was to receive half a biscuit for lunch. On 2/20/2020 at 1200 hours, an observation of lunch tray line was conducted with Dietary Aide 1 and the RD. Dietary Aide 1 was observed checking the meal tray for Resident 39 and placed it into the lunch tray cart. The RD was asked to pull the lunch tray for Resident 39 from the lunch tray cart. The RD verified Resident 39 received one full biscuit on his lunch tray. The RD stated the lunch tray cart was okay to be served. On 2/20/2020 at 1205 hours, an interview was conducted with the Food Services Manager (FSM). The FSM stated Resident 39 should have received half a biscuit according to the menu instead of one full biscuit. The FSM verified the resident's tray should not have been delivered with one full biscuit.

CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

Based on interview and facility document review, the facility failed to implement their quality assessment and assurance plan of action. There was no documentation to show the facility was monitoring ...

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Based on interview and facility document review, the facility failed to implement their quality assessment and assurance plan of action. There was no documentation to show the facility was monitoring the effects of the action plan to identify if they had achieved and sustained improvement for the repeated deficient practice cited at F760 in accordance with their plan of correction (POC) from the last recertification survey completed on 1/15/19. This had the potential to affect the quality of care for all the residents in the facility. Findings: On 2/25/2020 at 1321 hours, an interview and concurrent facility document review was conducted with the Administrator and the Assistant Administrator. Review of the POC submitted by the facility to the California Department of Public Health, Licensing and Certification Program for F760 cited from the last recertification survey completed on 1/15/19, showed the unit managers or charge nurses were to audit the bubble packs weekly for all patients to ensure the right dose was taken from the right bubble pack and the right bubble (compartment) to ensure the medications were administered as ordered. The audits were to be provided weekly to the DON and/or designee and quarterly to the QAPI Committee for review. The Administrator and Assistant Administrator verified there was no documentation to show the unit managers or charge nurses had audited the bubble packs weekly. Cross reference to F760.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

2. On 2/20/2020 at 0846 hours, three stacks of cardboard boxes labeled as dry washcloths were observed sitting on the floor in Station 3. On 2/20/2020 at 0940 hours, an observation and concurrent int...

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2. On 2/20/2020 at 0846 hours, three stacks of cardboard boxes labeled as dry washcloths were observed sitting on the floor in Station 3. On 2/20/2020 at 0940 hours, an observation and concurrent interview was conducted with Central Supply/Maintenance staff. The Central Supply/Maintenance staff stated they placed the boxed washcloths on Station 3's floor earlier this week with a cardboard barrier to prevent the boxes from coming in contact with the floor. The Central Supply/Maintenance staff stated someone must have removed the cardboard barrier, allowing the supply boxes to come in contact with the floor. The Central Supply/Maintenance staff stated the boxes should be raised off the floor. Based on observation and interview, the facility failed to ensure infection control practices were maintained. This had the potential for cross contamination. * The laundry department failed to maintain a clean environment. * The facility failed to ensure three stacks of boxed washcloths were stored off the ground. Findings: 1. On 2/25/2020 at 0928 hours, an observation and interview was conducted with the Environmental Services Supervisor. A Styrofoam cup, a dusty table top radio, and a dusty plastic plant were observed on the folding table in the clean laundry storage area. The Environmental Services Supervisor verified the finding.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility P&P review, and medical record review, the facility failed to ensure two of 25 final s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility P&P review, and medical record review, the facility failed to ensure two of 25 final sampled residents (Residents 53 and 92) remained free from accident hazards. * The facility failed to ensure the inside of the microwave used by residents to heat up food was free of toxic materials. This failure had the potential to cause harmful effects to residents using the microwave through exposure to the toxic material. * The facility failed to promptly conduct an investigation when Resident 53 was involved in an incident resulting in the resident sustaining knee pain. Failure to immediately initiate an investigation of the incident had the potential of not identifying the cause and prevent another incident from occurring. * The facility failed to ensure both of Resident 92's side rails were padded as ordered by the physician. This posed the risk of Resident 92 becoming injured by the side rails. Findings: 1. On 2/21/2020 at 0841 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated a month ago, he instructed an RT to microwave Gorilla Glue (a brand of polyurethane adhesive) in the resident microwave for 15 seconds to soften it up. The Maintenance Supervisor stated the RT microwaved it for longer than instructed and it exploded inside the microwave. The Maintenance Supervisor stated the RT was not able to clean it and informed him of the incident. The Maintenance Supervisor stated he tried to clean the microwave but could not remove all of the glue. He stated the residue on the bottom left inside of the microwave door is Gorilla Glue. The Maintenance Supervisor showed a picture on his phone of the microwave with a black residue on the inside left corner of the door. The Maintenance Supervisor verified the black residue was Gorilla Glue. Review of the Material Safety Data Sheet (MSDS - a document the Occupational Safety and Health Administration [OSHA] requires employers to have available for all hazardous material that staff use while performing their duties) showed Gorilla Glue is a polyurethane consumer adhesive used for building and carpentry. According to OSHA, a product is given a signal word to indicate the relative level of severity of the hazard. The two words used are Danger and Warning. Danger is used for the most severe hazards. Review of the MSDS for Gorilla Glue, showed the signal word is Danger. Hazard Statements include harmful if inhaled, may cause respiratory irritation, may cause allergy or asthma symptoms or breathing difficulties if inhaled. Precautionary statements showed not to breathe vapors, not to eat or drink when using this product, use it only in a well-ventilated area, and to wear protective gloves, clothing and eye protection. Under the section Precautions for Safe Handling, showed not to breathe smoke and gases created by overheating this material. Decomposition products can be highly toxic and irritating. Review of Important Medical Information provided by Gorilla Glue showed not to microwave or heat the product. On 2/21/2020 at 0848 hours, observation of the microwave was conducted in the dining room. The inside of the microwave door was noted with a black residue approximately an inch across on the left bottom corner of the door. On 2/21/2020 at 0854 hours, an interview was conducted with the Activities Supervisor. The Activities Supervisor stated the activities staff was always present during the workday in the dining room because that was where their office was located. The Activities Supervisor's desk was observed in direct view of the microwave in the same room. The Activities Supervisor stated she observed resident's food being heated in the microwave daily. The Activities Supervisor noted Family Member 2 heated up the resident's food daily. The Activities Supervisor stated she heard recently from maintenance that there was glue substance stuck on the inside of the microwave door. On 2/21/2020 at 0912 hours, a follow-up interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated RT 2 had tried to clean the microwave with hot water but could not get the glue off. The Maintenance Supervisor stated the glue was all over the inside of the microwave including the top and the sides. He stated he was able to clean almost all of it off except the door. The Maintenance Supervisor stated since the door is plastic, it was harder to remove the glue from the door. On 2/21/2020 at 1010 hours, an interview was conducted with RT 2. RT 2 stated he microwaved the Gorilla Glue at the direction of the Maintenance Supervisor. RT 2 stated he could not remember what he was trying to fix with the glue at the time. RT 2 stated he was the only one present when the incident happened. RT 2 stated he was not sure if it was the facility's policy to microwave the Gorilla Glue in the resident's microwave. On 2/21/2020 at 1022 hours, an interview was conducted with the RD. The RD stated the microwave in the dining room was used to heat up residents' food. The RD stated the only thing that should be microwaved was food. The RD stated glue should never be heated in the residents' microwave. The RD stated she had not heard about the incident regarding the Gorilla Glue being heated in the residents' microwave and exploding. The RD stated if she had been informed, she would have replaced the microwave and notified the supervisor and DON regarding the incident. On 2/21/2020 at 1030 hours, an interview was conducted with the Dietary Supervisor. The Dietary Supervisor stated only food should be heated in the residents' microwave. The Dietary Supervisor stated any chemicals being heated in the microwave are a big no-no and should not be microwaved. The Dietary Supervisor stated she was not made aware of the incident regarding Gorilla Glue being microwaved. The Dietary Supervisor stated if she heard about the incident she would have immediately removed the microwave. On 2/21/2020 at 1400 hours, an interview was conducted with the Administrator. The Administrator was informed of the incident with the Gorilla Glue and the residents' microwave. The Administrator stated this was not a concern to him and stated the microwave was safe to use. The Administrator was informed the product warns against microwaving. The Administrator stated this was probably due to not losing the product if microwaved and it exploded. 2. According to the facility's P&P (undated) titled Change in Resident's Condition, it is the policy to promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical condition or status. The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or on-call physician when there has been an accident or incident involving the resident and notify the resident's family or representative. Notifications will be made within 24 hours of a change occurring in the resident's medical condition or status. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. Medical record review for Resident 53 was initiated on 2/18/2020. Resident 53 was readmitted to the facility on [DATE]. On 2/18/2020 at 1506 hours, an observation and concurrent interview was conducted with Resident 53. Resident 53 was observed lying in bed with her legs and feet exposed. Resident 53's right knee was observed with green and purple discoloration. Resident 53 stated on Saturday (2/15/2020), facility staff was helping her transfer from a wheelchair to her bed via a Hoyer lift (a hydraulic device used to transfer residents between the bed and a chair) when the oxygen tank fell on her knee during the transfer. Resident 53 stated an x-ray was performed in her room. Resident 53 stated she experienced pain after the incident and staff administered Tylenol for the pain. Review of Resident 53's Progress Notes for February 2020 showed an entry dated 2/17/2020 at 1248 hours, showing the resident was administered acetaminophen 325 mg, two tablets by mouth for complaint of left knee pain. Review of Resident 53's Radiology Results Report, an x-ray of the right knee was conducted on 2/17/2020. On 2/19/2020 at 1052 hours, an interview was conducted with CNA 3. CNA 3 stated she was not aware of any incidents which occurred involving Resident 53 in the past week. On 2/19/2020 at 1102 hours, an interview was conducted with LVN 13. LVN 13 stated she was not aware of any incidents which occurred involving Resident 53 in the past week. On 2/19/2020 at 1113 hours, an interview and medical record review was conducted with RN 2. RN 2 was asked why Resident 53 had a bruised knee. RN 2 stated there was an incident which occurred during the weekend where Resident 53 was hit by the oxygen tank. RN 2 stated she was notified of the incident on Monday when she came back to work. RN 2 stated she could not remember who told her about the incident and she forgot to make a note in the resident's medical record when she was informed of what happened. RN 2 stated she only notified the physician when the incident occurred but was unable to show documentation of the notification. RN 2 verified Resident 53's medical record had no documentation in the Progress Notes of the incident occurring, no SBAR (situation, background, assessment, recommendation) was completed, and no pain or skin assessment was done. RN 2 stated the above should have been completed as soon as possible after the incident happened. On 2/26/2020 at 1509 hours, a telephone interview was conducted with the DON. The DON stated she interviewed Resident 53 and, to her recollection, the resident told her the incident happened on Friday when a CNA was putting her back to bed. The DON stated Resident 53 informed her when she was lifted to be transferred, the tank went with her and it landed on her left knee. The DON stated she can't recall the exact day she was first informed about the incident but she believes it was Monday (2/17/2020) or Tuesday (2/18/2020). The DON stated she did not know who the first person was who informed everyone about the incident. The DON stated as soon as she was informed of the incident, the RN supervisor was informed at Station 2. The DON stated she may not have been the one to inform the RN Supervisor because by the time she got to Station 2, the x-ray had already been ordered. The DON stated the investigation of the incident was not complete but was started as soon as she found out about the incident on 2/17 or 2/18/2020. The DON stated there is no time frame to finish the investigation. The DON verified an incident report was not completed and the investigation was not initiated on the day the incident occurred. The DON stated the incident should have been documented in the Progress Notes and an SBAR and pain assessment should have also been completed. 3. On 2/18/2020 at 1155 hours, during the initial tour of the facility, Resident 92 was observed lying in bed with bilateral side rails elevated by the head of the bed. The left side rail was padded, but the right side rail was not padded. Medical record review for Resident 92 was initiated on 2/18/2020. Resident 92 was admitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 11/6/19, for bilateral padded side rails to reduce the risk of injury due to epilepsy and a history of seizure disorder. Review of Resident 92's plan of care showed a care plan problem dated 5/1/19, to address the potential for seizure activity, injury related to seizure disorder, and uncontrollable movements. The interventions included the use of padded side rails for risk of injury during seizure activity. On 2/18/2020 at 1434 hours and on 2/19/2020 at 0705 hours, Resident 92 was observed lying in bed with bilateral side rails elevated by the head of the bed. The left side rail was padded, but the right side rail was not padded. On 2/19/2020 at 0709 hours, an interview was conducted with CNA 1, who was in Resident 92's room. CNA 1 verified Resident 92's right side rail was not padded. CNA 1 stated Resident 92's side rails needed to be padded because Resident 92 moved around in bed and moved her arms a lot. On 2/19/2020 at 0945 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 92's side rails were supposed to be padded to prevent injuries in case the resident hit the side rails.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 101 was initiated on 2/18/2020. Resident 101 was readmitted to the facility on [DATE]. Re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 101 was initiated on 2/18/2020. Resident 101 was readmitted to the facility on [DATE]. Review of Resident 101's Order Summary Report dated 2/19/2020, showed the following orders dated 1/28/2020: *administer supplemental oxygen via nasal cannula at 3 liters per minute continuous. *check the oxygen liter flow every shift. Review of Resident 101's Medication Administration Record for February 2020 showed Resident 101 received supplemental oxygen at 2 liters per minute on the following shifts: *2/3/2020 from 1900-0700 hours, *2/4/2020 from 0700-1900 hours, *2/4/2020 from 1900-0700 hours, *2/5/2020 from 0700-1900 hours, *2/5/2020 from 1900-0700 hours, *2/9/2020 from 1900-0700 hours, and *2/10/2020 from 0700-1900 hours. On 2/19/2020 at 0826 hours, Resident 101 was observed lying in bed. Supplemental oxygen was observed being administered via nasal cannula. The oxygen flow regulator showed the resident was receiving oxygen at 4 liters per minute. On 2/19/2020 at 1123 hours, Resident 101 was observed sleeping in bed with a nasal cannula in place. The oxygen flow meter showed the resident was receiving oxygen at 4 liters per minute. On 2/19/2020 at 1128 hours, an observation, interview and concurrent medical record review was conducted with LVN 8. LVN 8 verified Resident 101 was receiving oxygen at 4 liters per minute and had been when the LVN checked on the resident at 0730 hours. LVN 8 reviewed the resident's administration record and verified the resident's record showed an order for 3 liters per minute. On 2/20/2020 at 1047 hours, an interview and concurrent medical record review was conducted with LVN 13. LVN 13 reviewed Resident 101's Medication Administration Record for February 2020. LVN 13 verified the resident's record showed the resident received oxygen at 2 liters per minute for seven shifts and should have been on 3 liters per minute. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide safe respiratory care to the ventilator dependent residents in the subacute unit. * The facility failed to ensure policies and procedures for respiratory care and services were developed and implemented to address the provision of mechanical ventilation, including how to set, monitor, and respond to ventilator low pressure alarms. Low pressure alarms are used to detect a drop in peak airway pressure that occurs when a patient becomes disconnected from the ventilator. According to an interview conducted with the DON on 2/20/2020 at 1044 hours, there were 44 ventilator dependent residents in the subacute unit as of 2/18/2020. In addition, the facility failed to ensure the ventilator low pressure alarms for two of 25 final sampled residents (Residents 5 and 55) were set within safe parameters. This posed the risk for delayed care and interventions if the residents' ventilators did not alarm when they should have to alert the staff the residents were in distress or disconnected from their ventilators. * The facility failed to ensure Resident 101's supplemental oxygen was administered as ordered by the physician. Findings: Review of the Clinical Application of Mechanical Ventilation (2014), Fourth Edition, showed the low-pressure alarm should be set at 10 to 15 below the observed peak airway pressure. This alarm is triggered if the peak airway pressure is less than the alarm setting. Conditions that may trigger the low-pressure alarm may include circuit disconnection, exhalation valve driveline disconnection, endotracheal tube cuff leak, and loose circuit connection. 1. On 2/18/2020 at 1409 hours, during the initial tour of the facility, Resident 67 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator. The average peak airway pressure observed on the ventilator was 30 and the low-pressure alarm was observed set at 8. Medical record review for Resident 55 was initiated on 2/18/2020. Resident 55 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 2/7/2020, for ventilator settings of AC (assist control) mode, respiratory rate of 12, tidal volume of 500, and PEEP (positive end-expiratory pressure) of 5. On 2/19/2020 at 0721 hours, Resident 55's average peak airway pressure observed on the ventilator was 32 and the low-pressure alarm was observed set at 8. On 2/19/2020 at 1106 hours, Resident 55's average peak airway pressure observed on the ventilator was 33 and the low-pressure alarm was observed set at 8. On 2/19/2020 at 1335 hours, an observation of Resident 55's ventilator settings was conducted with RT 2. RT 2 verified how to check the ventilator settings. RT 2 verified Resident 55's average peak airway pressure observed on the ventilator was 33 and the low-pressure alarm was observed set at 8. RT 2 stated the low-pressure alarm should be set at 10 below the peak airway pressure. RT 2 stated the low-pressure alarm was important because it alerted the staff if the resident was disconnected from the ventilator. Review of Resident 55's Respiratory Therapy Ventilation Monitor Record dated 2/10/2020 at 0128 and 0820 hours, showed Resident 55's documented peak airway pressure was 31 to 33, and the low-pressure alarm was set to 6. Entries dated 2/18 at 1918 hours and 2/19/2020 at 0055, 0815, and 1335 hours, showed Resident 55's documented peak airway pressure was 30 to 36, and the low-pressure alarm was set to 8. RT 2 verified the findings. 2. On 2/18/2020 at 1217 hours, during the initial tour of the facility, Resident 5 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. The average peak airway pressure observed on the ventilator was 33 and the low-pressure alarm was observed set at 6. On 2/18/2020 at 1447 hours, Resident 5's average peak airway pressure observed on the ventilator was 38 and the low-pressure alarm was observed set at 6. Medical record review for Resident 5 was initiated on 2/18/2020. Resident 5 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 12/23/19, for ventilator settings of SIMV (synchronized intermittent mandatory ventilation) mode, respiratory rate of 10, tidal volume of 450, pressure support of 12, and PEEP of 5. On 2/19/2020 at 0715 and 0938 hours, Resident 5's average peak airway pressure observed on the ventilator was 25 to 26, and the low-pressure alarm was observed set at 6. On 2/19/2020 at 1104 and 1318 hours, Resident 5's average peak airway pressure observed on the ventilator was 34 to 35, and the low-pressure alarm was observed set at 6. On 2/19/2020 at 1401 hours, an observation of Resident 5's ventilator settings was conducted with RT 2. RT 2 verified Resident 5's average peak airway pressure observed on the ventilator was 35 and the low-pressure alarm was observed set at 6. Review of Resident 5's Respiratory Therapy Ventilation Monitor Record dated 2/18 at 0010 hours to 2/19/2020 at 1235 hours showed Resident 5's low-pressure alarm was not set 10 to 15 below the documented average peak airway pressures. For example, on 2/18/2020 at 1410 hours, Resident 5's documented peak airway pressure was 37 and the low-pressure alarm was set to 6. RT 2 verified the findings On 2/19/2020 at 1431 hours, an interview was conducted with RT 1. RT 1 stated the low-pressure alarm triggered if the resident was disconnected from the ventilator. RT 1 stated the low-pressure alarm should be set at 10 to 15 below the peak airway pressure. RT 1 stated if the low-pressure alarm was set too low, the low-pressure alarm may not trigger if the resident was disconnected from the ventilator. On 2/19/2020 at 1457 hours, an interview was conducted with RT 3. RT 3 stated the low-pressure alarm needed to be set at 10 to 15 below the peak airway pressure. 3. On 2/20/2020 at 0923 hours, an interview and concurrent facility document review was conducted with RTs 2 and 3. RTs 2 and 3 were asked for the facility's P&P on how to set the ventilator low pressure alarms. After reviewing the facility's P&P binders, RTs 2 and 3 verified there was no P&P to address how to set the ventilator low-pressure alarms. On 2/20/2020 at 0933 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Nurse Consultant, who was previously asked to locate the facility's P&P to address how to set the ventilator low pressure alarms, verified there was no P&P to address how to set the ventilator low pressure alarms.

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Based on interview, facility document review, and facility P&P review, the facility failed to maintain adequate CNA staffing to ensure each resident attained or maintained the highest practicable phys...

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Based on interview, facility document review, and facility P&P review, the facility failed to maintain adequate CNA staffing to ensure each resident attained or maintained the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and plan of care on numerous occurrences. This failure resulted in a delay in care and services to meet the residents ' needs. Findings: Review of the facility's P&P titled Nursing Services updated 11/14/17, showed the facility, through its integration of nursing and other services, will staff utilizing applicable staffing patterns to assist the resident to attain his/her highest level of functioning. The goals for the resident improvement recognize identified needs and the limits of disease, the normal aging process, the resident's right to treatment, cultural awareness, sensitivity, refusal of treatment, and resident safety. On 2/25/2020 at 0914 hours, an interview and concurrent facility document review was conducted with the Staffing Developer. Review of the New Orange Hills Care Staffing Assignment Sheets showed the following: - On 1/24/2020, the 2300 to 0700 hours shift was staffed with three CNAs. Each CNA was responsible for the care of 21 residents. The census was 64. Three of the three CNAs worked the previous shift, 1500 to 2300 hours. - On 1/25/2020, the 2300 to 0700 hours shift was staffed with three CNAs. Each was responsible for the care of 21 residents. The census was 64. One of the CNAs was responsible for training a new CNA on orientation. - On 2/14/2020, the 2300 to 0700 hours shift was staffed with four CNAs. Each CNA was responsible for the care of 16 residents. The census was 65. - On 2/15/2020, the 2300 to 0700 hours shift was staffed with three CNAs. Each CNA was responsible for the care of 21 residents. The census was 64. The Staffing Developer verified the above shifts were not adequately staffed. On 2/25/2020 at 1035 hours, an interview was conducted with CNA 2. CNA 2 verified three CNAs could not provide adequate and safe care to 64 residents in 7.5 hours. When asked what care they needed to provide and how long it took to provide care to each resident, CNA 2 stated they provided ADL care which included brushing teeth, dentures, placing hearing aides, changing bed linen, tidying up the rooms, vital signs, nail care, range of motion exercises, applying assistive devices, assisting with getting dressed, changing briefs, and providing peri-care. CNA 2 stated it took 35 minutes to provide basic care for one resident and to add another 30 minutes when a shower was provided. CNA 2 stated to add another 1.5 hours when the resident required extensive assistance and if a Hoyer Lift transfer was necessary. On 2/25/2020 at 1051 hours, an interview was conducted with CNA 3. CNA 3 stated three CNAs was inadequate to provide quality, safe care to 64 residents in 7.5 hours. CNA 3 stated she was asked daily to stay over and work the following shift due to staff shortages. On 2/25/2020 at 1201 hours, an interview was conducted with the DON. When asked about the amount of staffing on the night shift, the DON verified three CNAs was not adequate staffing to provide safe, quality care for a census of 64 residents in 7.5 hours. Cross reference to F550, examples #1, 2, and 3.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

Based on interview, medical record review, and facility document review, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing care and...

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Based on interview, medical record review, and facility document review, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing care and services in assisting the residents to attain or maintain their highest practicable level of physical, mental, functional, and psychosocial well-being. Prior to completing the facility's orientation process, LVN 10 provided nursing services to three of 25 final sampled residents (Residents 16, 101 and 520) and 17 nonsampled residents (17, 30, 33, 43, 51, 76, 95, 98, 100, 103, 110, 113, 114, 521, 523, 524 and 525). This posed the risk of an adverse outcome to the residents' care or services. findings: Medical record review for Resident 101 was initiated on 2/18/2020. Review of the Medication Administration Record showed blank spaces where the nurse should have documented the administration of medications to the resident on 2/14/2020. On 2/20/2020 at 1421 hours, an interview and concurrent medical record review for Resident 101 was conducted with LVN 8. When asked about the blank spaces on the Medication Administration Record for 2/14/2020, LVN 8 stated the blanks were indicators the scheduled tasks were not completed. Upon further review of Resident 101's Medication Administration Record, more blanks were observed for 2/14/2020. LVN 8 pulled up the administration status on 2/14/2020, for the nurse's assigned residents. The computer showed all the residents' administration icons in red. When asked what the red icons meant, LVN 8 stated the red meant there were unsigned tasks in the administration record for 2/14/2020. LVN 8 retrieved the assignment sheet for Station 2 on 2/14/2020. The assignment log showed LVNs 9 and 10 worked for a portion of the shift on 2/14/2020, with LVN 10 taking over LVN 9's assignment. Review of the facility's staffing assignment for 2/14/2020, showed LVN 10 assumed LVN 9's room assignments. Review of the facility's census dated 2/14/2020, showed LVN 9 provided nursing services to 20 residents, Residents 16, 17, 30, 33, 43, 51, 76, 95, 98, 100, 101, 103, 110, 113, 114, 520, 521, 523, 524 and 525. Review of LVN 10's time punches showed LVN 10 clocked in for work on 2/14/2020 at 1530 hours and clocked out on 2/15/2020 at 0915 hours. The hours worked showed 18.75 hours. On 2/25/2020 at 0912 hours, a telephone interview and facility record review was conducted with LVN 10. LVN 10 stated she was a newly graduated LVN and obtained her LVN license in December 2019. LVN 10 stated she had not completed the facility's orientation and verified she worked independently on 2/14/2020 from 1530 hours. LVN 10 stated she worked on the floor performing medication administration and resident care for her assigned residents for 16 hours and then worked another 2.75 hours completing documentation. When asked how much floor orientation LVN 10 had received prior to working on 2/14/2020, LVN 10 stated she had two days of floor orientation which entailed her shadowing other nurses. LVN 10 clarified she followed and observed the training nurse. LVN 10 stated they did not perform any tasks during the training, did not administer medication or complete any documentation. When asked about the blanks in the Medication Administration Record for 2/14/2020, LVN 10 stated she hadn't been trained on the computer system and was having issues documenting and did not know where to complete backup documentation. On 2/25/2020 at 0934 hours, an interview was conducted with the DON. The DON stated she did not realize LVN 10 had not completed the facility's orientation when she asked her to come in to work. On 2/25/2020 at 1020 hours, an interview was conducted with the DSD. The DSD stated LVN 10 had not completed the facility's new hire nursing orientation. The DSD stated newly hired clinical staff received a new hire floor competency checklist for the staff to complete while they were training the new hire. When asked if the DSD had any nursing competencies for LVN 10, the DSD stated she did not, as those were turned in to her after the new hire completed their orientation. On 2/25/2020 at 1052 hours, an interview and facility document review was conducted with the DON. The DON provided copies of the facility's orientation schedule. The DON verified the schedule showed newly graduated nursing staff were to complete 88 hours of orientation training over a two week period. Week one training included eight hours of training on the electronic health record system and 12 hours of floor orientation caring for four residents. Week two included 12 hours of floor orientation caring for six residents, another 12 hours of floor orientation caring for eight residents and then 12 hours of floor orientation caring for 12 residents. On 2/25/2020 at 1420 hours, an interview and concurrent facility record review was conducted with the Staffing Developer. The Staffing Developer reviewed LVN 10's Time & Attendance - Detail Report, TA. The Staffing Developer stated on 1/26/2020, LVN 10 had night shift orientation on 1/26/20, 2/7 and 2/8/2020. The Staffing Developer stated on 214/2020, LVN 10 worked the floor, and then resumed orientation training on 2/15 and 2/16/2020. Cross reference to F842.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmacy services to meet the residents' needs. * The facility failed to ensure the administration of medications as ordered by the physician for one of 25 final sampled residents (Resident 520) and three nonsampled residents (Residents 95, 98 and 100). This failure had the potential for residents to experience adverse effects. * The facility failed to account for the usage of document controlled medications for two of 25 final sampled residents (Residents 2 and 520) and two nonsampled residents (Residents 521 and 522). This resulted in controlled medications not being accounted for and possible diversion of the controlled opioids. * The facility failed to ensure nine of 12 glucometers (a device which measures the amount of sugar in the blood) on Stations 1 and 2 were calibrated. The facility failed to ensure the glucometer monitoring logs were completed. This posed the risk for inaccurate blood glucose test results and inappropriate treatments, which posed the risk of inaccurate blood glucose readings used to determine the residents' insulin doses. Findings: Review of the facility's P&P titled Preparation and General Guidelines: Controlled Substances updated January 2017 showed the licensed nurse administering the medication immediately enters the date and time of administration on both the Medication Administration Record and the Controlled Medication Count Sheet. 1. Review of the staff assignment log for Station 2 on 2/14/2020, showed LVNs 9 and 10 were assigned to Residents 95, 98, 100, and 520. a. Medical record review for Resident 95 was initiated on 2/19/2020. Resident 95 was admitted to the facility on [DATE]. Review of Resident 95's Medication Administration Record for February 2020 showed on 2/14/2020 at 1400 hours, the resident's clonidine (a blood pressure medication) 0.1 mg dose was left blank for the scheduled 1400 hours dose. b. Closed Medical record review for Resident 100 was initiated on 2/19/2020. Resident 100 was admitted to the facility on [DATE] and discharged on 2/17/2020. Review of Resident 100's Medication Administration Record for February 2020 showed on 2/14/2020 at 1400 hours, the enulose solution (a laxative) 20 gm was left blank for the scheduled 1400 hours dose. c. Medical record review for Resident 98 was initiated on 2/19/2020. Resident 98 was admitted to the facility on [DATE]. Review of Resident 98's Medication Administration Record for February 2020 showed on 2/14/2020 at 1400 hours, potassium bicarbonate-citric acid (a nutritional supplement) 10 meq, four tablets was left blank for the scheduled 1400 hours dose. d. Medical record review for Resident 520 was initiated on 2/18/2020. Resident 520 was admitted to the facility on [DATE]. Review of Resident 520's Medication Administration Record for February 2020 showed on 2/14/2020 at 1400 hours, showed ferrous sulfate (an iron supplement) 325 mg was left blank for the scheduled 1400 hours dose. On 2/21/2020 at 1358 hours, an interview was conducted with LVN 9. LVN 9 stated on 2/14/2020, he finished working on the unit at 1300 hours and did not administer any 1400 medications. On 2/21/2020 at 1358 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above Medication Administration Records for Residents 95, 98, 100, and 520 on 2/14/2020 at 1400 hours were blank. On 2/21/2020 at 1407 hours, an interview was conducted with RN 3. When RN 3 was asked if she administered any medications on 2/14/2020, after LVN 9 left, she stated she could not recall if she had administered medications. RN 3 stated if she had administered any medications, she would have signed them as administered. On 2/25/2020 at 0912 hours, a telephone interview was conducted with LVN 10. LVN 10 stated she assumed care of her assigned residents when she arrived on 2/14/2020 at 1530 hours. LVN 10 stated on 2/14/2020, she did not administer any medications scheduled at 1400 hours. Cross reference to F697. 2. On 2/19/2020 at 1527 hours, a concurrent inspection of Station 2' s Medication Cart 1, interview, and medical record review was conducted with LVN 8. a. Medical record review for Resident 521 was initiated on 2/19/2020. Resident 521 was admitted to the facility on [DATE]. Review of the Resident 521's Controlled Medication Count Sheet for hydromorphone (an opioid pain medication) 2 mg tablets showed: * On 2/17/2020 at 0600 hours, two tablets of hydromorphone were removed from the controlled medication supply. * On 2/14/2020 at 2200 hours, two tablets of hydromorphone were removed from the controlled medication supply. Review of Resident 521's Medication Administration Record for February 2020 failed to show hydromorphone was administered to the resident at the above times. LVN 8 verified the findings. b. Medical record review for Resident 520 was initiated on 2/18/2020. Resident 520 was admitted to the facility on [DATE]. Review of the Resident 520's Controlled Medication Count Sheet for Fentanyl (an opioid pain medication) 25 mcg/hour patch showed on 2/14/2020 at 1920 hours, one Fentanyl patch was removed from the controlled medication supply. Review of Resident 520's Medication Administration Record for February 2020 failed to show Fentanyl was administered to the resident at the above time. LVN 8 verified the findings. 3. On 2/19/2020 at 1336 hours, a concurrent inspection of Station 2's Medication Cart 2, interview, and medical record review was conducted with LVN 8. a. Medical record review for Resident 522 was initiated on 2/19/2020. Resident 522 was admitted to the facility on [DATE]. Review of Resident 522's Controlled Medication Count Sheet for Percocet (an opioid pain medication) 5-325 mg tablets showed: * On 2/18/2020 at 0800 hours, one tablet of Percocet was removed from the controlled medication supply. * On 2/18/2020 at 1400 hours, one tablet of Percocet was removed from the controlled medication supply. Review of Resident 522's Medication Administration Record for February 2020 failed to show Percocet was administered to the resident at the above times. LVN 8 verified the findings. b. Medical record review for Resident 2 was initiated on 2/19/2020. Resident 2 was readmitted to the facility on [DATE]. Review of the Resident 2's Controlled Medication Count Sheet for Norco (an opioid pain medication) 10-325 mg tablets showed: * On 2/17/2020 at 2150 hours, one tablet of Norco was removed from the controlled medication supply. * On 2/18/2020 at 1800 hours, one tablet of Norco was removed from the controlled medication supply. Review of Resident 2's Medication Administration Record for February 2020 failed to show Norco was administered to the resident at the above times. LVN 8 verified the findings. 3. Review of the blood glucose quality assurance/quality control reference manual titled Assure Platinum Blood Glucose Monitoring System revised 3/14 under Assure Dose Control Solution showed for use with glucometer and test strips as a quality control check to verify the accuracy of blood glucose test results. a. On 2/20/2020 at 0711 hours, a concurrent inspection of Station 1's Medication Cart 2, interview, and facility document review was conducted with LVN 1. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record showed the record did not match the serial number of the glucometer, and the daily quality control was not performed from 2/1 through 2/4/2020. LVN 1 verified the findings. b. On 2/20/2020 at 0711 hours, a concurrent inspection of Station 1's Medication Cart 4, interview, and facility document review was conducted with RN 1 and LVN 2. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record showed the daily quality control was not performed on 2/1 and 2/2/2020. RN 1 and LVN 2 verified the findings. c. On 2/19/2020 at 1605 hours, a concurrent interview and facility document review for Station 1' s Medication Cart 5 was conducted with LVN 3. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record showed the daily quality control was not performed on 1/ 2, 1/23, 1/24, 1/25, 1/26, 1/27, 1/28, 1/29, 1/30, and 1/31/2020. LVN 3 verified the finding. d. On 2/19/2020 at 1336 hours, a concurrent interview and facility document review for Station 2' s Medication Cart 2 was conducted with LVN 8. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for December 2019 showed the daily quality control was not performed on 12/9, 12/10, 12/16, 12/21, 12/22, 12/25, 12/26, 12/30, and 12/31/19. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for January 2020 showed the daily quality control was not performed on 1/3 to 1/5, 1/12, 1/15, 1/17 to 1/19, 1/23, 1/25 to 1/27, 1/29, and 1/30/2020. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for February 2020 showed the daily quality control was not performed on 2/4, 2/12, and 2/14 through the date of inspection. LVN 8 verified the findings. e. On 2/19/2020 at 1527 hours, a concurrent interview and facility document review for Station 2's Medication Cart 1 was conducted with LVN 8. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for January 2020 showed the daily quality controls were not performed on 1/1, 1/2, 1/4 to 1/7, 1/12, 1/13, 1/15 to 1/18, 1/20 to 1/23, 1/27, and 1/28/2020. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for February 2020 showed the daily quality control was not performed on 2/15 and 2/16/2020. LVN 8 verified the findings. f. On 2/19/2020 at 1600 hours, an interview and facility document review for Station 2's Medication Cart 3 was conducted with LVN 13. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for December 2019 showed the daily quality controls were not performed on 12/16, 12/20 through 12/26, and 12/29 through 12/31/19. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for January 2020 showed the daily quality controls were not performed on 1/2 to 1/5, 1/11 to 1/14, 1/17 to 1/19, 1/23, 1/27, 1/28, and 1/30/2020. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for February 2020 showed the daily quality controls were not performed on 2/1, 2/5, 2/6, 2/10 through 2/12, and 2/14 through 2/17/2020. LVN 13 verified the findings. g. On 2/19/2020 at 1607 hours, a concurrent interview and facility document review for Station 2's Medication Cart 4 was conducted with LVN 13. Inspection of the medication cart showed the lot number for the glucometer test strips currently in use was 010920B. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record showed on 2/18/2020, the latest daily quality control was performed with test strip lot number 127019B. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for December 2019 showed the daily quality controls were not performed on 12/10, 12/11, 12/15 through 12/17, 12/19, 12/23 through 12/25, and 12/27 through 12/31/2019. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for January 2020 showed the daily quality controls were not performed from 1/2 through 1/6, 1/10 through 1/12, 1/21, 1/24 through 1/26, 1/28, and 1/30/2020. LVN 13 verified the findings. h. On 2/19/2020 at 1608 hours, a concurrent interview and facility document review for Pulmonary Medication Cart 1 was conducted with LVN 16. Review of the Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record for February 2020 showed the daily quality controls were not performed from 2/1 through 2/4 and 2/12 through 2/15/2020. LVN 16 verified the finding. i. On 2/19/2020 at 1612 hours, a concurrent interview and facility document review for Pulmonary Medication Cart 2 was conducted with LVN 17. Review of the Quality Control Record Assure Platinum Blood Glucose Monitoring System for February 2020 showed the daily quality controls were not performed on 2/14 and 2/15/2020. LVN 17 verified the finding.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. On [DATE] at 1527 hours, a concurrent inspection of Station 2's Medication Cart Cart 1, interview, and medical record review ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. On [DATE] at 1527 hours, a concurrent inspection of Station 2's Medication Cart Cart 1, interview, and medical record review was conducted with LVN 8. Inspection of the medication cart showed 40 tablets of Norco (an opioid pain medication) 5-325 mg for Resident 101 was located in the controlled medication drawer. Medical record review for Resident 101 was initiated on [DATE]. Review of Resident 101's physician's orders showed the Norco was discontinued on [DATE]. LVN 8 verified the Norco should have been removed from the cart and given to the DON once it was discontinued. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure proper labeling, storage, and disposal of medications. * The facility failed to ensure the discontinued medications for five of 25 final sampled residents (Residents 6, 53, 94, 101 and 420), and seven nonsampled residents (Residents 3, 51, 52, 67, 69, 107, and 119) were removed from the medication cart. This had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure inhalation solution vials were stored in the foil pouch and labeled with the opened date. This posed the risk for unsafe medication storage and a potential of harm to residents receiving the medications. * The facility failed to dispose of an expired medication in the respiratory treatment cart. This posed the risk of residents receiving expired medication. Findings: Review of the facility's P&P titled Medication Storage in the Facility dated 1/17 showed potentially harmful substances (such as disinfectants) are clearly identified and stored in a locked area separately from medications. Review of the facility's P&P titled Medication Destruction dated 1/7 showed discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed. Controlled substances are retained in a securely locked area using double lock procedures, with restricted access until destroyed by the facility DON or RN employed by the facility and a consultant pharmacist. Medication is destroyed within 90 days from the date the medication was discontinued. Review of the drug information sheet for budosenide (steroid used to reduce inflammation) revised 2/16 showed to keep budosenide inhalation suspension in the aluminum foil envelope to protect from light until ready to use. Review of the drug information sheet for levalbuterol (bronchodilator, relaxes muscles in the airway and increases air flow to the lungs) revised 1/19 showed when a levalbuterol inhalation solution foil pouch is opened, use the vials within two weeks, and when levalbuterol inhalation solution vials are removed from the foil pouch, use them right away or within one week. Review of the drug information sheet for ipratropium bromide and albuterol solution (same as Duoneb, bronchodilator) revised date [DATE], showed vials should be protected from light before use; therefore, keep unused vials in the foil pouch or carton. Review of the drug information sheet for albuterol (bronchodilator) revised date [DATE], showed to store in pouch until time of use. Review of the drug information sheet for ipatropium (bronchodilator) revised date [DATE], showed to store unused vials in the foil pouch. 1. On [DATE] at 1401 hours, an inspection of the respiratory treatment cart and concurrent interview was conducted with RT 1. The following was observed: - A bottle of chlorhexidine solution had an expiration date of 8/2019. - Two vials of levalbuterol medication were observed not stored in a foil pouch. - An opened foil pouch containing levalbuterol vials was observed with no opened date. - Opened foil pouches containing ipratropium vials were observed without opened dates. - Opened foil pouches containing albuterol vials were observed without opened dates. - Opened foil pouches containing budesonide vials were observed without opened dates. RT 1 verified the above findings. 2. On [DATE] at 1444 hours, a concurrent inspection of the IV treatment cart, interview, and medical record review was conducted with RN 1. The following was observed: - Vials of ondansetron (antiemetic, used to prevent nausea and vomiting) for Resident 6 were observed in the cart. Review of the medical record for Resident 6 failed to show a physician's order to administer the ondansetron. - Vials of pantoprazole (blocks the production of acid by the stomach) for Resident 94 were observed in the cart. Review of the medical record for Resident 94 showed this medication was discontinued on [DATE]. RN 1 verified the above findings. 3. On [DATE] at 0711 hours, a concurrent inspection of Station 1' s Medication Cart 2, interview, medical record review, and facility document review was conducted with LVN 1. The following medications were observed for Resident 69: - A bottle of clindamycin lotion (antibiotic); - A bottle containing hydralazine (used to treat high blood pressure) tablets; - A bottle containing omeprazole (blocks the production of acid by the stomach) tablets; and - A tube of betamethasone ointment (steroid, used to treat inflammation). Review of the medical record for Resident 69 showed the following: - clindamycin lotion was discontinued on [DATE]; - hydralazine was discontinued on [DATE]; - omeprazole was discontinued on [DATE]; and - bethametasone ointment was discontinued on [DATE]. LVN 1 verified the findings. LVN 1 stated discontinued medications should be removed from the medication cart right after the medication was discontinued and store the medication in the medication room. 4. On [DATE] at 0711 hours, a concurrent inspection of Station 1's Medication Cart 4, interview, medical record review, and facility document review was conducted with RN 1 and LVN 2. The following was observed: - A bottle containing omeprazole 20 mg tablets for Resident 67. Review of the medical record for Resident 67 showed omeprazole 20 mg was discontinued on [DATE]. - A container of bleach wipes was observed stored in the same compartment with liquid iron (supplement) medication, and Centrum multivitamin (supplement) medication. RN 1 and LVN 2 verified the above findings. 6. On [DATE] at 1405 hours, a concurrent inspection of Station 2's Medication Cart 4, interview, and medical record review was conducted with LVN 4. The following was observed: - Opened foil pouches containing albuterol vials were observed without opened dates. - Duoneb vials were observed not inside a foil pouch. - A bottle of omeprazole 40 mg for Resident 53. Review of the medical record for Resident 53 did not show a physician's order to administer omeprazole 40 mg to Resident 53. - A bubble pack containing lorazepam (antianxiety medication) 0.5 mg for Resident 107. Review of the medical record for Resident 107 showed lorazepam 0.5 mg as needed was discontinued on [DATE]. - A bubble pack containing temazepam (antianxiety medication) 7.5 mg for Resident 3. Review of the medical record for Resident 3 showed temazepam 7.5 mg as needed was discontinued on [DATE]. - A bubble pack containing alprazolam (antianxiety medication) 0.25 mg for Resident 119. Review of the medical record for Resident 119 showed alprazolam 0.25 mg was discontinued on [DATE]. - A bubble pack containing zolpidem (hypnotic, used to treat insomnia) 5 mg for Resident 51. Review of the medical record for Resident 51 showed zolpidem 5 mg was discontinued on [DATE]. LVN 4 verified the findings. LVN 4 stated discontinued medications should be given to the DON. 7. On [DATE] at 1405 hours, a concurrent inspection of Station 2's Medication Cart 4, interview, and medical record review was conducted with LVN 5. The following was observed: - A bubble pack containing clonazepam (antianxiety medication) 2 mg for Resident 420. Review of the medical record for Resident 420 showed clonazepam 2 mg was discontinued on [DATE]. - A bubble pack containing alprazolam 0.25 mg for Resident 52. Review of the medical record for Resident 52 showed alprazolam 0.25 mg was discontinued on [DATE]. LVN 5 verified the findings.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, and facility P&P review, the facility failed to ensure sanitary requirements were met in the dietary department. * The facility failed to ensure foods in a personal re...

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Based on observation, interview, and facility P&P review, the facility failed to ensure sanitary requirements were met in the dietary department. * The facility failed to ensure foods in a personal resident refrigerator used to store food brought in from outside the facility were labeled and dated. * The facility failed to ensure the microwave used for residents' food was clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the facility. Findings: Review of the CMS 672 Resident Census and Conditions of Residents dated 2/19/2020, and signed by the DON, showed 80 of the 128 residents residing in the facility received food prepared in the kitchen. 1. According to the facility's P&P titled Foods Brought by Family/Visitors (undated) food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Containers will be labeled with the resident's name, the item, and the use by date. On 2/20/2020 at 0925 hours, a full-sized refrigerator was observed in the corner of the dining room with locks on the refrigerator and freezer door. On 2/20/2020 at 0930 hours, an observation of the full-sized refrigerator and concurrent interview was conducted with the Activities Supervisor. The Activities Supervisor stated the refrigerator was a personal refrigerator belonging to Resident 29. She stated Family Member 2 cooked food for the resident each day and brought it to the facility to store in the refrigerator. The Activities Supervisor stated the refrigerator and freezer were locked and the keys had to be obtained from Resident 29 or Family Member 2 in order to open it. The Activities Supervisor obtained the keys to the refrigerator and opened the refrigerator door. The following items were observed: - Six bottles of a yellow drink with no date and no label, - Two containers containing prepared food with no date and no label, - Cut pears in a container with no date and no label, and - Two bottles of a pink drink with no date and no label. The Activities Supervisor verified the above. On 2/20/2020 at 1004 hours, an interview was conducted with the RD. The RD stated Resident 29's personal refrigerator was not the facility's property and the nurses did not access it since they did not have a right to open it. The RD stated, therefore, it was not the facility's responsibility to label and date the food inside the refrigerator. On 2/20/2020 at 1019 hours, RN 4 stated Resident 29 ate both facility food and food Family Member 2 brought in from home. RN 4 stated the nurses provided Resident 29 with the lemon juice stored in his personal refrigerator in the dining room. RN 4 stated Resident 29 and Family Member 2 both had a key the nurses retrieved when it is time to serve the lemon juice to Resident 29. RN 4 confirmed nurses were able to access Resident 29's personal refrigerator when Family Member 2 was not at the facility. 2. On 2/20/2020 at 0939 hours, the resident microwave located in the dining room was observed with brown and yellow residue inside. The top inside of the microwave had what appeared to be splashes of food and the microwave door had an approximately one-inch long black residue on the left corner of the door. On 2/20/2020 at 0942 hours, an observation of the resident microwave and concurrent interview was conducted with the Housekeeper. The Housekeeper stated she cleaned the dining room this morning, but did not clean the microwave because somebody was using it at the time, and she did not come back to clean it. the Housekeeper verified the brown residue on the inside of the microwave and on the inside of the microwave door. On 2/20/2020 at 0947 hours, an observation of the resident microwave and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the inside of the microwave was covered in brown residue. The Maintenance Supervisor stated the inside of the microwave did not appear to have been cleaned for longer than one day, especially the inside of the microwave door. On 2/21/2020 at 0841 hours, a follow-up interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated a month ago, he instructed an RT to microwave Gorilla Glue (a brand of polyurethane adhesive) for 15 seconds to soften it up. The Maintenance Supervisor stated the RT microwaved it for longer than instructed and it exploded inside the microwave and the residue was left over on the inside of the microwave door. The Maintenance Supervisor verified the inside of the left corner of the microwave door was Gorilla Glue that was not able to be fully removed. Cross reference to F689, example #1.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure accurate medical ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure accurate medical records for four of 25 final sampled residents (Residents 16, 49, 101 and 520) and 17 nonsampled residents (Residents 17, 30, 33, 43, 51, 76, 95, 98, 100, 103, 110, 113, 114, 521, 523, 524 and 525). * The facility failed to ensure the Medication Administration Records for Residents 16, 17, 30, 33, 43, 51, 76, 95, 98, 100, 101, 103, 110, 113, 114, 520, 521, 523, 524 and 525 were complete and accurate. This had the risk of the residents' care needs not being met as their medical information was inaccurate. * The facility failed to show accurate RD assessments for Resident 49. The inaccurate RD assessment had the potential for Resident 49's pressure ulcer to worsen. findings: Review of the facility's P&P titled Preparation and General Guidelines: Medication Administration - General Guidelines updated January 2017 showed the nurse administering the medication will record the administration on the residents' administration record at the end of each medication pass. The nurse will review the administration record to ensure necessary doses were administered and documented. The P&P also showed the nurse will not report off-duty without recording the medications administered. Review of the facility's P&P titled Blood Pressure, Measuring dated 7/16/15, showed after obtaining the residents' blood pressures, documentation of the results will be completed. 1. Medical record review for Resident 101 was initiated on 2/18/2020. Review of Resident 101's Medication Administration Record for February 2020 showed blanks for the following medication administrations, monitoring and nursing care scheduled for 2/14/2020: * Lasix (a diuretic) 40 mg at 0800 hours, * potassium (supplement) 10 meq at 0800 hours, * prednisone (a steroidal anti-inflammatory) 20 mg at 0900 hours, * nasal Iodophor (an iodine antiseptic) swab to each nostril at 0900 and 1700 hours, * Voltaren gel (non-steroidal anti-inflammatory) 1%, apply 2 gm transdermally (applied to the skin) for pain at 0900 hours, * continuous supplemental oxygen at 3 liters per minute via nasal cannula for shifts 0700-1900 hours and 1900-0700 hours, * indwelling urinary catheter (a catheter inserted through the urethra into the bladder to drain urine) care for shifts 0700-1900 hours and 1900-0700 hours, * monitor and document pain level for shifts 0700-1900 hours and 1900-0700 hours, * health shakes (nutritional supplement) at 0800, 1200 and 1700 hours, * monitor blood pressure at 1400 hours, and * monitor intake and output for day, evening, and night shifts. On 2/20/2020 at 1421 hours, an interview and concurrent medical record review was conducted with LVN 8. While reviewing Resident 101's Medication Administration Record, blank spaces were observed for 2/14/2020. LVN 8 verified the blanks and stated the blanks meant the scheduled tasks and medications were not documented as completed. Upon further review of the resident's medical record, more blanks were observed for 2/14/2020. LVN 8 pulled up the Medication Administration Record status on 2/14/2020, for assigned residents. The computer showed all the residents' medication administration icons were in red. When asked what the red icons meant, LVN 8 stated the red meant there were unsigned tasks in the Medication Administration Record for 2/14/2020. LVN 8 retrieved the assignment sheet for Station 2 on 2/14/2020. The assignment log showed LVNs 9 and 10 worked for a portion of the shift on 2/14/2020, with LVN 10 taking over LVN 9's assignment. Review of the facility's staffing assignment for 2/14/2020, showed LVN 10 assumed LVN 9's room assignment. Review of the facility's census dated 2/14/2020, showed LVNs 9 and 10 were the assigned nurses to 20 residents (Residents 16, 17, 30, 33, 43, 51, 76, 95, 98, 100, 101, 103, 110, 113, 114, 520, 521, 523, 524 and 525). Review of Medication Administration Records for Residents 16, 17, 30, 33, 43, 51, 76, 95, 98, 100, 103, 110, 113, 114, 520, 521, 523, 524 and 525's for February 2020 showed blanks for each resident on 2/14/2020. On 2/21/2020 at 1104 hours, an interview was conducted with LVN 9. LVN 9 stated he worked on 2/14/2020, with his assigned residents until 1300 hours, and then left the unit to complete his documentation. LVN 9 stated they did not complete the shift monitoring documentation, because he was only there for the first part of the shift. Review of LVN 10's time punches showed LVN 10 clocked in for work on 2/14/2020 at 1530 hours and clocked out on 2/15/2020 at 0915 hours. On 2/25/2020 at 0912 hours, a telephone interview and facility record review was conducted with LVN 10. LVN 10 stated on 2/14/2020, she began her shift at 1530 hours. LVN 10 stated she worked on the floor performing the residents' medication administrations and nursing care for 16 hours and then worked another 2.75 hours completing documentation. When asked about the blanks in the Medication Administration Record for her shift on 2/14 to 2/15/2020, LVN 10 stated she had not been trained on the computer system and was having issues documenting and did not know where else to complete backup documentation. On 2/21/2020 at 1202 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the blanks in the Medication Administration Records for Residents 95, 100, 110 and 525. 2/21/20 at 1358 hours, during a follow-up interview and concurrent medical record review with the DON, the DON verified the blanks in the Medication Administrations Records for the remaining 16 residents (Residents 16, 17, 30, 33, 43, 51, 76, 98, 101, 103, 113, 114, 520, 521, 523 and 524) assigned to LVNs 9 and 10 on 2/14 to 2/15/2020. The DON verified all 20 of the 20 residents assigned to LVNs 9 and 10 had blanks in their Medication Administration Records, resulting in inaccurate resident records. 2. Review of the facility's P&P titled Nutrition and Hydration for Skin Integrity revised 10/10 showed nutritional assessment of the resident should be performed by a dietitian. Components of the assessment should include intake of calories, protein, vitamins C and D, iron, and zinc. Medical record review for Resident 49 was initiated on 2/18/2020. Resident 49 was readmitted to the facility on [DATE]. Review of Resident 49's Order Summary Report showed the following physician's orders dated 12/15/19: - Administer Pro Stat SF (protein supplement, sugar-free) 30 ml two times a day for wound healing for 30 days (discontinue 1/14/2020); - Administer ascorbic acid (vitamin C, supplement) 500 mg, 5 ml one time a day for wound healing for 30 days (discontinue 1/14/2020); and - Administer zinc sulfate (supplement) 220 mg one time a day for wound management for 14 days (discontinue 12/29/19). Review of Resident 49's Progress Notes showed a Nutrition/Dietary Note dated 1/6/2020, showing medications reviewed, Pro Stat sugar free 30 ml twice a day, ascorbic acid 500 mg, and zinc sulfate. The interventions/recommendations included to discontinue zinc sulfate, completed for 14 days, excessive zinc increase risk of copper deficiency. Review of Resident 49's Progress Notes showed a Nutrition/Dietary Note dated 2/14/2020, showing medications reviewed, Pro Stat sugar free 30 ml twice a day, ascorbic acid 500 mg, and zinc sulfate. The Updates showed wound was stable but not improved . continue with current regimen to provide adequate protein for optimal wound healing. On 2/21/2020 at 0741 hours, an interview and concurrent medical record review for Resident 49 was conducted with RD 1. RD 1 stated for residents with a Stage 4 pressure ulcer (full-thickness loss of skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer), the protocol was to administer zinc sulfate for 14 days, vitamin C for 30 days, and Pro Stat or protein supplement for 30 days. RD 1 stated these supplements were reviewed during the monthly assessments. RD 1 stated the monthly assessment for Resident 49 included a review of the medications Resident 49 was currently taking. When asked about the Progress Notes dated 1/6/2020, RD 1 stated she reviewed the current medications at the time and she documented Pro-Stat, vitamin C and zinc sulfate. When asked about her recommendations, RD 1 stated she recommended to discontinue the zinc sulfate due to an increased risk of copper deficiency. When asked if Resident 49 was taking zinc sulfate at that time, RD 1 reviewed Resident 49's medical record, and acknowledged Resident 49 was no longer on zinc sulfate. On 2/21/2020 at 1544 hours, a telephone interview was conducted with RD 2. RD 2 stated she remembered Resident 49, with a Stage 4 pressure ulcer. RD 2 stated residents with a Stage 4 pressure ulcer and who are high risk for developing pressure ulcers were monitored really closely by the IDT. RD 2 verified she documented the IDT notes (Progress Notes) on 2/14/2020. RD 1 stated she reviewed the current medications at the time. RD 2 verified she documented Pro-stat, vitamin C and zinc sulfate. When RD 2 was informed these medications were already discontinued, RD 2 stated maybe it was a visual error on her part.

MINOR (B)

Minor Issue - procedural, no safety impact

Safe Environment (Tag F0584)

Minor procedural issue · This affected multiple residents

Based on observation and interview, the facility failed to maintain a homelike environment for one of 25 final sampled residents (Resident 15). The window in Resident 15's room was broken and the vert...

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Based on observation and interview, the facility failed to maintain a homelike environment for one of 25 final sampled residents (Resident 15). The window in Resident 15's room was broken and the vertical blinds had several missing panels. This failure had the potential to negatively impact Resident 15's perception of a homelike environment. Findings: On 2/18/2020 at 1602 hours, during the initial tour of the facility, a concurrent observation and interview was conducted with Resident 15 and the resident's family member. Resident 15 stated the window was very difficult to open. On 2/18/2020 at 1625 hours, observation in Resident 15's room showed there were several missing panels from the vertical blinds. The window looked out to a playground of a nursery school located close to the facility. On 2/19/2020 at 0823 hours, a concurrent observation and interview was conducted with the Maintenance Assistant. The Maintenance Assistance verified the window was broken and the panels were missing from the vertical blinds.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0914 (Tag F0914)

Minor procedural issue · This affected multiple residents

Based on observation and interview, the facility failed to ensure full visual privacy was provided for one of 25 final sampled residents (Resident 15) when the ceiling suspended curtain was not long e...

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Based on observation and interview, the facility failed to ensure full visual privacy was provided for one of 25 final sampled residents (Resident 15) when the ceiling suspended curtain was not long enough to enclose the entire bed. This failure had the potential to negatively affect Resident 15's privacy and dignity. Findings: On 2/18/2020 at 1602 hours, during the initial tour, an observation was conducted of Room A, Bed C, next to the window. The privacy curtain was pulled partially around Resident 15's bed. The privacy curtain was not long enough to fully extend along the side and foot of the bed, leaving Resident 15 exposed to anyone outside the window. On 2/19/2020 at 0835 hours, a concurrent observation and interview were conducted with the Infection Control Director. The Infection Control Director observed the curtain and verified the ceiling suspended curtain did not provide adequate privacy for Resident 15. On 2/20/2020 at 1132 hours, a concurrent observation and interview were conducted with LVN 13. LVN 13 verified the ceiling suspended curtain did not fit around Resident 15's bed to provide full privacy for the resident during care.

NEW ORANGE HILLS

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NEW ORANGE HILLS

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