What is Shoreline Care Center's CMS rating?

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

Does Shoreline Care Center have any serious inspection findings?

Yes, Shoreline Care Center has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 68 total deficiencies from recent inspections.

What are the staffing levels at Shoreline Care Center?

Shoreline Care Center has a four-star staffing rating from CMS with 0.50 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 Shoreline Care Center located?

Shoreline Care Center is located in Oxnard, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Shoreline Care Center have?

Shoreline Care Center has 193 certified beds.

Who owns Shoreline Care Center?

Shoreline Care Center is a for profit - limited liability company facility and is part of the COVENANT CARE chain.

Is Shoreline Care Center safe?

Shoreline Care Center has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at Shoreline Care Center stick around?

Shoreline Care Center has average staff turnover at 35%, which is typical for the nursing home industry.

Was Shoreline Care Center ever fined?

Yes, Shoreline Care Center has been fined $22,952 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is Shoreline Care Center on any federal watch list?

No, Shoreline Care Center is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at Shoreline Care Center?

Medicare inspectors have found 68 deficiencies at Shoreline Care Center: 1 critical, 67 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting Shoreline Care Center?

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

How does Shoreline Care Center compare to other nursing homes?

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

Shoreline Care Center | 26/100 (Grade F)

Aug 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after the resident was transferred to the veteran VA hospital for medication evaluation...

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Based on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after the resident was transferred to the veteran VA hospital for medication evaluation and adjustment.The facility's failure placed Resident 1 at risk of being admitted to another facility which is far from the wife's residence therefore unable to visit frequently.A complaint was received by the California Department of Public Health (CDPH) on 7/14/25 alleging that Resident 1 had been transferred to an acute care hospital for medication evaluation and adjustment. According to the information provided, a representative of the resident was informed by facility staff that the resident's bed would be held and that the resident would be readmitted to the facility following hospitalization. However, the facility subsequently declined to readmit the resident upon discharge from the hospital.During an interview on 7/14/25 at 12:15 p.m., with Resident 1's responsible person (RP - person who makes healthcare decisions for a patient who is unable), the RP reported that the facility declined to readmit Resident 1 following a hospital transfer. According to the RP, nursing staff notified them on 7/2/25 that Resident 1 would be transferred to [name of facility] for a medication evaluation and adjustment. The RP stated they were informed by facility staff that Resident 1 would be able to return following the hospital stay. However, the hospital case manager later informed the RP that the facility would not readmit Resident 1, and alternate placement would be required.During a review of Resident 1's Notice of Transfer or Discharge dated 7/2/25, the document indicated Resident 1 was transferred to [name of facility] on 7/2/25 at 2:40 p.m. The document indicated the transfer was necessary for Resident 1's welfare and that Resident 1's needs could not be met at the facility. However, there was no documentation indicating which needs could not be met. There was no documentation as to what attempts were made to meet Resident 1's needs. The sections were not completed on the document, these sections were left blank.During an interview on 7/17/25 at 2:23 p.m. with Licensed Vocational Nurse (LVN) 1, who transferred Resident 1 to [name of facility] on 7/2/25, LVN 1 stated that Resident 1 required a medication adjustment. LVN 1 confirmed marking/documenting on the transfer form that the transfer was necessary for Resident 1's welfare and that Resident 1's needs could not be met at the facility. Furthermore, when asked if the responsible person ([RP]) was informed there would be a Bed Hold (process of reserving a bed for a resident who is temporarily absent) for Resident 1, LVN 1 stated, Yes, I told the [RP] there was a bed hold for Resident 1 because that's our policy. During an interview on 7/16/25 at 12:30 p.m. with the Business Office Manager (BOM), the BOM was asked if information regarding private pay or reserve bed payment requirements was provided to the responsible person ([RP]) to hold the bed for Resident 1. The BOM stated, No, I did not. I did not have to because the resident was not going to be readmitted back. you need to speak with the administrator. During a telephone interview with the facility administrator (Admin) on 7/16/25 at 12:34 p.m., the Admin indicated the facility did not have to readmit Resident 1 because Resident 1 had attacked another resident. The Admin indicated the facility declined readmission due to Resident 1's behavior.Further review of Resident 1's Notice of Transfer or Discharge dated 7/2/25 did not indicate that Resident 1's transfer was due to the safety of individuals in the facility being endangered by the resident's clinical or behavioral status, or that the health of individuals in the facility would otherwise be endangered.A review of Resident 1's Physician's Discharge Summary dated 7/7/25, did not indicate that the reason Resident 1 was discharged was because the health and safety of individuals in the facility would be endangered.A review of the facility policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, in the BED HOLD and readmission section of the policy indicates A resident, whose leave exceeds the bed hold period. will be allowed to return to the facility to their previous room if available or immediately upon the first availability of a bed in a semi- private room, if the resident requires the services provided by the facility and is eligible for.skilled nursing facility services.

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 F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to:1. Ensure two of three sampled residents (Resident 1 and 2) were provided with a written bed-hold notification upon transfer to general acu...

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Based on interview and record review, the facility failed to:1. Ensure two of three sampled residents (Resident 1 and 2) were provided with a written bed-hold notification upon transfer to general acute care hospitals. 2. Ensure Resident 1's wife was provided with the bed hold private payment information before the resident was transferred to the veteran (VA) emergency department (ED).These failures resulted in the residents not having a bed-hold and were at risk of not being able to return to the facility.1. A review of the facility's policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, indicated Upon transfer or discharge, a notice of transfer and discharge, as well as the bed-hold notification will be completed and given to the resident at the time of transfer or discharge or as soon as practicable. In the BED HOLD and readmission section of the policy indicated the facility will notify the resident or resident representative at the time of admission and again prior to hospital transfer or therapeutic leave, of the bed hold and readmissions policies.a) A complaint was submitted to California Department of Public Health (CDPH) on 7/14/25 indicating Resident 1 was transferred to [name of facility] for a medication evaluation and adjustment. The complainant agreed to the transfer after being notified by the facility that the facility would save Resident 1's bed, and that Resident 1 would be re-admitted back to the facility. However, the facility declined to readmit Resident 1 back to the facility.During an interview with Resident 1's responsible person (RP - person who makes healthcare decisions for a patient who is unable) on 7/14/25 at 12:15 p.m., RP reported the facility did not provide a written bed-hold notice upon Resident 1's transfer to [name of facility].A record review for Resident 1 was conducted on 7/15/25. Resident 1's Notice of Transfer or Discharge dated 7/2/25 indicated Resident 1 was transferred to [name of facility] on 7/2/25 at 2:40 p.m. On the Part B, Bed Hold (process of reserving a bed for a resident who is temporarily absent) section of the document indicated a Bed hold was authorized for Resident 1. The document titled Bed Hold Notification dated 9/4/24 indicated on 9/4/24 the (first notice) admission bed hold notification was performed. The (second notice) bed hold section of the notice that was supposed to be completed upon transferring of the resident, was not completed, the section was blank.During an interview on 7/17/25 at 2:23 p.m., with licensed vocational nurse (LVN) 1 who transferred Resident 1 to [name of facility] on 7/2/25 indicated not remembering if the written bed hold notice (second notification) was provided to the Resident 1's RP.During an interview with the assistant director of nursing (ADON) on 7/23/25 at 11:18 a.m., ADON acknowledged the Bed Hold Notification Form was not completed and not provided to the resident or representative upon the resident's transfer to the hospital.b) A record review for Resident 2 was conducted on 7/15/25. The [name of facility] Notice of Transfer or discharge date d 6/30/25 document indicated Resident 2 was transferred to Saint John's Regional Medical Center at 5:05 a.m. On part B- Bed Hold Section of the document indicated a Bed-hold was authorized for this resident. The document titled Bed Hold Notification Form, dated 6/19/25, indicated on 6/19/25 the (first notice) admission bed hold notification was performed. The (second notice) bed hold section of the notice that was supposed to be completed upon transferring of the resident, was not completed, the section was blank.During an interview with the assistant director of nursing (ADON) on 7/23/25 at 11:18 a.m., ADON acknowledged the Bed Hold Notification Form was not completed and not provided to the resident or representative upon the resident's transfer to the hospital.2. A review of the facility policy and procedure titled Admission, Transfer, Discharge and Bed-Holds, dated 12/2016, in the BED HOLD and readmission section of the policy indicates The notification will include the duration of the bed hold allowance in which the resident is permitted to return and resume residence within the facility and the reserve bed- payment requirements.During an interview with Resident 1's RP on 7/14/25 at 12:15 p.m., RP reported the facility did not provide her with any bed-hold private payment information for the resident's bed to be reserved or held while resident was at the [name of facility]. During an interview with the business office manager (BOM) on 7/16/25 at 12:30 p.m., the BOM was asked if Resident 1's RP was provided with private pay or the reserve bed-payment requirements information to hold the bed for the resident. BOM stated No, I did not.

Jul 2025 5 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 2) was protected from physical and verbal abuse from a fellow resident (Resident 1) who...

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Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 2) was protected from physical and verbal abuse from a fellow resident (Resident 1) who was having undirected behavioral symptoms and outbursts. This facility failure resulted in Resident 2 being slapped by Resident 1 and sustaining bruises (purplish/reddish skin discoloration) to the left arm and hand. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, Resident 2 had diagnoses including, chronic obstructive pulmonary disease (lung disease that makes breathing difficult), acute and chronic respiratory failure with hypoxia (low oxygen levels in the blood), anxiety disorder (excessive feelings of worry, fear, and unease that significantly interfere with daily life), and depression (feeling of sadness, hopelessness, and loss of interest in activities previously enjoyed). During a review of Resident 2's Situation, Background, Assessment, Recommendation (SBAR), dated 5/24/25, the SBAR indicated, around 1 a.m. Resident 2 was slapped by another resident (Resident 1), staff intervened and separated both residents. The SBAR further indicated, on 5/24/25 evening shift 3-11 p.m., Resident 2 was observed with physical signs of injury described as bruising to the right arm and hand. The SBAR with evening nursing notes dated 5/26/25 indicated dark red colored bruise on left shoulder, arm, and hand. Further review of the SBAR which was started on 5/24/25 by night shift - 5/27/25, the bruises found on Resident 2 were identified not on the right hand and arm but on the left shoulder, arm, and hand. During a review of Resident 2's Care Plan (CP), dated 5/26/25, the CP indicated, bruising (purplish/reddish skin discoloration) on the resident's left arm and shoulder. During a concurrent observation and interview on 6/2/25 at 5:18 p.m. with Resident 2, Resident 2 was observed with a large bruise on the left forearm. Resident 2 stated that Resident 1 had accused her of stealing cigarettes and shampoo and then slapped her on the left arm. Resident 2 stated, A Certified Nursing Assistant (CNA) had to pull Resident 1 off of me. Resident 2 further stated not feeling safe being in the same room with Resident 1 and did not want to move to another room unless the other roommate (Resident 3) changed rooms too. In addition, Resident 2 stated the police had been at the facility at least six to seven times that week because of Resident 1's behavior. During a review of Resident 1's Clinical Record, the Clinical Record indicated, Resident 1 had multiple mental and behavioral undirected outbursts secondary to existing behavioral diagnoses including, psychosis (loss of contact with reality, symptoms of hallucinations, delusions and disorganized thinking) and unspecified schizophrenia (mental disorder characterized by disruptions in thinking, perception, emotions, and social interactions). Further review of Resident 1's Clinical Record, indicated, on 5/24/25, Resident 1 had a verbal and physical altercation with a roommate (Resident 2), resulting in Resident 2 sustaining bruises on the left arm. Resident 1's clinical record further indicated, from 5/9/ through 5/29/25 the facility had numerous documentation regarding the resident having undirected aggressive behaviors towards staff and other residents. The crisis team and law enforcement were also called in to the facility due to the escalation of behaviors. The psychiatrist plan was to provide 1:1 staff for Resident 1. During an observation and record review on 6/2/25 at 5:52 p.m. in the facility's smoking patio, Resident 2 was smoking in the same area as Resident 1 with no visible 1:1 staff. During a review of Resident 1's Physician Progress Notes, dated 5/29/25 at 12:10, the Notes indicated, PLAN: facility will continue 1:1 staffing. During an interview on 6/2/25 at 6 p.m. with the Director of Nurses (DON), the DON acknowledged that it is the facility's responsibility to protect the residents. During a review of the facility's policy and procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting, dated 10/2022, the P&P indicated in part, Each resident has the right to be free from abuse .Resident to Resident abuse means the willful infliction of injury .with resulting physical injury, pain or mental anguish by one resident towards another.

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 F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's Interdisciplinary Team (IDT - a group of medical staff that w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's Interdisciplinary Team (IDT - a group of medical staff that work together to provide care of residents) failed to initiate a Significant Change in Status Assessment (SCSA - a comprehensive assessment) for one of four sampled residents (Resident 1) when: 1. Resident 1 refused to take schizophrenia (mental disorder that affects how a person thinks, feels, and behaves), depression (persistent feelings of sadness that interfere with daily life) and other medications. As a result, Resident 1 developed severe symptoms of distress including psychosis (loss of touched with reality), delusions, hallucinations, and paranoia. 2. Resident 1 showed physical and verbal aggression towards other residents and staff, and refused to follow the facility's smoking rules. These failures resulted in Resident 1's escalating behavior becoming more erratic, with increased aggressiveness toward others. No appropriate clinical interventions were implemented, which placed residents and staff at risk for danger and harm when Resident 1 started a fire in the facility. Findings: Review of Centers for Medicare & Medicaid Services (CMS), version 1.20.1 dated October 2025, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, page 45, in the section titled, Significant Change, in Status Assessment (SCSA) the Manual indicated, The SCSA .must be completed when the IDT has determined that a resident had a major decline .in status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. 1. During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including, fracture of right and left calcaneus (breaks in both heel bones), psychosis (loss of contact with reality, symptoms of hallucinations, delusions and disorganized thinking), schizophrenia, chronic pain, opioid (controlled pain medication) dependence, anxiety (feeling of apprehension, tension, and uneasiness) disorder, and depression. Resident 1 was admitted with orders for Physical Therapy (PT) to address admitting condition of right and left heel bone fractures. 1. During a review of Resident 1's Medication Administration Record (MAR), dated 5/1/25 to 5/31/25, the MAR indicated on: 5/8/25 - Resident 1 began refusing the Pro-Stat supplement and incentive spirometer treatments (use of a handheld device to help take slow, deep breaths and expand lungs). The refusal continued the month of May. 5/18/25 - Resident 1 began refusing to take aripiprazole (medication used to manage and treat mental conditions such as schizophrenia, and depression) and sertraline (medication used to treat depression, anxiety, and improve mood). The refusal of Resident 1 to take the medications (aripiprazole and sertraline) continued 5/20, 5/21, 5/24, 5/25, 5/26, 5/27, and 5/28/25. According to Talkspace.com-Abrupt discontinuation of Aripiprazole (Abilify) can lead to a range of withdrawal symptoms, which may include: Neuropsychiatric: Anxiety, restlessness, agitation, irritability, decreased concentration, and mood changes, cause neuroadaptation in the brain, where the brain adjusts to having a new level of dopamine. Suddenly stopping the medication can disrupt this balance, potentially leading to withdrawal symptom and can also increase the risk of a relapse or return of the symptoms that the medication was intended to treat. It's crucial to consult with a doctor before stopping Abilify to ensure a safe and effective tapering plan. There was no evidence in Resident 1's clinic record of an IDT review or determination to initiate a SCSA from 5/18/25 to 5/28/25 when the resident started refusing the regular ordered dose of aripiprazole and sertraline. 2. During a review of Resident 1's PNR dated 5/24/25, the PNR indicated, Resident 1 left facility without signing self out per facility's policy. During a review of Resident 1's Change in Condition Nurse's Notes (CIC), dated 5/25/25, the CIC indicated, the evaluation was due to behavioral symptoms (e.g. agitation, psychosis). The physical assessment outcome indicated, new or worsened delusions or hallucinations and other symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking) for mental status and physical and verbal aggression, danger to self or others, other behavioral symptoms for behavioral status. There was no evidence in Resident 1's clinic record of an IDT review or determination to initiate a SCSA in reference to the CIC for behavioral symptoms dated 5/25/25. During further review of Resident 1's clinical record, the PNR indicated on: 5/9/25 - Resident 1 began displaying symptoms of agitation (restlessness, inability to stay calm, paranoia, suspiciousness, irritability, hostility, confusion, disorientation, inability to communicate, and violent behavior) starting on 5/9/25 and continued 5/13, 5/21, 5/24, and 5/26/25. 5/21/25 - Resident 1 started displaying increased symptoms of verbal aggression towards others. 5/24/25 - Resident 1 had a verbal and physical altercation with a roommate (Resident 2) on 5/24/25, resulting in Resident 2 sustaining bruises on the left arm. 5/25/25 - Resident 1 became verbally and physically aggressive towards a licensed staff (LN 8). 5/25/25 - The crisis team was called to address the physical aggression of Resident 1 in the facility. The facility was informed the crisis team can't respond to any physical aggression secondary to a hands-off approach. 5/27/25 - The crisis team was called again regarding Resident 1's behavior, history of slapping another resident, refusing medication administration, and for being verbally and physically aggressive. The crisis team arrived at the facility, talked to Resident 1 and offered to take the resident to the hospital. Resident 1 refused and claimed not wanting to go back to the psychiatric hospital and will sue the psychiatric hospital. Resident stated her cigarettes and medications were poisoned including that people were being raped. The crisis team stated they can't do anything for the resident or the facility but if the resident continued to refuse medications and meals to call them again to reassess. 5/28/25 - Resident 1 became verbally and physically aggressive towards LN 6. 5/28/25 - Resident 1 took the one-on-one caregiver s notes away, tore several pages from the notebook and started a fire with the torn pages in the patio smoking area. 5/28/25 - The crisis team was called again regarding Resident 1's behavior outside the facility (referring to the fire started in the facility patio area). The crisis team responded, Since there is no suicidal ideation or homicidal ideation, we can't do anything about her behavior. 5/28/25 - The police were called regarding resident's behavior of lighting a fire in the facility's smoking area. LN 1 asked Resident 1 for her lighter, Resident 1 attempted to hit LN 1's arm but the police stopped the resident. The police indicated they can't take the resident out of the facility due to a mental health condition and that the resident had to be moved to a different facility by social services or administration. 5/29/25 - The police were called back to the facility again in regard to Resident 1 starting a fire in the room. While waiting for the police to arrive, Resident 1 took a cell phone from nearby, LN 7 asked the resident to give the cell phone back and Resident 1 threatened to kill LN 7. The resident refused to return the cell phone until the police showed up. The police were able to retrieve the lighter that was used to start a fire inside the Resident 1's room. 5/29/25 - A resident informed LN 7 of being assaulted when Resident 1 ran into his wheelchair. 5/29/25 - Resident 1 threatened the Administrator (ADM) by throwing coffee at the ADM when resident was asked to surrender her lighter for safe keeping. Resident 1 refused to turn in the lighter. 5/29/25 - MD notes indicated a visit to see Resident 1 in the facility. The police and crisis team had been at the facility numerous times over the past four days. Resident 1 stopped taking ordered behavioral medications, is psychotic, paranoid, and delusional, has assaulted several staff and residents, last night started a fire in her room. The police had confiscated her lighter last night, but the resident was able to obtain more this morning. The police were not able to arrest the resident despite the arson and assault on staff and residents due to mental health. Resident was admitted from a psychiatric facility secondary to jumping off a table and breaking both feet. Resident is now refusing to eat and take medications. The crisis team in the building with MD to assess the resident but the crisis team will not take the resident on a 5150 (involuntary 72-hour psychiatric hold) due to resident not posing a threat to self or others. The plan indicated the facility will continue 1:1 staffing, call 911 as needed, and file an APS (Adult Protective Services) report. On 6/1/25, Resident 1 left the facility again (first episode on 5/24/25) without signing self out as per facility's policy. There was no evidence in Resident 1's clinic record of an IDT review or determination to initiate a SCSA in reference to behavioral changes/escalation which began on 5/9/25. During an interview on 6/2/25 at 5 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had an altercation with Resident 2 one week prior. The DON stated that Resident 1 slapped Resident 2. Resident 1 was having behavioral issues. During a concurrent observation and interview on 6/2/25 at 5:18 p.m. with Resident 2, Resident 2 was observed with a large bruise on left forearm (purplish/reddish skin discoloration). Resident 2 stated that Resident 1 had accused her of stealing cigarettes and shampoo and then slapped her on the left arm. A Certified Nursing Assistant (CNA) pulled Resident 1 off of Resident 2. Resident 2 further stated not feeling safe being in the same room with Resident 1 and did not want to move to another room unless the other roommate (Resident 3) changed rooms too. During an observation on 6/2/25 at 5:52 p.m. in the facility's smoking area, Resident 1 was smoking in the same area a few steps away from Resident 2. No facility staff/supervision was visible within the perimeter smoking area. R 1 was observed to be heading towards the unlocked smoking area gate leading to the facility parking lot. Resident 1 then stopped and laid down on the grassy area near the gate. During an interview on 6/2/25 at 6:05 p.m. with Resident 4, who was within the smoking area with other residents also smoking, Resident 4 stated that Resident 1 went bonkers when she stopped taking meds, would push other residents with the wheelchair, would make other residents spill their coffee on themselves, and was verbally abusive to residents and staff. Resident 4 further stated that Resident 1 started a fire with a lighter and was concerned she will burn the whole place down. A review of the facility's initial admission assessment dated [DATE] indicated Resident 1 had no behavioral symptoms, including physical (hitting, grabbing), and verbal. The MDS assessment additionally indicated Resident 1 did not have behavioral symptoms that impacted any other residents. During an interview on 6/2/25 at 10 p.m. with the Minimum Data Set Registered Nurse (MDS-RN), and the DON, the MDS RN stated that an MDS assessment was performed on Resident 1 upon admission, but no other assessments were done. The DON confirmed that no SCSA or other additional MDS assessments were completed when Resident 1 had changes in behavior. The DON indicated no assessments had been performed since Resident 1's admission. During a review of the facility's policy & procedure (P&P) titled, Psychoactive Medication Management, dated August 2014, the P&P indicated, in part, When a resident presents with symptoms or behavior that causes impairment in function, alteration in emotional well-being, or a danger to the resident or others, it is the responsibility of the IDT to determine if the emotional or behavioral symptoms may be caused by a transient medical condition, or reversible environmental and/or psychological stressor. This can be assessed through the MDS/CAA process or by a team evaluation documented in the IDT notes.

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), had their health...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), had their health status accurately documented on the admission Minimum Data Set (MDS: a comprehensive assessment that helps nursing home staff identify health problems and track the improvement or decline of those problems). This failure had the potential to result in an inaccurate plan of care, compromising the resident's quality of life and leading to unmet needs, inappropriate interventions, and negative health outcomes. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted on [DATE] with diagnoses that included, fracture of right and left calcaneus (breaks in both heel bones), psychosis (loss of contact with reality, symptoms of hallucinations delusions and disorganized thinking), unspecified schizophrenia (psychotic symptoms that do not meet the criteria for a more specific schizophrenia spectrum or other psychotic disorder), chronic pain, opioid (moderate to severe pain medication) dependence, anxiety (feeling of apprehension, tension, and uneasiness) disorder, and depression (persistent sadness or loss of interest that interferes with daily life). During a review of Resident 1's MDS, dated [DATE], the MDS sections (I) Active Diagnoses and (J) Fall History on Admission/Entry or Reentry did not accurately reflect Resident 1's health status when questions J1700A, J1700B, and J1700C were marked no which indicated, Resident 1 did not have a fall any time in the last month, in the last 2-6 months, or had sustained a fracture related to a fall in the 6 months prior to admission/entry or reentry. During review of Resident 1's Psych (psychiatric) Discharge Note (PDN), dated 3/06/25, and Health and Physical (H&P), dated 3/7/25, the PDN and H&P did not indicate a diagnosis of schizophrenia. The PDN indicated, Resident 1 was discharged with diagnoses of, anxiety disorder, opiate dependency, and psychosis. The H&P indicated, Resident 1 had diagnoses of, left and right calcaneus fractures, anxiety, and opiate dependency. During review of Resident 1's Order Summary Report (OSR), dated 6/5/2025, the OSR indicated, Resident 1 was prescribed aripiprazole (medication used to manage and treat mental conditions) for psychosis and sertraline (medication used to treat depression, anxiety, and improve mood) for depression. During a concurrent interview and record review on 6/12/25 at 3:18 p.m., with the Minimum Data Set Coordinator (MDS-C), Resident 1's Medication Administration Record (MAR) and MDS were reviewed. MDS-C stated questions J1700A, J1700B, and J1700C in section J of the MDS were incorrectly answered as no and should have been answered as yes. MDS-C acknowledged the MAR indicated Resident 1 was prescribed aripiprazole for psychosis and that the H&P did not include a diagnosis of schizophrenia. MDS-C stated schizophrenia was selected as an active diagnosis in section I of the MDS because the PDN indicated Resident 1 had a history of schizophrenia. During a concurrent interview and record review on 6/13/25 at 11:13 a.m. with the MDS-C and the Director of Nursing (DON), the CMS manual titled, Long-Term Care Facility Resident Assessment Instrument 3.0 (a manual that provides guidance on completing the MDS), dated 10/2025, section I for Active Diagnoses was reviewed. DON and MDS-C acknowledged the absence of a comprehensive psychiatric evaluation and documentation of currently treating Resident 1 for the diagnosis of schizophrenia. Review of the CMS manual titled, Long-Term Care Facility Resident Assessment Instrument 3.0, dated 10/25, the Manual indicated, on page 341, in the section titled, Steps for Assessment, Determine whether diagnoses are active: Once a diagnosis is identified, it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current .medical treatments .during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses .Listing a disease/diagnosis (e.g., arthritis) on the resident's medical record problem list is not sufficient for determining active or inactive status. To determine if arthritis, for example, is an active diagnosis, the reviewer would check progress notes (including the history and physical) during the 7-day look-back period for notation of treatment of symptoms of arthritis, doctor's orders for medications for arthritis, and documentation of physical or other therapy for functional limitations caused by arthritis.

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 and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) when: 1. Female staff were not consistently assigned to Resident 1 as care planned. This failure had the potential to cause emotional distress and compromise Resident 1's psychosocial well-being. 2. Resident 1's cam boot (foot/ankle brace) was replaced with a non-weight-bearing immobilizer cast (a stiff wrap that keeps an injured area stable) on the left foot with no protocol in place for care. This failure had the potential to result in poor circulatory function and delayed healing of Resident 1's left foot fracture. Findings: During a review of Resident 1's admission Record (AR), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including, psychosis (loss of contact with reality, hallucinations, delusions and disorganized thinking) and unspecified schizophrenia (mental disorder characterized by disruptions in thinking, perception, emotions, and social interactions) and fracture of right and left calcaneus (breaks in both heel bones). Resident 1's primary purpose for admission was for physical therapy. 1. During a review of Resident 1's Care Plan (CP), dated 5/26/25, the CP indicated, risk for decline in psychosocial well-being. CP interventions included, Assign a female staff to do 1:1 (one-to-one; one staff member to provide direct, continuous supervision and/or care) CNA (certified nursing assistant) to help with ADL's (activities of daily living). During a review of Resident 1's Interdisciplinary Team (IDT) notes, dated 5/26/25, the IDT indicated, continue 1:1 supervision with female staff. During a review of the facility's Daily Assignment Sheets (DAS), dated 5/24/25 through 6/2/25, the DAS indicated, male staff were assigned as 1:1 caregivers for Resident 1 on 5/29/25 and 5/30/25. During an interview on 6/13/25 at 11:13 a.m. with the Director of Nursing (DON), the DON acknowledged male staff were assigned to provide 1:1 care for Resident 1 on 5/29/25 and 5/30/25, contrary to the formulated care plan dated 5/26/25 specifying that only female staff should be assigned. 2. During a review of Resident 1's Orthopedic Progress Note (OPN), dated 4/11/25, the OPN indicated, a non-weight bearing immobilizer cast to left foot. During a review of Resident 1's Care Plan (CP), dated 3/5/25, the CP titled, Alteration in musculoskeletal status r/t (related to) fracture of left and right calcaneus had no update for the 4/11/25 order of non-weight bearing immobilizer cast to left foot. Further review of the care plan indicated, no interventions in relation to the circulatory function of the left foot while wearing an immobilizer cast. During an interview on 6/13/25 at 11:13 a.m. with the Director of Nursing (DON), DON acknowledged Resident 1's cam boot was changed to a non-weight bearing immobilizer cast on left foot. DON confirmed Resident 1's care plan was not updated to reflect the current immobilizer cast in use/care.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to maintain infection control practices in one of two sampled residents (Resident 2) when Resident 2's respiratory care equipment...

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Based on observation, interview, and record review the facility failed to maintain infection control practices in one of two sampled residents (Resident 2) when Resident 2's respiratory care equipment was not stored in a manner to prevent cross-contamination (accidentally transferring harmful bacteria) or labeled/dated. These facility failures had the potential to result in cross-contamination that could negatively impact Resident 2's health and safety and cause preventable HAIs (Healthcare Associated Infections). Findings: During a review of Resident 2's admission Record (AR), the AR indicated, Resident 2 had diagnoses including, chronic obstructive pulmonary disease (lung disease that makes breathing difficult), acute and chronic respiratory failure with hypoxia (low oxygen levels in the blood), anxiety disorder (excessive feelings of worry, fear, and unease that significantly interfere with daily life), and depression (feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During an observation on 6/2/25 at 5:18 p.m. inside Resident 2's room, a nebulizer (a device that produces a fine spray of liquid for inhaling a medicinal drug) that was not being used was on the bedside table without any dates on the tubing and not stored in a bag/enclosed container. Resident 2's nasal cannula oxygen tubing (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) had no date indicating when the oxygen tubing was last changed. During a concurrent observation and interview on 6/2/25 at 5:40 p.m. with Licensed Nurse (LN1), LN1 observed Resident 2's nebulizer was not stored in a plastic bag and the oxygen tubing was not dated. LN1 acknowledged the nebulizer tubing and oxygen tubing must be dated so staff know when to change them, and the nebulizer should be stored inside a plastic bag when not in use. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated August 2014, the P&P indicated, g. Label humidifier with date and time opened. During a review of the facility's P&P titled, Nebulized Medication/Hand-Held Nebulizer, dated 2008, the P&P indicated in part, .store in a plastic bag that is labeled with the resident name and room number.

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the facility's South Side dining room was safe and clean as evidenced by: 1. A wet and dirty plastic container, surrou...

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Based on observation, interview, and record review, the facility failed to ensure the facility's South Side dining room was safe and clean as evidenced by: 1. A wet and dirty plastic container, surrounded by flying insects (fruit flies), was underneath the sink while ten residents were inside the dining room eating lunch. 2. Next to the sink was a trash can surrounded by flying insects (flies). 3. The corner next to the sink was dirty and the walls had food particles adhered to the wall. 4. The sink had been nonfunctional since 6/1/25, was not covered and without any signage indicating the sink was not working. 5. The dining room floor has broken tiles in multiple areas. 6. The dining room had lots of dark stains especially around the corners. These facility failures exposed residents to risks of contamination, cross-contamination, illness, infection, and injuries from tripping and falling. Findings: 1. A review of the facility's policy and procedure titled Safe, Clean, Comfortable, and Home like Environment, dated 6/2023, indicates In accordance with Residents Rights, the facility will strive to provide a safe, clean .environment . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment . The facility will strive to maintain/enhance a safe, clean, comfortable environment by engaging in the following general practices and considerations: k. Promptly reporting issues to maintenance department, such as: issues with pest or vermin. During a concurrent tour of the South Side dining room and interview with the shift coordinator (SC) on 6/24/25 at 12:12 p.m., a wet and dirty plastic container was surrounded by flying insects (fruit flies) was observed underneath the sink while 10 residents were inside the dining room. Flies were flying in front of the residents' faces, but the residents were not coherent enough to notice the flies. The SC confirmed the observation and stated Yes, those are fruit flies. I did not see this (container with dirty plastic) before. This should not be here. However, the SC didn't remove the container. The container remained underneath the sink. During a concurrent observation of the container with the dirty plastic inside underneath the sink and interview with nursing supervisor (NS) on 6/24/25 at 12:45 p.m., the NS confirmed the observation and stated Yes, I see what you mean. The container is surrounded with the fruit flies and the residents are here eating. This is not good . 2. A review of the facility policy and procedure titled Resident Room Cleaning and Disinfection, dated 2021, indicates It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development of transmission of infections to the extent possible. During a concurrent observation of the South Side dining room trash can, next to the sink, the trash can was surrounded by flying insects (flies) and interview with nursing supervisor (NS) on 6/24/25 at 12:45 p.m., the NS confirmed the corner was dirty and the trash can was surrounded by insects. NS stated, I agree the corner is dirty, there are fruit flies flying around the trash can and the residents are eating here now. 3. A review of the facility policy and procedure titled Resident Room Cleaning and Disinfection, dated 2021, indicates Consistent surface cleaning and disinfection will be conducted with a detailed focus on high touch areas . cleaning of walls . will be conducted when visibly soiled. During a concurrent observation of the South Side dining room corner and interview with the infection preventionist (IP) on 6/24/25 at 1:02 p.m., the dining room corner, next to the sink, and the corner's walls and floor were dirty. One wall had food particles adhered to the wall. Another wall had liquid stains like some liquid had been splashed, drops got on the wall and the liquid ran down the wall. The floor had dark stains, especially at the corners of the floor. The IP confirmed the observation and stated, I agree, this area (corner) is dirty. I heard about the flies around the bucket. I agree, this is an infection control problem. 4. According to the centers for disease control (CDC) 2024, in the section Construction, Renovation, Remediation, Repair, and Demolition indicates Implement infection-control measures relevant to construction ., maintenance ., and repair. Establish and maintain surveillance for airborne environmental disease (e.g., aspergillosis) as appropriate during .repair activities to ensure the health and safety of patients. During a concurrent observation of the South Side dining room sink and interview with the IP on 6/24/25 at 1:02 p.m., the cabinet door where the sink was mounted, had been removed, and an open pipe was exposed, and the sink had not been functional since 6/1/25. The IP indicated making rounds daily however had not seen the sink cabinet door missing, and was not aware the sink was not functioning. The area where the sink was located was not isolated or covered with a barrier to ensure the area was separated from the area where the residents were eating or congregating. The IP agreed and confirmed the sink area was not isolated or covered with a barrier to ensure the residents were not exposed to possible contaminants from the opened pipe, and repair activities. During a concurrent observation of the South Side dining room sink and interview with the director of maintenance, & housekeeping (DMH) on 6/24/25 at 12:26 p.m., the cabinet where the sink was mounted, door had been removed, an open pipe was exposed, and the sink had not been functional since 6/1/25. The DMH confirmed the sink being under repairs, the cabinet door was removed and the cabinet (including the pipe) left exposed or uncovered. Furthermore, agreed there was no signage indicating the sink was under repair. 5. A review of the facility policy and procedure titled Safe, Clean, Comfortable, and Home like Environment, dated 6/2023, indicates .Maintenance services will be provided as necessary to maintain a sanitary, safe, orderly, and comfortable environment. ED, DON, and/or Maintenance/Housekeeping supervisor should conduct regular facility rounds and provide general monitoring/oversight of efforts to maintain a safe, clean, comfortable, environment. During a concurrent observation of the South Side dining room floor and interview with the DMH on 6/24/25 at 12:49 p.m., approximately 12 floor tiles were noted with cracks on tiles, some cracks were larger than others. One tile between the sink and the table where residents were eating was noted to have a large crack with pieces of the tile detached and floating around the area. The DMH reported not being aware of the cracked floor tiles and the staff had not notified him of the tiles needing repair. The DMH confirmed the numerous floor tiles being cracked, and agreed the residents might trip and fall with the tile between the sink and the table where residents seat to each. 6. A review of the facility policy and procedure titled Housekeeping Services, dated 2012, indicates Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. During a concurrent observation of the South Side dining room floor and interview with the infection preventionist (IP) on 6/24/25 at 1:02 p.m., the dining room floor was noted to have numerous areas with dark stains on the floor, especially around the corners of the dining room. The IP acknowledged the observation and stated, I agree the floor is dirty with stains. The IP was asked how often the floor was buffed and/or waxed. The IP stated No, I don't know . On 6/24/25 at 1:50 pm., the nursing supervisor (NS) was asked to provide logs or documentation indicating when the dining room floor was buffed/waxed. The NS requested such documentation from the DMC. The NS reported that according to the DMC, the facility does not have any documentation or logs indicating when or how often the dining room floor is being buffed or waxed.

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a resident's fall incident with fracture to the Department f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report a resident's fall incident with fracture to the Department for one of two residents (Resident 1). Resident 1 experienced an unwitnessed fall, complained of pain on the left hip with an X-ray (process of imaging, using radiation) that indicated an acute fracture. This failure delayed the Department's investigation into the incident and had the potential for Resident 1 and other residents to experience a decline in safety, comfort, and overall well-being. Findings: On 5/16/25, an unannounced visit was made to the facility to investigate a complaint regarding a resident's unwitnessed fall. During a review of Resident 1's admission Record, this indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning) and fracture in the right femur (break in the right leg bone). A review of the Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/28/25, indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 03 that indicated severe impairment. During a review of incident report (SBAR - a standardized communication tool) dated 5/6/25, this indicated an unwitnessed fall on 5/6/25 at 4:30 p.m. This document further indicated, Resident 1 was found on the floor supine position at the end of the bed; when asked what happened, Resident 1 stated, I fell off the bed and was also asked if he tried to walk, stated, I don't know. A review of the Order Summary Report dated 5/7/25, this indicated, May send to ER(Emergency Room) for evaluation and treatment r/t (related to) Left acute Intertrochanteric femoral fracture (a break in the thigh bone). A review of Resident 1's medical record titled First Choice Radiology Service .Radiology Interpretation with a date of exam on 5/7/25, this indicated: Significant Findings Left Hip .Impression: 1. Acute intertrochanteric femoral fracture . During the interview on 5/16/25 at 10:15 a.m., with the Licensed Nurse (LN 1) confirmed Resident 1 had an unwitnessed fall on 5/5/25 at around 4:30 p.m. and was reported to the charge nurse. During the interview on 5/16/25 at 10:30 a.m., with the Director of Nursing (DON), DON stated the Resident 1 had an unwitnessed fall incident that resulted to left hip fracture. During the interview on 5/29/25 at 3:15 p.m., Certified Nurse Assistant (CNA 1), CNA 1 stated that Resident 1 fell while she was showering another resident. A review of the California state law title 22, section 78427 (a)(1), indicated, Death, injury and unusual incidents shall be reported within 48 hours to the Department (Health Facilities Licensing).

Apr 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to change a hearing aid filter for one of three sampled residents (Resident 1) per instructions from an outside clinic. This failure had the p...

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Based on interview and record review, the facility failed to change a hearing aid filter for one of three sampled residents (Resident 1) per instructions from an outside clinic. This failure had the potential for Resident 1's hearing aid to be less effective, potentially impacting Resident 1's ability to hear and communicate. Findings: During a concurrent interview and record review, on 4/16/25, beginning at 3:30 p.m., with the Health Information Manager (HIM 1) and Assistant Director of Nursing (ADON 1), Resident 1's medical record was reviewed. Resident 1 had an appointment at an outpatient clinic on 2/27/25, where Resident 1 returned to the facility with new hearing aids. The outside clinic provided instructions to change the hearing aid filter once a month. The HIM 1 and ADON 1 verbalized Resident 1's hearing aid filter should have been changed on 3/27/25, but it did not happen until 4/8/25. The ADON 1 verbalized the facility could not provide documentation indicating when it received Resident 1's office visit summary with care instructions for Resident 1's 2/27/25 outpatient clinic visit. Resident 1's Progress Notes dated 4/2/25, indicated the facility was not aware Resident 1's hearing aid needed a filter change until 4/2/25, when Resident 1's responsible party requested for Resident 1's hearing aid filter to be changed.

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

Based on interview and record review, the facility failed to follow its scabies (a contagious skin disease marked by itching and small raised red spots, caused by mites) protocol for one of three samp...

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Based on interview and record review, the facility failed to follow its scabies (a contagious skin disease marked by itching and small raised red spots, caused by mites) protocol for one of three sampled Residents (Resident 1). This failure had the potential for scabies to spread throughout the facility. Findings: During a concurrent interview and record review, on 4/17/25, at 1:50 p.m., with the Assistant Director of Nursing (ADON 1), Resident 1's medical record was reviewed. Resident 1's medical record indicated Resident 1 was seen by a Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) on 4/4/25, where Resident 1 was suspected to have scabies. Resident 1 was prescribed Permethrin 5% cream (a medication commonly used to treat scabies). The ADON 1 verbalized the facility could not provide documentation indicating it placed Resident 1 on enhanced barrier precautions on 4/4/25, upon return to the facility, when Resident 1 was suspected of having scabies. During a concurrent interview and record review, on 4/17/25, at 2:48 p.m., with the Infection Preventionist (IP 1), Resident 1's medical record and scabies protocol were reviewed. The IP 1 verbalized and confirmed Resident 1 should have been placed on isolation precautions upon return to the facility on 4/4/25, with suspected scabies, but was not. The IP 1 was asked if the IP 1 had developed a contact identification list, when Resident 1 returned to the facility on 4/4/25, with suspected scabies. The IP 1 verbalized no. The IP 1 verbalized and confirmed facility nursing staff had not received any training on how to recognize and report residents with signs and symptoms consistent with scabies infestation. When asked what scabies protocol the facility utilized/adhered to, the IP 1 provided the document Prevention and Control of Scabies in California Healthcare Settings dated 8/20. The document indicated in part, Contact isolation precautions should be instituted until the suspected (or preliminary) diagnosis has been confirmed and appropriately treated or ruled out .The scabies prevention, control and outbreak management program should include training all physicians, nurses and other HCP (health care personnel) to recognize and report any patient/resident with signs and symptoms consistent with scabies infestation .As soon as a possible case of scabies is identified, the IP (infection preventionist) should develop a contact identification list.

Mar 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow physician orders for the administration of insulin for one of two sampled residents (Resident 1). This facility failure had the pote...

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Based on interview and record review, the facility failed to follow physician orders for the administration of insulin for one of two sampled residents (Resident 1). This facility failure had the potential to expose Resident 1 to unsafe insulin doses, and preventable medication errors. Findings: During a concurrent record review and interview, on 3/12/25, beginning at 3:10 p.m., with the Director of Nursing (DON 1) and Health Information Manager (HIM 1), Resident 1's Medication Administration Record (MAR) was reviewed. Resident 1 had an order for Novolog (a fast acting insulin) 100 unit/ml(milliliter) FLEXPEN (a device used to deliver the insulin) inject as per sliding scale .BS (blood sugar) more than 401 give 16 units and call MD. On 1/25/25, Resident 1's blood sugar was 481. Resident 1's Progress Notes indicated a nurse administered only 14 units of insulin and called the MD. The DON 1 and HIM 1 verbalized the nurse administered the incorrect amount of insulin. The DON 1 and HIM 1 could not provide documentation indicating Resident 1's physician acknowledged the nurses notification or responded to it. During a concurrent and interview and record review, on 3/26/25, beginning at 2:40 p.m., with HIM 1, Resident 1's MAR was reviewed. Resident 1's MAR indicated an order for Novolog 100 unit/ml FLEXPEN inject as per sliding scale .BS more than 401 give 5 units and call MD. On 2/24/25, Resident 1's blood sugar was 485. Resident 1's Progress Notes indicated Resident 1 received only 4 units of insulin. The HIM 1 verbalized the nurse should have administered 5 units of insulin but only administered 4 units. The HIM 1 could not provide documentation indicating Resident 1's physician acknowledged the nurses notification or responded to it. During a review of Resident 1's Care Plan dated 12/25/25, indicated in part, Resident 1 Has Diabetes Mellitus with an intervention of to administer Diabetes medication as ordered by the doctor.

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 record review and interview, the facility failed to provide quality care for one of two sampled residents (Resident 1) ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide quality care for one of two sampled residents (Resident 1) when: 1. Numerous medications were not administered to Resident 1, due to Resident 1 being offsite at a dialysis center. 2. Physical therapy sessions were not provided to Resident 1 as ordered. 3. There was a facility delay following physician orders for Resident 1 to begin weight bearing physical therapy. These facility failures had the potential to result in negative outcomes for Resident 1 and for a delay in care. Findings: 1. During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (a severe condition where the kidneys permanently lose their ability to function properly) type two diabetes (a disease in which blood sugar levels are to high) and dependence on renal dialysis (a life sustaining treatment that filters blood when kidneys fail to remove waste end excess fluid). During a concurrent interview and record review, on 3/12/25, beginning at 12:06 p.m., with the Health Information Manager (HIM 1) Resident 1's Medication Administration Record (MAR) was reviewed. Resident 1's MAR indicated Resident 1 did not receive physician ordered Farxiga (a medication used to treat type two diabetes and chronic kidney disease) on 1/2/25, 1/4/25, 1/7/25, 1/11/25 and 1/14/25, due to Resident 1 receiving dialysis at an offsite dialysis center. Resident 1's MAR further indicated Resident 1 did not receive physician ordered Insulin Glargine (a medication used to treat diabetes) on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25,1/25/25 and 1/30/25, due to Resident 1 receiving dialysis at an offsite dialysis center. The HIM 1 verbalized Resident 1's physician was not made aware of Resident 1 missing these medications due to Resident 1 being at an offsite dialysis center. No documentation could be provided indicating the facility had reached out to Resident 1's physician for either a medication hold or medication administration time change, to ensure Resident 1 received the ordered medications. During a concurrent interview and record review, on 3/26/25, beginning at 2:40 p.m., with the HIM 1, Resident 1's MAR was reviewed. Resident 1's MAR indicated Resident 1 did not receive the following medications and supplements from 1/1/25 through 3/12/25, due to Resident 1 being offsite at a dialysis center: Ferrous Sulfate (used to treat or prevent low iron levels in the blood) give one 325 mg (milligram) tablet one time a day for supplementation at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. Fluticasone Propionate Suspension (a medication used to treat asthma [a lung condition in which your airways narrow]) one spray in each nostril one time a day for asthma at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/4/25, 1/7/25, 1/11/25, 1/13/25 and 1/14/25. Oxybutynin (a medication used to treat symptoms of overactive bladder) give one tablet by mouth one time a day for overactive bladder at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/3/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. Trelegy Ellipta (a medication used to treat lung disorders) one inhalation inhale orally one time a day for wheezing at 0900. The facility did not administer this medication to Resident 1 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 1/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/11/25. Aspirin (a medication used for a variety of purposes including pain reliver, blood thinner, fever reducer) give one 325 mg tablet by mouth two times a day at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25, 2/22/25, 2/25/25. Docusate Sodium (a medication used to treat constipation) give one 100 mg capsule by mouth two times a day for constipation at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/2/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15,25, 2/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. Glycolax Powder (a medication used to treat constipation) give 17 grams by mouth two times a day for constipation at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/13/25, 1/14/25, 1/16/25, 1/18/25, 1/21/25, 1/23/25, 1/25/25, 1/28/25, 1/30/25, 2/1/25, 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25 and 3/11/25. Macrobid (an antibiotic medication) give one 100 mg capsule by mouth two times a day for a urinary tract infection at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/14/25 and 1/16/25. Gabapentin (a pain medication) give one 100 mg capsule by mouth three times a day for pain at 0900, 1300, and 1700. The facility did not administer this medication to Resident 1 at 0900 on 1/2/25, 1/3/25, 1/4/25, 1/7/25, 1/9/25, 1/11/25, 1/18/25 and 1/21/25. Insulin Glargine inject 10 units subcutaneously (under the skin) one time a day for diabetes mellitus at 0900. The facility did not administer this medication to Resident 1 on 2/4/25, 2/6/25, 2/8/25, 2/11/25, 2/13/25, 2/15/25, 2/18/25, 2/20/25 2/22/25 and 3/1/25. Buspirone HCL (a medication used to treat anxiety disorders) give one tablet orally two times a day for anxiety related to restlessness at 0900 and 1700. The facility did not administer this medication to Resident 1 at 0900 on 2/20/25, 2/22/25, 2/25/25, 2/27/25, 3/1/25, 3/4/25, 3/6/25, 3/8/25, 3/11/25. The HIM 1 verbalized Resident 1's physician was not made aware of Resident 1 missing these medications due to Resident 1 being at an offsite dialysis center. No documentation could be provided indicating the facility had reached out to Resident 1's physician for either a medication hold or medication administration time change, to ensure Resident 1 received the ordered medications. During a review of the facility's policy and procedure titled Hemodialysis Care dated 9/7, indicated in part Newly admitted Dialysis Resident .Coordinate provisions for medication administration. 2. During a concurrent record review and interview, on 3/28/25, starting at 11:05 a.m., with the Rehabilitation Director (RD 1), Resident 1's physical therapy records were reviewed. Resident 1's PT (physical therapy) Evaluation form indicated a treatment plan for Resident 1 to receive PT services five times a week for four weeks from 12/24/24 through 1/20/25. Resident 1's PT Evaluation form indicated Resident 1 only received four of the five scheduled physical therapy sessions during the weeks of 12/25/24 to 12/31/24 and 1/1/25 to 1/7/25. The RD 1 verbalized and confirmed Resident 1 only received four of the ordered five physical therapy sessions during those two weeks. 3. During a concurrent record review and interview, on 3/28/25, beginning at 1:35 p.m., with RD 1, HIM 1 and the Assistant Director of Nursing (ADON 1), Resident 1's medical record was reviewed. Resident 1 received an outside physician order on 1/31/25, of May be WT (weight) bearing to tolerance on both LE (lower extremities). The ADON 1 verbalized this order was not implemented until 2/12/25, due to an order discrepancy. The ADON 1 and RD 1 acknowledged due to this order discrepancy, there was a delay in Resident 1 being evaluated by the physical therapy department for weight bearing physical therapy. During a review of Resident 1's Care Plan dated 12/25/25, indicated in part Resident 1 has an alteration in musculoskeletal status r/t (related to) bilateral ankle fractures .Follow MD orders for weight bearing status.

Feb 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 record review, the facility failed to maintain complete and accurate medical records for one of two sampl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of two sampled residents (Resident 1) when an interdisciplinary team (IDT- team members from different discipline with common purpose, to set goals, share responsibilities and make decisions together) admission assessment form was incomplete. This failure had the potential for Resident 1 to have inaccurate and incomplete medical records which could affect the care being provided to them. Findings: During a review of Resident 1's admission Record (AR), dated 2/28/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include COVID-19 (contagious viral infection that affects breathing) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a concurrent interview and record review on 2/28/25 at 12:10 p.m. with the Director of Nursing (DON), Resident 1's IDT admission Assessment, dated 2/18/25 was reviewed. The following sections of the assessment were blank and incomplete: - section A. IDT review date - section B. Hospitalizations and procedures - section C. Diagnosis - Section D. High risk medications - section F. Current functional status - section GG. specific functional status and goals - section G. Skin and Continence - section I. Psychoactive Medications - Section J. Medication Reconciliation - section K. Pain - section L. Advanced Directive - Section M. Safety risk - Section N. Devices - section NN. Bed Rails or positioning/Transfer Bars - Section O. Education - Section OO. CNA Narrative DON acknowledged the IDT admission Assessment is incomplete, and it should have been completed. During a review of the facility's Policy and Procedure (P&P) titled Interdisciplinary Walking Rounds dated 2017, the P&P indicated 72 hour Comprehensive Assessment .Complete the Admission/readmission IDT WR Assessment .Each discipline collects pertinent data and documents on the IDT WR Assessment within 72 hours prior to the scheduled Walking Rounds.

Feb 2025 3 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 2/27/25 at 5:40 p.m., during a supervisory visit, a concurrent observation and interview was conducted with the Administrator...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 2/27/25 at 5:40 p.m., during a supervisory visit, a concurrent observation and interview was conducted with the Administrator (Admin), Director of Nursing (DON) and the Manager for Environmental Services (MES). The DON stated the South wing of the facility was not a 'secured unit' but a unit with doors with alarms. Further observations with the DON and MES were conducted. The 2nd fire exit door exit was observed and was towards end of hallway. Four resident rooms were close by, room [ROOM NUMBER] was where Resident 1 was, with 1:1 sitter and a roommate at the time. The DON stated the sitter sits by the door of the resident's room. A sign code pink was posted on exit door with information on what to do with resident elopement. The DON confirmed code pink referred to a resident trying to elope/have eloped. This fire exit door with STOP sign in red color, opens easily, loud alarms on when opened, leads to a ramp, and one gate, the other side is a fence (not high). Ramp was very close to the street (J St.). The DON stated this ramp was not used for ambulance transport, and was the door where Resident 1 used to exit to the street. The plan of correction submitted on 2/18/25 was observed and confirmed implemented. Based on observation, interview and record review, the facility failed to: Provide adequate supervision for one of two sampled residents (Resident 1) to prevent accidents. Additionally, the facility failed to: -Accurately assessed Resident 1's risk for elopement. -Follow interventions for the administration of anti-anxiety medications. -Call the physician/medical practitioner for change in condition (increased agitation) to seek appropriate care intervention for Resident 1. -Place Resident 1 in a room farther away from the fire exit door which opens to a busy street. These failures resulted in Resident 1 opening an exit door on 2/14/25 between 5:30 a.m. to 5:35 a.m., walked to a busy street, was hit by a moving vehicle, sustained fatal injuries, and was pronounced dead at a local hospital on 2/14/25 at 6:40 a.m. Findings: A review of Resident 1's face sheet indicated Resident 1 was a [AGE] year old male, admitted to the facility on [DATE] with diagnoses including unspecified dementia (signifies memory loss, impaired thinking), psychotic disturbance (a mental health condition characterized by a loss of touch with reality), mood disturbance (prolonged periods of sadness, irritability, or extreme highs), and anxiety (feeling of fear, dread, and uneasiness) per the facility's admission Record. A review or Resident 1's care plan dated 8/6/24, indicated anxiety manifested by aggressiveness or wandering/pacing agitated behavior, and poor impulse control with the goals of reducing anxiety, to keep self and others safe. Interventions include to provide reassurance, redirection or diversion, to administer anti-anxiety medication as ordered, refer to psychiatrist for possible medication adjustment and to reassess and evaluate the appropriateness of his current psychotropic medication regimen. A review of Resident 1's care plan included a focus area initiated on 10/28/2024, indicated the Resident 1 had struck another resident using an empty coffee cup. Interventions included instructions to keep the residents away from each other when in a common area (initiated 10/18/2024). The care plan also indicated a focus area revised on 12/19/2024, of the Resident having episodes of physical aggression related to dementia and poor impulse control. The care plan further indicated Resident 1 had hit another resident on 12/19/2024. Interventions to analyze the time of day, place, circumstances, triggers, and what Resident 1's behavior (initiated 12/15/2024); monitor the resident for behaviors of aggressiveness and document the behavior (initiated 12/15/2024); intervene when the resident becomes agitated (initiated 12/15/2024); and indicated the resident was to receive one-to-one staff supervision, pending an interdisciplinary team (IDT) review (initiated 12/19/2024). A review of the IDT notes dated 1/14/25 , indicated the IDT met following an incident involving the resident grabbing another resident by the jacket and pushing the other resident against a wall. Per care plan dated 1/14/25, to refer for Psych evaluation to review medications for possible adjustment. During a review of Resident 1's psychiatric practitioner's (PP) progress notes dated 2/5/25, indicated Resident was seen for ongoing episodes of physical striking out at other residents, resident is secured in the facility's south wing due to the risk of elopement, self-harm or the need for extensive supervision. During an interview on 2/28/25 at 1:45 p.m., with a certified nurse assistant (CNA2), CNA2 stated there was an instance in January 2025 when Resident 1 went outside the main entrance door in South station by following a visitor who was going out when the door opened. During an interview on 3/7/25 at 11:50 a.m., with Nurse Supervisor 3 (NS 3), NS 3 confirmed she did the elopement risk assessment of Resident 1 on 1/10/25 and evaluated him without elopement risk. NS 3 confirmed not reviewing any records and only based her evaluation to the best of her knowledge of the resident through interview but admitted not reviewing past evaluations, history and other pertinent information. During an interview on 3/8/25 at 12:15 a.m., CNA1 stated that Resident 1 was able to get out of the facility between 5:30 a.m. and 5:35 a.m. on 2/14/25. Resident 1 just got up from bed, went outside room [ROOM NUMBER], Resident 1 pushed the rear emergency exit door (few steps from room [ROOM NUMBER] door), alarm went off, Resident 1 stepped out the door on to the U-shaped handicapped ramp that connects to the street. CNA1 described that while Resident 1 was walking towards the middle of the road; Resident 1 was struck by a car and fell face down to the ground and towards the side of the road. A review of the hospital's trauma progress note dated 2/14/25, indicated, Patient in full arrest after auto vs pedestrian with head trauma .Patient pronounced dead in trauma bay at 6:40 am. During an interview on 3/12/25 at 2:50 p.m., with Licensed Nurse (LN 3), LN3 stated that on 1/2/25, she observed Resident 1 being restless (pacing back and forth) and on 1/6/25, she observed Resident 1 with episode of being suspicious that someone will steal from him. A review of the record titled Elopement Evaluation dated 1/10/25, indicated Resident 1 was not at risk for elopement. During interview on 3/12/25 at 3:05 p.m., the License Nurse (LN 4) stated that on 1/4/25, Resident 1 was observed to have restlessness as manifested by pacing back and forth. During a review of Resident's 1 Medication Administration Record (MAR) dated February 2025, indicated on 2/12/25 anxiety episodes were observed four times during morning shift, 2 times during evening shift, and two times during night shift, and paranoia (suspiciousness) three times in morning shift, two times in evening, and two times at night shift. Moreover, on 2/13/25 anxiety episodes were observed six times during morning shift, two times during evening shift, and two times during night shift, and paranoia (suspiciousness) four times in morning shift, two times in evening, and two times at night shift. However, there were no indications that staff provided non-pharmacological interventions prior to medication administration, nor administered medication (Lorazepam 0.5 mg tablet every six hours) as needed for anxiety. During an interview on 3/14/25 at 3:55 p.m. with LN 5, LN 5 stated that during her afternoon shifts (3pm to 11pm) on 2/12/25 and 2/13/25, Resident 1 told LN 5, I want to go home, someone was out to get me prompting LN 5 to enter 2 behavior episodes in the MAR under behavior monitoring dated February 2025. LN 5 stated she did not call the physician for the behaviors. During an interview on 3/15/25 at 5:22 a.m., a Nursing Supervisor (NS 2), stated during the night shift (11 pm to 7 am) on 2/13/25, she helped Charge Nurse (CN 1) enter a behavior monitoring observation for Resident 1 in the MAR dated 2/12 and 2/13 for behaviors manifested as restlessness (pacing back and forth), and a belief that someone will get him. During an interview on 3/15/25 at 4:15 p.m., LN 2 stated during her morning shifts (7 am to 3 pm) on 2/12/25 and 2/13/25 not administering the antianxiety medication because Resident 1 calmed down with redirection but admitted there was no documentation of the nonpharmacological interventions done and stated not calling the physician for the increased episodes in behavior. During an interview on 3/18/25 at 1:00 p.m., the Psychiatric Practitioner (PP) stated not receiving a call from the facility staff on 2/12/25 and 2/13/25 and further stated he could have ordered medication if he was told of the increased episodes in Resident 1's behavior. A review of the facility's P&P titled Elopement and Missing Resident dated 12/17 indicated, It is policy to monitor and evaluate residents at risk for wandering and elopement. The Interdisciplinary Team (IDT) is responsible for identifying residents at risk for elopement, implementing preventative measures to reduce risk, and provide a process for action if an incident of elopement occurs . A review of the facility's policy and procedure (P&P) titled Resident Assessment, dated 2006, P&P under Care Plan Documentation Guidelines indicated, Nursing service has the overall responsibility to coordinate care among all disciplines to achieve the established goals. A review of the facility's P&P titled Behavioral Health Services, dated 10/22, this indicated, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) Assessment (an assessm...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) Assessment (an assessment tool) for one of two residents (Resident 1). As a result, the elopement risk assessment did not accurately reflect Resident 1's status. Findings: A review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (signifies memory loss, impaired thinking). During the interview on 2/28/25 at 1:45 p.m., with a Certified Nurse Assistant (CNA2), CNA2 stated there was an instance in January 2025 when Resident 1 went outside the main entrance door in South station by following a visitor who was going out when the door opened. CNA2 reported the incident to charge nurse. During a review of Resident1's Medication Administration Record (MAR) dated February 2025, under behavior monitoring, this indicated two episodes of anxiety (one episode on 2/4 and another on 2/6), and one episode of paranoia (suspiciousness) on 2/2. During a concurrent interview and record review on 3/7/25 at 11:50 a.m., with Nurse Supervisor (NS 3), NS 3 confirmed to have completed the elopement risk assessment for Resident 1 on 1/10/25 and the evaluation indicated Resident 1 was not at risk for elopement. NS 3 stated not reviewing any records and only based the evaluation completed to the best of her knowledge of the resident through an interview and acknowledged not reviewing past evaluations, the resident's history and other pertinent information from other staff. During an interview on 3/12/25 at 3:05 p.m. with the Social Services Assistant (SSA), SSA confirmed to have completed the Quarterly Minimum Data Set Section E- Behavior assessment on 1/7/25. SSA acknowledged not checking the MAR dated January 2025 for behavior monitoring for Resident 1. A review of the facility's policy and procedure (P&P) titled Behavioral Health Services, dated October 2022, the P&P indicated, the facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care which includes but not limited to obtaining history from medical records, the resident, and as appropriate the resident's family regarding mental, psychosocial, and emotional health.

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 and record review, the facility failed to ensure interventions of a behavioral care plan was implemented for ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure interventions of a behavioral care plan was implemented for one of two residents (Resident 1). This failure resulted in increased behavioral episodes of aggression, anxiety and paranoia (suspiciousness) for Resident 1. Findings: A review of the facility's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (signifies memory loss, impaired thinking). A review of Resident1's initial psychiatric evaluation by a practitioner dated 8/8/25, this indicated Resident1 was in the hospital due to code 5150 (danger to self and others), struck another resident on admission day, was easily agitated, and was given 1:1 care (1 staff assigned solely to Resident1). A review or Resident 1's care plan dated 8/6/24, indicated focused care on anxiety manifested by aggressiveness or wandering/pacing agitated behavior, and poor impulse control with the goals of reducing anxiety, to keep self and others safe, with interventions that include but not limited to provide reassurance, redirection or diversion, to administer anti-anxiety medication as ordered, refer to psychiatrist for possible medication adjustment and to reassess and evaluate the appropriateness of current psychotropic medication regimen. During a review of Resident's 1 Medication Administration Record (MAR) dated February 2025, it indicated that on 2/12/25 anxiety episodes were observed four times during morning shift, 2 times during evening shift, and two times during night shift, and paranoia (suspiciousness) three times in morning shift, two times in evening, and two times at night shift. Additionally, on 2/13/25 anxiety episodes were observed six times during morning shift, two times during evening shift, and two times during night shift, and paranoia (suspiciousness) four times in morning shift, two times in evening, and two times at night shift. However, there was no documented evidence that staff provided non-pharmacological approach prior to medication administration or administered medication (Lorazepam 0.5 mg tablet every six hours) as needed for anxiety. During the interview on 3/14/25 at 3:55 p.m., with Licensed Nurse (LN5), LN 5 stated that during the afternoon shift (3pm to 11pm), Resident 1 had said I want to go home, someone was out to get me prompting LN 5 to enter 2 behavior episodes in the MAR under behavior monitoring dated February 2025. LN 5 further stated not calling the physician for the behaviors. During the interview on 3/15/25 at 5:22 a.m., NS 2 stated during the night shift (11 pm to 7 am), she helped Charge Nurse (CN 1) entered a behavior monitoring observation for Resident 1 in the MAR dated 2/12 and 2/13 for behaviors manifested as restlessness (pacing back and forth), and a belief that someone will get him. During the interview on 3/15/25 at 4:15 p.m., LN 2 stated not administering the antianxiety medication because Resident 1 calmed down with redirection but acknowledged there was no documentation of the nonpharmacological interventions done and not calling the physician for the increased episodes in behavior. During an interview on 3/18/25 at 1 p.m., with the Psychiatry Practitioner (PP), PP stated not receiving a call from the facility staff on 2/12 and 2/13 and could have ordered for medication if the increased episodes in Resident 1's behavior was reported by staff. A review of facility's policy and procedure (P&P) titled Resident Assessment, dated 2006, P&P under Care Plan Documentation Guidelines indicated, Nursing service has the overall responsibility to coordinate care among all disciplines to achieve the established goals.

Jan 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain a clean and homelike environment in two shower rooms. These facility failures had the potential to negatively impact...

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Based on observation, interview, and record review, the facility failed to maintain a clean and homelike environment in two shower rooms. These facility failures had the potential to negatively impact residents. Findings: During a concurrent observation and interview, on 1/28/25, starting at 4:41 p.m., with the Health Information Manager (HIM 1), the facility's shower rooms were observed. Inside shower room one, located in the south wing of the facility, eight clean/unused razers were found on top of a dirty sharp's container. Inside shower room two, located in the south wing of the facility, seven clean/unused razers were found on top of the dirty sharp's container. The HIM 1 verbalized the clean/unused razers should have been stored at the nurse's station, inside a cabinet, and not on top of the dirty sharp's containers in both shower rooms. Shower room two, located in the south side of the facility along with shower room two, located in the central wing of the facility had broken floor tiles. The HIM 1 confirmed the broken floor tiles in both the south and central wings shower rooms. During a review of the facility's policy and procedure titled Safe, Clean, Comfortable, and Homelike Environment dated 6/23, indicated in part The facility will strive to maintain/enhance a safe, clean, comfortable environment by engaging in the following general practices and considerations .Properly labeling and/or storing personal ADL (Activities of daily living) supplies when not in use .Promptly reporting issues to maintenance department.

Jan 2025 5 deficiencies

CONCERN (E)

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

Based on record review, interview, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident during 4 (10/28/2024, 12/15/2024, 12/19/...

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Based on record review, interview, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse by a resident during 4 (10/28/2024, 12/15/2024, 12/19/2024, and 01/12/2025) of 4 incidents of resident-to-resident abuse involving Resident #118. Findings included: A facility policy titled, Alleged or Suspected Abuse and Crime Reporting, revised 10/2022, indicated, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy further indicated, The facility will monitor the adequacy of assessment, care planning and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse, neglect, exploitation and misappropriation and mistreatment such as, which included, Physically aggressive or self-injurious behaviors. Resident #118's admission Record indicated the facility admitted the resident on 08/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, psychosis, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/22/2024, revealed Resident #118 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #118 did not exhibit any physical or verbal behavioral symptoms directed toward others during the assessment period. Resident #118's care plan included a focus area initiated 10/28/2024, that indicated the resident had struck another resident using an empty coffee cup. Interventions included instructions to keep the residents away from each other when in a common area (initiated 10/18/2024). The resident's care plan revealed a focus area revised 12/19/2024, that indicated the resident had episodes of physical aggression related to dementia and poor impulse control. The care plan indicated the resident had hit another resident on 12/19/2024. Interventions directed staff to analyze the time of day, place, circumstances, triggers, and what de-escalated the resident's behavior (initiated 12/15/2024); monitor the resident for behaviors of aggressiveness and document the behavior (initiated 12/15/2024); intervene when the resident becomes agitated (initiated 12/15/2024); and indicated the resident was to receive one-to-one staff supervision, pending an interdisciplinary team (IDT) review (initiated 12/19/2024). 1. Resident #118's Progress Notes revealed a Social Services note, dated 10/28/2024 at 4:26 PM, that revealed a police department was contacted regarding an altercation between Resident #118 and another resident. 2. Resident #118's Progress Notes revealed a Nursing note, dated 12/15/2024 at 9:52 AM, that revealed a police officer interviewed Resident #118 regarding Resident #118 smacking another resident. 3. Resident #118's Progress Notes revealed a Nursing note, dated 12/19/2024 at 7:00 PM, that indicated a police officer arrived at the facility to make a report. The Progress Notes revealed a note, dated 12/20/2024 at 12:24 AM, that indicated the resident was placed on one-to-one staff supervision. A note, dated 12/20/2024 at 10:15 AM, indicated a psychiatrist had been notified that the resident had punched a resident on the left cheek, and indicated that it was the same resident that Resident #118 smacked on 12/15/2024. 4. Resident #118's Progress Notes revealed an IDT note, dated 01/14/2025 at 10:28 PM, that revealed the IDT met following an incident involving the resident grabbing another resident by their jacket and pushing them against a wall. The note indicated that staff intervened promptly. Per the note, the resident was interviewed and said the incident occurred when the other resident attempted to take Resident #118's chair. The note indicated that the resident stated they (Resident #118) tried to throw a punch at the other resident, but backed off. The note indicated that the resident's statement was not corroborated by staff witnesses. The note indicated that staff observed the resident sitting alone at a table when another resident approached them, and without a verbal exchange between the residents, Resident #118 grabbed the resident and pushed them against the wall. During an interview on 01/13/2025 at 11:21 AM, Resident #28's responsible party (RP), RP #19, stated they had been notified by the facility the prior evening at around 7:00 PM that Resident #28 had been pushed against a wall by another resident at around 6:30 PM. Resident #28's admission Record indicated the facility admitted the resident on 09/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of dementia, post-traumatic stress disorder, psychosis, depression, and repeated falls. A quarterly MDS, with an ARD of 11/12/2024, revealed Resident #28 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #28 did not exhibit any physical or verbal behavioral symptoms directed toward others during the assessment period. Resident #28's care plan included a focus area revised 11/19/2024, that indicated the resident had impaired cognitive function related to dementia, and indicated the resident was at risk for cognitive and behavior changes. Interventions directed staff to administer the resident's medications as ordered and to monitor the effectiveness (initiated 09/05/2024), and to cue, reorient and supervise the resident as needed (initiated 09/05/2024). Resident #28's SBAR [Situation, Background, Assessment, and Recommendation] Alleged Abuse Report of Incident, dated 01/12/2025, revealed an incident of physical abuse had occurred between Resident #118 and Resident #28 on 01/12/2025 at 6:10 PM. The report indicated Resident #118 was sitting in the dining room when Resident #28 approached Resident #118 and told the resident to get out of their (Resident's #28's) chair. The report indicated Resident #118 stood up, grabbed Resident #28 by their jacket, pushed Resident #28 against the wall, and said, What did you say? The report indicated that staff immediately separated the residents. During a telephone interview on 01/15/2025 at 3:01 PM, Certified Nurse Aide (CNA) #10 stated she was the aide assigned to Resident #118 on the day of the altercation. CNA #10 stated she had walked with Resident #118 to the dining room. She stated Resident #118 had sat down at the dining room table, and she had turned to get the resident's food from the food cart in the dining room. She stated she was walking toward the table with the tray when Resident #28 approached Resident #118 and tried to remove Resident #118 from the chair. CNA #10 stated Resident #118 pushed Resident #28 back and asked Resident #28 why they did that to them. CNA #10 stated she set the tray down and separated the residents. She stated Resident #118 returned to their room and she followed the resident to their room with their food tray, and the resident ate in their room. During an interview on 01/15/2025 at 3:10 PM, CNA #13 stated she was in the dining room when the altercation between Resident #28 and Resident #118 occurred. She stated Resident #28 approached Resident #118 and asked why Resident #118 was in their seat. She stated Resident #118 then shoved Resident #28. CNA #13 stated CNA #10 intervened immediately. She said CNA #10 was getting Resident #118's food tray when the incident occurred. She stated she assisted with redirecting Resident #28 after the incident. CNA #13 stated she had never witnessed Resident #118 react like that before but knew the resident had. She stated that Resident #118 received one-to-one staff supervision so staff could monitor them. During a telephone interview on 01/16/2025 at 8:35 AM, Licensed Vocational Nurse (LVN) #17 stated she did not witness the entire incident between Resident #118 and Resident #28, by the time she saw it, Resident #118 had already pushed Resident #28 against the wall. LVN #17 stated she assisted with separating the residents. She stated Resident #118 and Resident #28 were kept separate after the incident. LVN #17 stated she notified the supervisor of the incident. During an interview on 01/15/2025 at 3:39 PM, LVN #16 stated she was the supervisor on the day of the altercation between Resident #28 and Resident #118. LVN #16 stated staff had called her to the unit after the incident. She stated that she was told Resident #118 was sitting in a chair and Resident #28 approached the resident and was leaning over them telling them to get out of their (Resident #28's) chair. LVN #16 stated that Resident #118 stood up and pushed Resident #28 and said, What did you say to me? She stated staff intervened and separated the residents at that point. She stated Resident #118 was receiving one-to-one staff supervision at the time, but the aide had turned to get the resident's tray when Resident #28 approached Resident #118. LVN #16 stated that both residents were assessed with no injuries noted. LVN #16 stated she had notified the Executive Director (ED), law enforcement, and the responsible parties. LVN #16 stated Resident #118 had been receiving one-to-one staff supervision since a previous altercation in December. During an interview on 01/16/2025 at 9:58 AM, the Director of Nursing (DON) stated if there was a resident altercation, she expected staff to separate the residents, and when the residents were safe, the nurse or supervisor notified her. The DON stated she notified the California Department of Public Health within two hours of any allegation of abuse. The DON stated she also notified the police, Ombudsman, responsible parties, and the physicians. The DON stated an SBAR was completed, and the resident was evaluated for any skin injuries. She stated social services staff followed up to monitor the resident for any mood or behavior changes or emotional distress. She stated if there were any changes, the resident was referred for psychiatric services. She stated the facility staff completed a root cause analysis. She stated medication changes were discussed, and laboratory tests were completed and discussed with the physician. The DON stated they discussed possible interventions, including room changes and keeping residents separate from each other. The DON stated the investigation included locating witnesses, including staff and alert residents. The DON stated staff received training and were reminded of who needed to be kept away from each other. The DON stated Resident #118 had received one-to-one staff supervision since a previous incident in December. The DON stated they had looked at alternative placement for Resident #118 but had not been successful, so Resident #118 would remain on one-on-one supervision. During an interview on 01/16/2025 at 10:49 AM, the ED stated if there was a resident altercation, the residents were immediately separated and staff ensured residents were safe, then notified all required parties. He stated they started an investigation, had an IDT meeting to review the cause, and implemented interventions to prevent a recurrence. The ED stated Resident #118 was on one-to-one staff supervision. He stated that he knew Resident #118 had behaviors, so they tried to monitor the resident with one-to-one staff supervision, but the resident could react spontaneously, and things could happen quickly.

CONCERN (E)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected multiple residents

2. Resident #26's admission Record indicated the facility admitted the resident on 06/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of paranoid...

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2. Resident #26's admission Record indicated the facility admitted the resident on 06/04/2024. According to the admission Record, the resident had a medical history that included diagnoses of paranoid schizophrenia (onset date 06/04/2024) and anxiety disorder (onset date 06/04/2024). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/12/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, Resident #26 had active diagnoses of schizophrenia and anxiety disorder. Resident #26's care plan included a focus area revised initiated 06/07/2024, that indicated the resident had anxiety. Interventions directed staff to administer anti-anxiety medication as ordered (initiated 06/07/2024) and to encourage the resident to identify and express causes of their anxiety (initiated 06/07/2024). Resident #26's care plan included a focus area initiated 06/07/2024, that indicated the resident had a potential behavior disturbance related to paranoid schizophrenia. Interventions directed staff to administer medications as ordered (initiated 06/07/2024) and to monitor for anti-psychotic medication side effects (initiated 06/07/2024). Resident #26's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 06/04/2024, completed by a hospital, revealed Section III- Serious Mental Illness Screen, question #10 was answered No and did not reflect the resident's diagnoses of schizophrenia or anxiety disorder. The screening revealed the results were Negative and did not require a Level II evaluation. During an interview on 01/15/2025 at 1:41 PM, the Director of Nursing (DON) stated Resident #26's Level I PASRR screening was completed at the hospital prior to admission. She stated she considered Resident #26's Level I PASRR screening to be inaccurate. She stated diagnoses of schizophrenia or anxiety disorder should trigger as serious mental illness. She stated she was responsible for the PASRR screenings in the facility. The DON stated if a resident was newly admitted , the Level I PASRR screening was sent to the facility from the hospital, and she, as well as medical records staff or the Assistant Director of Nursing (ADON), reviewed the screening for accuracy. The DON stated the facility staff should be looking at the Level I PASRR screenings closer to ensure they were completed correctly. She stated the facility staff needed to make sure the proper referral was made to ensure the resident received the appropriate services. She stated if the Level I PASRR screening from the hospital was not completed correctly, then the facility staff needed to submit a new one. During an interview on 01/15/2025 at 2:54 PM, the DON stated Resident #26 had no other Level I PASRR screenings in their medical record. During an interview on 01/16/2025 at 10:10 AM, the Executive Director (ED) stated the hospital completed the Level I PASRR screenings and sent them to the facility for new admissions. The ED further stated that upon admission, nursing staff or the interdisciplinary team (IDT) reviewed the Level I PASRR screenings to ensure appropriate placement of the resident. The ED stated that he was not a clinician, but he considered schizophrenia to be a serious mental illness. 3. An admission Record revealed the facility admitted Resident #103 on 11/16/2024. According to the admission Record, the resident had a medical history that included diagnoses of psychosis (onset date 11/16/2024) and depression (onset date 11/16/2024). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/23/2024, revealed Resident #103 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses of depression and psychotic disorder. Resident #103's care plan revealed a focus area that indicated the resident had diagnoses that included depression and psychosis. Resident #103's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 11/16/2024, completed by a hospital, specified that the resident required a stay of less than 15 calendar days. The screening revealed the Level I PASRR screening was Negative and revealed, Exempted Hospital Discharge. A letter from the California Department of Health and Senior Services addressed to Resident #103, dated 11/16/2024, indicated that the Level I PASRR screening's result was Negative, indicating Exempted Hospital Discharge. The letter revealed, If the individual remains in the NF [nursing facility] longer than 30 days, the facility must resubmit a new Level I Screening as a Resident Review on the 31st day. During an interview on 01/15/2025 at 1:41 PM, the Director of Nursing (DON) stated she was responsible for the PASRR screenings in the facility. The DON stated a hospital exempted discharge Level I PASRR screening was sufficient for a resident who was in the facility for a short stay but if the resident was to stay long term, then a new Level I PASRR screening needed to be submitted. The DON stated if the facility admitted a resident on 11/16/2024 and they remained in the facility, a new Level I PASRR screening needed to be submitted. She stated that the purpose of submitting a Level I PASRR screening after the 30-day exemption period was to determine if they triggered for a serious mental illness. She stated that she would have to check to see if a new Level I PASRR screening was submitted for Resident #103. During an interview on 01/15/2025 at 2:54 PM, the DON stated there was not an additional Level I PASRR screening located for Resident #103. During an interview on 01/16/2025 at 10:09 AM, the Executive Director (ED) stated a Level I PASRR screening was completed at the hospital, and the hospital sent the screening with the admission inquiry or upon admission to make sure the resident was placed in the proper facility or location for the individual. The ED stated the nursing staff, or the interdisciplinary team (IDT) reviewed the Level I PASRR screening to make sure the facility had it, ensured proper placement of the resident, ensured it was accurate, and followed up with the resident if the resident planned to transition to long-term care. The ED reviewed Resident #103's Level I PASRR screening and stated that according to the document, Resident #103 should have had a new Level I PASRR screening submitted after 30 days. Based on interview, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure Level I PASRR screenings were accurate and also failed to submit a new Level I PASRR screening after a resident remained in the facility longer than 30 days, during which they were exempt from the requirement. The deficiencies affected 3 (Residents #26, #103, and #129) of 4 residents reviewed for PASRR requirements. Findings included: A facility policy titled, Resident Assessment-Coordination with PASARR [Preadmission Screening and Resident Review; PASRR] Program, reviewed/revised 05/2024, revealed, This facility coordinates assessments with the preadmission screening and Resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy revealed, 1. Applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I- Initial pre-screening that is completed prior to admission [sic] i. Negative Level I Screen- permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level I Screen- necessitates a PASARR Level II evaluation prior to admission. The policy revealed, 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. 3. A record of the pre-screening shall be maintained in the Resident's medical record. 4. Exemptions to the preadmission screening program include those individuals who: a. Are readmitted directly from a hospital. b. Are admitted directly from a hospital, requires nursing facility services for the condition for which the individual received care in the hospital, and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a Resident who was not screened due to an exception above and the Resident remains in the facility longer than 30 days: a. The facility should screen the individual using the State's Level I screening process and refer any Resident who has or may have MD [mental disorder], ID [intellectual disability] or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. The California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine if the individual may have a serious mental illness and benefit from specialized services. Question 10. Diagnosed Mental Illness *Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? *If 'yes', there will be a text box question [to] provide the type of mental illness. 1. An admission Record indicated the facility admitted Resident #129 on 08/15/2023. According to the admission Record, the resident had a medical history that included diagnoses of unspecified psychosis (onset date 08/15/2023) and depression (onset date 08/15/2023). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses of depression and psychotic disorder. Resident #129's care plan revealed a focus area initiated 08/17/2023, that indicated the resident had potential behavior disturbance related to psychosis. Interventions directed staff to monitor the resident for aggressive behaviors, redirect the resident, and document the behaviors (initiated 08/17/2023). Resident #129's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 08/08/2023, completed by a hospital, revealed Section III- Serious Mental Illness Screen, question #10 was answered No and did not reflect the resident's diagnoses of psychosis or depression. The screening revealed the results were Negative and did not require a Level II evaluation. On 01/15/2025 at 1:41 PM, the Director of Nursing (DON) reviewed Resident #129's diagnoses and stated that the resident had a diagnosis of psychosis and stated question #10 of the resident's Level I PASRR screening and was not answered correctly. She stated diagnoses of depression or psychosis should trigger as serious mental illness. She stated Resident #129's Level I PASRR screening was considered inaccurate. She stated they had no additional Level I PASRR screenings for Resident #129. On 01/16/2025 at 11:17 AM, the Executive Director (ED) stated Resident #129 had a diagnosis of psychosis, and a new Level I PASSRR screening should have been submitted.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation, interview, and facility document and policy review, the facility failed to serve meals according to the recipes for the planned menu for residents prescribed a pureed diet. Speci...

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Based on observation, interview, and facility document and policy review, the facility failed to serve meals according to the recipes for the planned menu for residents prescribed a pureed diet. Specifically, staff pureed plain beef instead of beef stew, mixed breadcrumbs in water in place of sliced bread to make pureed bread and served applesauce in place of pureed baked apple slices to residents on a pureed diet. This deficient practice had the potential to affect 22 residents who received pureed diets. Findings included: A facility policy titled, Menus, effective February 2009, indicated, 1.0 PURPOSE To ensure food variety, adequate nutrition, and allow for effective planning of food and dining service. The policy indicated the section titled 2.0 FUNDAMENTAL INFORMATION included 3. Therapeutic (Special) diet descriptions/extensions are written for physician-ordered special diets. The policy further indicated the section titled 4.0 PROCEDURE included 6. Recipes are available for use and will be utilized. A facility policy titled, Therapeutic Diets, effective February 2009, indicated, 1.0 PURPOSE Ensure therapeutic diets are written and available as ordered. The policy indicated the section titled 4.0 PROCEDURE included 3. The Food and Dining Services Manager and/or Registered Dietitian writes the therapeutic and mechanically altered menus as an extension of the regular menu, utilizing the same foods when possible. The policy further indicated, 7. The facility prepares and serves all special diets as planned. The facility's Resident Listing Report dated 01/15/2025 indicated 22 residents received a pureed diet. During an interview on 01/14/2025 at 9:30 AM, [NAME] #6 stated she prepared about 45 servings of pureed foods. The facility's menu for Week 5 dated 10/20/2024 revealed the scheduled lunch meal for 01/14/2025 was beef stew, mashed potatoes, mixed green salad, wheat bread, and baked apple slices. The facility's Diet SpreadSheet X-format dated 01/14/2025 revealed the food that residents with pureed diets should have received for lunch included two #8 scoops of beef stew pureed, one #16 scoop of wheat bread pureed, and one #10 scoop of baked apple slices pureed. The BEEF STEW 3OZ [ounces] SCR [scratch] FRSH [fresh] recipe directions for 40 servings included 10 pounds of beef stew meat, one-quarter cup and 2 tablespoons of vegetable oil, 13 oz of diced onions, 1 pound (lb) 9.5 oz of diced celery, 2.25 quarts and 0.5 cup of water, 1 tablespoon and 1 teaspoon of salt, 0.75 teaspoon of black pepper, 3 lbs and 3 oz of diced potatoes, 3 lbs and 3 oz of sliced or diced carrots, additional 1 5/8 teaspoon of salt, additional 0.75 teaspoon of black pepper, 1 cup flour, and 1.5 cup and 2 tablespoons of water. The BEEF STEW 3OZ SCR FRSH PU [pureed] recipe directions for 40 servings included 40 1 cup servings of the scratch prepared beef stew, ½ cup two tablespoons of food thickener bulk, and 1 ¼ quart of water or stock. During a concurrent observation and interview on 01/14/2025 at 9:42 AM, [NAME] #6 pureed 20, 4 oz scoops of plain beef stew meat while adding water. [NAME] #6 said she liked to add the water a little at a time to determine the thickness. [NAME] #6 did not puree the scratch prepared beef stew and was not observed to add food thickener. The WHEAT BREAD CONV [converted] PU recipe directions for 40 servings included 40 slices of bread, 1 ¼ quart of water or juice, and ½ cup 2 tablespoons of food thickener bulk. During a concurrent observation and interview on 01/14/2025 at 10:12 AM, [NAME] #6 filled a 1/3 size, 6-inch-deep steam table pan with hot water and added breadcrumbs while continuously mixing until smooth. [NAME] #6 stated she was preparing the pureed bread. During an interview on 01/15/2025 at 9:06 AM, [NAME] #6 stated she pureed plain beef stew meat instead of beef stew because sometimes the vegetables did not puree well. [NAME] #6 stated she knew the recipe indicated to puree the beef stew, but that she did it differently. [NAME] #6 said she used breadcrumbs instead of sliced bread to make the pureed bread because they had sandwiches for dinner the prior night and she did not want to use up all the bread. The BAKED APPLE SLICES recipe directions for 40 servings included 1 ¼ gallon 1 cup apple slices, 2 ½ cup sugar or brown sugar, 2 3/8 teaspoon ground cinnamon, and 6 ½ oz margarine. The BAKED APPLE SLICES PU recipe directions for 40 servings included 40 ½ cup servings of baked apple slices prepared according to the regular recipe, and 2 ½ cups of food thickener bulk. During an interview on 01/14/2025 at 10:10 AM, [NAME] #8 stated the dessert for lunch that day was baked apple slices, so he just opened a container of applesauce and poured that into small cups for the pureed residents. During a follow-up interview on 01/16/2025 at 8:31 AM, [NAME] #8 stated he used applesauce on 01/14/2025 instead of the baked sliced apples because he knew the applesauce would be the right consistency instead of pureeing the sliced baked apples. During an observation on 01/14/2025 at 11:45 AM revealed [NAME] #6 served the pureed plain beef stew meat, water and breadcrumb mixture, and small cups of applesauce on the tray line for service to the pureed residents. During an interview on 01/15/2025 at 9:49 AM, the Manager of Dietary stated she had been struggling with her staff to follow the menu. She further stated her staff felt overwhelmed to follow the recipes, so they chose the easiest way to get things done. She stated [NAME] #8 did not discuss with her that he used applesauce instead of pureeing the baked sliced apples for dessert. She further stated [NAME] #6 did not puree the beef stew because she felt the celery in the stew would not puree. The Manager of Dietary stated not having the vegetables in the pureed beef stew affected the flavor. During an interview on 01/15/2025 at 11:52 AM, the RD stated the kitchen staff had been trained multiple times to follow the recipes. The RD said staff should check with her if they substitute anything on the menu. The RD stated staff should puree according to the recipe to maintain proper nutrition. During an interview on 01/16/2025 at 10:10 AM, the Executive Director (ED) stated the kitchen staff should follow the diet spreadsheet for the planned menu. The ED further stated staff should follow the menu for pureed diets to ensure the proper nutrition and flavor.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specif...

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Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility's kitchen staff failed to maintain clean food preparation equipment, date and label leftovers, thaw raw meat properly, wear gloves when handling ready-to-eat (RTE) food, and ensure hair restraints were worn in the food preparation areas. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: 1. A facility policy titled, Kitchen Sanitation & [and] Cleaning Schedules, effective in February 2009, indicated 2.0 POLICY Maintain a clean, sanitary, and safe kitchen. The policy indicated, 3.0 PROCEDURE 1. The Food and Dining Services Manager develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals. The policy further indicated, The Food and Dining Services Manager/designee will check the cleaning schedule at the end of each shift to assure assignments have been completed. During a concurrent observation and interview on 01/13/2025 at 9:03 AM, the walk-in freezer had multiple dried liquid spills, food debris, and trash on the floor. Dietary Aide (DA) #18 stated staff cleaned the floor of the freezer on Tuesdays and Saturdays when they received food deliveries. DA #18 said there should not be any trash or debris on the freezer floor. During a concurrent observation and interview on 01/13/2025 at 9:06 AM, a plastic restaurant silverware holder storing clean scoops and serving utensils next to the food preparation station contained spilled food, crumbs, and built-up grime on the holder with multiple crumbs on the food contact portion of the clean utensils. [NAME] #1 stated the plastic restaurant silverware container was cleaned on Wednesdays per the cleaning schedule and then added he would wash the container and utensils at that time because they were dirty. During a concurrent observation and interview on 01/13/2025 at 9:08 AM, the can opener attached to the food preparation table was covered with built up food debris and grime making the metal of the blade on the opener not visible. It was also sticky to the touch. [NAME] #1 removed the can opener out of its stand and stated that he was going to wash it since it was dirty and should not be. During an interview on 01/15/2025 at 9:49 AM, the Manager of Dietary stated she expected her staff to follow the guidelines and regulations for kitchen sanitation. The Manager of Dietary further stated they deep cleaned the kitchen every Thursday and Sunday. She said the freezer floor, the plastic restaurant silverware container, and the can opener should have been cleaned to where there was no food or built-up grime on any of the items. The Manager of Dietary said the kitchen was short staffed and they were not having time to clean as they should. During an interview on 01/15/2025 at 11:52 AM, the Registered Dietitian (RD) stated she expected the kitchen staff to keep up with the cleaning schedules for cleaning the kitchen and expected them to sweep and mop after meals. During an interview on 01/16/2025 at 10:10 AM, the Executive Director (ED) stated he expected the kitchen to be kept clean for food safety to prevent any contamination in the food service areas. 2. A facility policy titled, Food Safety in Receiving and Storage, effective in February 2009, indicated, 1.0 PURPOSE Food is received and stored by methods to minimize contamination and bacterial growth. The policy indicated the section titled General food storage guidelines included 3. Food that is repackaged will be placed in a leak-proof, pest proof, non-absorbent, sanitary container with a tight-fitting lid. The container will be labeled with name of the contents and dated with the date it was transferred to the new container. During a concurrent observation and interview on 01/13/2025 at 9:11 AM, undated, unlabeled, plastic containers containing applesauce, canned peaches, canned pineapples, boiled eggs, and diced ham were in the walk-in refrigerator. There was no date or label on the containers. The Manager of Dietary stated the kitchen went through food so fast that her staff probably opened all those items that morning, The Manager of Dietary then asked Dietary Aide (DA) #2 about the unlabeled containers and DA #2 stated she did not know how long the food in the plastic containers had been there. During an interview on 01/15/2025 at 9:49 AM, the Manager of Dietary stated she expected all foods to be dated and labeled so staff knew what items were and how old they were. The Manager of Dietary said it was challenging to get her staff to consistently date and label leftover food items. During an interview on 01/15/2025 at 11:52 AM, the Registered Dietitian (RD) stated she expected all foods to be dated and labeled to maintain food quality and freshness. During an interview on 01/16/2025 at 10:10 AM, the Executive Director (ED) stated he expected leftover food to be dated and discarded within the appropriate time frame for food safety reasons. 3. A facility policy titled, Safe Food Handling, effective in February 2009, indicated, 2.0 POLICY Sanitary food handling and practices will be followed. The policy indicated the section titled Preparation included 14. Frozen foods are thawed during the cooking process, under refrigeration (preferred method) or by immersion under running potable water of a temperature of 70 degrees F [Fahrenheit] or lower. An observation on 01/14/2025 at 9:28 AM revealed a pan containing three plastic bags of raw chicken with pooling blood on a preparation table at room temperature with no staff attending to it. During an interview on 01/14/2025 at 10:20 AM, [NAME] #6 stated the raw chicken in the pan on the food preparation table was pulled out about 9:15 AM and it was still a little frozen, so they left it on the food preparation table to thaw. During an interview on 01/15/2025 at 9:49 AM, the Manager of Dietary stated the chicken was thawing in the refrigerator prior to being placed on the food preparation table by another cook who was supposed to marinate it. The Manager of Dietary said she expected her staff to thaw meat in the refrigerator or under running water and not at room temperature to prevent foodborne illness. During an interview on 01/15/2025 at 11:52 AM, the Registered Dietitian (RD) stated she expected staff to thaw raw meat in the refrigerator to maintain food safety. The RD said a cook pulled out the raw chicken to season it and it was left out accidentally, so they discarded it. During an interview on 01/16/2025 at 10:10 AM, the Executive Director (ED) stated he expected staff to thaw raw meat in the refrigerator but did not know the expected time frames. 4. A facility policy titled, Safe Food Handling, effective in February 2009, indicated, 2.0 POLICY Sanitary food handling and practices will be followed. The policy indicated the section titled Preparation included 2. Use utensils to handle food or wear disposable gloves when it is necessary to handle food directly with your hands. During an observation on 01/14/2025 at 12:32 PM, [NAME] #7 carried two heads of romaine lettuce and 2 heads of iceberg lettuce with his bare hands and set them on a food preparation table. [NAME] #7 then retrieved two more heads of romaine lettuce from the walk-in refrigerator with his bare hands, set them on the food preparation table, then placed the heads of lettuce into a large pan. [NAME] #7 then jokingly tore a leaf of romaine lettuce off and threw it at another cook. Part of the lettuce leaf landed on the other side of the steam table past the food and the other parts landed on the floor by the trash can. [NAME] #7 then picked up the lettuce leaves that fell on the floor and threw them out. [NAME] #7 did not wash his hands or wear gloves during this process. During an interview on 01/14/2025 at 12:34 PM, [NAME] #7 stated the lettuce was for salads that he was about to prepare and that he did not wear gloves when touching RTE food because he washed his hands all the time. During an interview on 01/15/2025 at 9:49 AM, the Manager of Dietary stated staff should wear gloves when handling RTE food and should not handle it with their bare hands to prevent cross contamination. The Manager of Dietary said throwing lettuce was unacceptable behavior. During an interview on 01/15/2025 at 11:52 AM, the Registered Dietitian (RD) stated the kitchen staff should not handle RTE food with their bare hands but should wear gloves. The RD said they had already spoken to [NAME] #7 about how he should not have thrown lettuce and said he was a newer cook but should not be doing that. During an interview on 01/16/2025 at 10:10 AM, the Executive Director (ED) stated he expected the kitchen staff to wear gloves when handling RTE foods and to wash their hands between glove changes. 5. A facility policy titled, Personnel Sanitation Standards, effective in February 2009, indicated, 2.0 POLICY Food and dining services personnel follow sanitary standards and practices. The policy indicated the section titled 3.0 PROCEDURE included a. Hair must be restrained or covered (via [by way of] hat or hair net). During a concurrent observation and interview on 01/14/2025 at 9:30 AM, Dietary Aide (DA) #3 was wearing a baseball cap with no hairnet or beard net on in the food preparation area putting away clean dishes. DA #3's hair was approximately three inches long on his neck and DA #3 had a full beard approximately one inch long. DA #3 stated he had never been told to wear a beard net. During a concurrent observation and interview on 01/14/2025 at 9:33 AM, DA #4 had a goatee approximately 0.5 centimeters long with no beard net on in the food preparation area retrieving food from storage. DA #4 stated there was no reason he was not wearing a beard net. During a concurrent observation and interview on 01/14/2025 at 9:35 AM, DA #5 had a goatee approximately 0.5 centimeters long with no beard net on in the food preparation area retrieving food from storage. DA #5 stated he had never heard of wearing a beard net when in the food preparation area. During an interview on 01/15/2025 at 9:49 AM, the Manager of Dietary stated she expected her staff to wear hairnets and beard nets when in the kitchen. The Manager of Dietary said she started a year ago and it had been a challenge with this staff to get them to wear beard nets. During an interview on 01/15/2025 at 11:52 AM, the Registered Dietitian (RD) stated she expected the kitchen staff to wear hairnets when in the kitchen. The RD said it was important to wear hair restraints when in the kitchen to prevent any hair from getting in the food. During an interview on 01/16/2025 at 10:10 AM, the Executive Director stated he expected staff to restrain all hair when in the kitchen but did not know that facial hair needed to be restrained using a beard net as well.

CONCERN (F)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Based on observation, interview, and facility policy review, the facility failed to dispose of garbage and refuse properly affecting 3 of 3 dumpsters. Specifically, the trash and recycle dumpster lids...

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Based on observation, interview, and facility policy review, the facility failed to dispose of garbage and refuse properly affecting 3 of 3 dumpsters. Specifically, the trash and recycle dumpster lids were open with overflowing trash piled up over the top of the dumpsters and trash and debris was on the ground surrounding the base of the dumpsters. This had the potential to affect all 171 residents who resided in the facility at the time of the survey. Findings included: A facility policy titled, Garbage & Rubbish Disposal, effective in February 2009, indicated, 1.0 PURPOSE Maintain a sanitary and safe environment through effective disposal of garbage and rubbish. The policy indicated the section titled 3.0 PROCEDURE included 8. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area. During a concurrent observation and interview on 01/13/2025 at 9:15 AM, one recycle dumpster was observed with both lids open and one trash dumpster with one of two lids open with overflowing trash piled up over the top of the dumpster. An additional trash dumpster was observed with both lids resting on top of overflowing bags of trash. A bag of trash was observed on the ground with multiple pieces of trash and food debris spread out around the base of the three dumpsters. The Manager of Dietary stated she would notify maintenance to come and clean the ground around the dumpsters. An observation on 01/14/2025 at 3:57 PM revealed three of the four lids to the trash dumpsters were open with one of the dumpsters overflowing with bags of trash piled up over the top of the dumpster. An observation on 01/15/2025 at 8:30 AM revealed one of two lids were open on one of the trash dumpsters. During an interview on 01/15/2025 at 9:49 AM, the Manager of Dietary stated she expected the dumpster lids to always be closed. The Manager of Dietary said housekeeping and maintenance picked up trash on the grounds around the dumpsters and that it should be done whenever there was trash on the ground. The Manager of Dietary further stated facility staff were not up to date with keeping the grounds around the dumpsters clean. During an interview on 01/15/2025 at 11:01 AM, the Supervisor of Maintenance stated the city provided dumpster services and swept the street every other Friday but could not remember the last time the street was swept. The Supervisor of Maintenance stated there was trash all over the ground and that he cleaned it up daily. During an interview on 01/15/2025 at 11: 52 AM, the Registered Dietitian (RD) stated the dumpsters should remain closed. During an interview on 01/16/2025 at 8:43 AM, the Director of Nursing (DON) stated she expected the dumpsters to be secured, lids closed, and not overflowing. The DON further stated there should be no trash on the ground around the dumpsters. During an interview on 01/16/2025 at 10:10 AM, the Executive Director (ED) stated he expected staff to maintain the dumpsters by keeping the lids closed. The ED further stated it was challenging due to the dumpsters being located on the street and people opened them up looking for leftover food and recyclables. The ED stated it was important to maintain the dumpster area for infection control and to prevent any rodent infestation.

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to obtain a physician order, prior to providing one of two sampled residents (Resident 1) with psychological services. This failure had the po...

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Based on record review and interview, the facility failed to obtain a physician order, prior to providing one of two sampled residents (Resident 1) with psychological services. This failure had the potential for Resident 1 to receive services not approved by a physician. Findings: During a concurrent record review and interview, on 9/17/24, starting at 11:01 a.m., with the Health Information Manager (HIM 1) Resident 1 ' s medical record was reviewed. When asked if Resident 1 was receiving psychological services while at the facility, the HIM 1 verbalzied yes. Resident 1 ' s medical record indicated Resident 1 had received psychological services from 11/1/23 to 7/17/24. The HIM 1 could not provide documentation indicating Resident 1 ' s physician had written an order for Resident 1 to receive psychological services. During an interview on 9/19/24, at 1:48 p.m., with the Director of Nursing (DON 1), the DON 1 verbalzied the facility could not provide documentation indicating Resident 1 ' s physician had written and order for psychological services. During a review of the facility ' s policy and procedure titled F250 Social Services dated 11/16, indicated in part Providing or arranging provision of needed counseling services .An MD order is required.

Aug 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure physician orders for wound care treatment were followed, for one of two sampled Residents (Resident 1). This failure had the potenti...

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Based on record review and interview, the facility failed to ensure physician orders for wound care treatment were followed, for one of two sampled Residents (Resident 1). This failure had the potential for Resident 1 to experience complications from worsening pressure ulcers including increased pain and wound infections. Findings: During a review of Resident 1's admission Record undated, the admission Record indicated in part, Resident 1 had diagnoses including a pressure ulcer (an injury that breaks down the skin and underlying tissue) of the sacral region (lower back area), which was unstageable (full thickness tissue loss), Type Two Diabetes (a chronic condition that causes high blood glucose levels in the blood, which in turn, can delay and/or complicate wound healing), and abnormalities of gait (walking) and mobility (movement). During a concurrent record review and interview, on 8/20/24, starting at 2:00 p.m., with the Health Information Manger (HIM 1), Resident 1's medical record was reviewed. Resident 1's Order Details undated, indicated in part, Resident 1's physician on 7/3/24, at 12:47 p.m., ordered Hydrogel (a gel that promotes wound healing) Apply to Sacrum topically every day and evening shift for pressure injury cleanse with normal saline (a wound cleansing solution), apply Hydrogel. Cover with dry dressing. Review of Resident 1's Treatment Administration Record (TAR), undated, indicated missing entries on the evening shift on 7/3/24, and 7/5/24. The HIM 1 confirmed the missing entries on the TAR and verbalized the facility could not produce any records indicating the physician order was carried out on those dates. During a review of the facility's policy and procedure (P&P) titled, Wound Treatment Management, dated 10/19/19, the P&P indicated in part, It is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to reorder medication from the pharmacy according to their policy and procedure, for one of three sampled residents (Resident 1). This failur...

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Based on interview and record review, the facility failed to reorder medication from the pharmacy according to their policy and procedure, for one of three sampled residents (Resident 1). This failure had the potential to trigger seizures (sudden, uncontrolled burst of electrical activity in brain that can cause temporary changes in behavior, movement, feelings, and level of consciousness) to Resident 1 that can lead to fall or other serious injuries. Findings: During a review of medical records (admission, assessments, history and physical), indicated Resident 1 was admitted in the facility on 4/24/24 with diagnosis of other seizures. BIMS (Brief Interview for Mental Status- a tool used to screen and identify cognitive condition of residents upon admission into a long-term care facility) score of 15 indicated Resident 1 has an intact cognition. Per history and physical as indicated in the order summary, physician determines Resident 1 has the mental capacity to make healthcare decisions. Order summary indicated Resident 1 has an order for Lacosamide (medication to treat partial seizures). During the interview on 7/15/24 at 3:00 pm, Resident 1 stated that about a week ago, she missed her antiseizure medication (Lacosamide) for two days because it was not available as told by the medication nurse. During the interview on 7/15/24 at 3:30 pm with a Registered Nurse (RN), RN stated that they can electronically send a refill request to the pharmacy by way of PCC (facility's computer system) but there is no alert system to track the order status. RN stated that staff rely on verbal endorsements during shift reports without any written communication process to facilitate the timely availability of the medication/s to the resident. During the interview on 7/15/24 at 4:00 pm, Licensed Nurse (LN 1) stated that any LN in any shift who finds the medication inventory being low should initiate the refill request in PCC. LN 1 stated that there was no clear instruction who is responsible for ordering, reordering, and tracking, a potential that it can be overlooked. During the interview on 7/15/24 at 4:15 pm, Assistant Director of Nursing (ADON) stated that per policy, when medication inventory is running low, staff should request refill to the pharmacy five to seven days in advance. During a review of facility Medication Administration Record (MAR) dated July 2024, it indicated Lacosamide was not administered on 7/7/24 at 9 pm and on 7/8/24 at 9 am. During a review of nurse progress notes dated 7/7/24 at 8:25 pm, indicated that Lacosamide was not covered by insurance and followed up with pharmacy. During a review of nurse progress notes dated 7/8/24 at 10:16 am, indicated still awaiting pharmacy delivery of the medicine. During a review of pharmacy supply link for Resident 1, it indicated Lacosamide was ordered on 7/6/24 and was delivered on 7/8/24. During a review of facility's policy and procedure (P&P) titled, Medication and Ordering from Pharmacy Policy, dated May 2022, indicated reorder medication in advance of need to assure an adequate supply is on hand and medication that requires special processing, order at least 7 days in advance of need.

Jun 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain a resident room and restroom, in a clean and homelike manner. This failure had the potential to negatively impact re...

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Based on observation, interview, and record review, the facility failed to maintain a resident room and restroom, in a clean and homelike manner. This failure had the potential to negatively impact residents. Findings: During a concurrent observation, and interview, on 6/20/24, starting at 3:30 p.m., with the Maintenance Director (MTD 1), Resident 2's room was toured. Inside Resident 2's room, the wall was observed in multiple places, to be in a state of disrepair, with large scrapes and areas of missing paint. Inside Resident 2's restroom, a hand sanitizing dispenser, located above the sink, was missing a front cover. The MTD 1 verbalized the wall would need to be repaired and a front cover would need to be installed on the hand sanitizing dispenser. The MTD 1 confirmed these environmental concerns had not been reported by staff nor were these environmental concerns listed on the maintenance log, as items that needed to be addressed. During a review of the facility's policy and procedure titled Resident Environmental Quality dated 10/22, indicated in part It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public .All facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue.

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and revise the care plan for one of three sampl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and revise the care plan for one of three sampled residents (Resident 1) after a verbal altercation with another resident. This failure had the potential to cause psychosocial harm to Resident 1. Findings: Resident 1 was admitted to Shoreline Care Center on 2/28/24, with a primary diagnosis of Unspecified Intracranial Injury (trauma to the head) with Loss of Consciousness. A Minimum Data Set (MDS) cognitive assessment tool reveals Resident 1 of having Brief Interview of Mental Status (BIMS) score 09 (moderately impaired cognition), indicating a mental capacity for an interview. During a concurrent observation and interview on 3/13/24 at 2:30 p.m. at room [ROOM NUMBER], Resident 1 was observed laying in her bed, calm and cooperative, call lights within reach. Resident 1 stated that she became nauseous (urge to vomit), anxious (experiencing worry, unease, or nervousness), and unable to sleep for few nights after the incident last Saturday (3/9/24). During the interview on 3/13/24 at 3:50 pm. with Licensed Nurse (LN 2), LN 2 stated that on 3/9/24 she heard a commotion in room [ROOM NUMBER] and from hallway she saw Resident 2 screaming in a threatening tone, at Resident 1. During the interview on 3/14/24 at 3:00 pm. with the Assistant Social Worker (ASW), ASW stated that Resident 1 told her on 3/11/24 that she was unable to sleep, became nauseous and had anxiety for few nights after the altercation with Resident 2. During concurrent interview and record review on 3/15/24 at 10:07 am, with a registered nurse supervisor (NS), NS stated she was the supervisor on 3/9/24 (Saturday) and she was aware of the incident and witnessed the verbal altercation between Resident 1 and Resident 2. Nursing note entry was not found regarding the incident. NS confirmed assessment and follow-up were not done. During a record review of Res 1's SBAR (Situation, Background, Assessment, and Recommendation), a facility documentation regarding a change in condition, dated 3/11/24 indicated social services entered a note Resident 1 did not sleep well due to stress and nursing notes indicating Resident 1 verbalizing anxiety after the incident. During a record review of facility Progress Notes dated 3/11/24, indicates Psychiatric Physician Assistant recommended Xanax 0.25 mg (medication that helps relieve anxiety) every four hours if needed for anxiety and insomnia (inability to sleep). The medication was ordered and started on 3/12/24 three days after the incident. During a review of Resident 1's care plan regarding the risk for decline in psychological well-being, goals and interventions were initiated on 3/11/24, two days after the incident. During a review of facility Policy and Procedure (P&P), titled Change of Condition , dated 2016, P&P indicates document assessment findings and communications as soon as practical, and notify the physician of assessment findings and subsequent actions.

Feb 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 record review and interview, the facility failed to provide adequate supervision for one of two sampled residents (Resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 eloped (a situation where a resident leaves the facility, without the knowledge of the staff) on two separate occasions. This facility failure had the potential for Resident 1 to suffer negative outcomes. Findings: During a review of Resident 1 ' s admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) stimulant dependence (a condition where a person misuses certain drugs or medications to the point that it has negative effects on their life), post-traumatic stress disorder (a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events, or set of circumstances), and history of traumatic brain injury (an injury that affects how the brain works). During a review of Resident 1 ' s Order Summary Report undated, indicated in part Resident 1 had an active physician order dated 1/26/24, which read May go out on pass for 2-4 hours for therapeutic purposes. During a concurrent record review and interview, on 2/1/24, at 2:55 p.m., at the central nurse ' s station, with licensed nurse (LN 1), the LN 1 explained the facility process for signing out residents who leave the facility on pass. The LN 1 verbalized residents sign out using the form titled Release of Responsibility For Leave of Absence which includes the approximate time the resident leaves the facility and approximate time the resident returns to the facility. The form requires a releasing nurse and receiving nurse to initial the form when a resident leaves and returns to the facility. During a concurrent record review and interview, on 2/1/24, starting at 2:37 p.m., with LN 1, Resident 1 ' s Progress Notes were reviewed. Resident 1 ' s progress notes indicated in part on 1/29/24, Resident (Resident 1) left facility in the AM last seen around 9am. Did not sign out, did not notify nurse [Resident 1] was leaving. Resident (Resident 1) is not answering phone calls. Resident 1 ' s progress notes further indicated in part on 1/29/24, Resident (Resident 1) returned at 14:55pm. Per resident (Resident 1) had fallen asleep under a tree in the corner of the property. The LN 1 verbalized Resident 1 leaving the facility on 1/29/24, without notifying staff and staff being unaware of where Resident 1 was, would be elopement. The LN 1 was asked to clarify why LN 1 ' s progress notes on 1/29/24, indicated Resident 1 had not signed out, yet the Release of Responsibility For Leave of Absence form had been partially completed. The LN 1 verbalized an unknown staff member had Resident 1 sign the Release of Responsibility For Leave of Absence form upon Resident 1 ' s return to the facility on 1/29/24. The LN 1 confirmed Resident 1 had not signed the form prior to leaving the facility on 1/29/24. The LN 1 acknowledged the form still lacked a releasing and receiving nurse signature on 1/29/24. During an interview on 2/1/24, starting at 3:55 p.m., with licensed nurse (LN 3), the LN 3 verbalized on 1/30/24, after coming back from a break, Resident 1 could not be found. The LN 3 confirmed the last time Resident 1 had been seen in the facility, per LN 3 ' s progress note, was around 6:40 p.m. The LN 3 verbalized reporting to licensed nurse (LN 4) that Resident 1 was missing. The LN 3 further verbalized searching the inside and outside of the building, to try to locate Resident 1. The LN 3 confirmed Resident 1 had not signed out with nursing staff at the nurse ' s station, prior to leaving the facility on 1/30/24, sometime after 6:40 p.m. When asked if Resident 1 leaving the facility without notifying staff, and staff being unaware of where Resident 1 had gone on 1/29/24 and 1/30/24, were instances elopement, the LN 3 verbalized they were. During an interview on 2/6/24, starting at 4:00 p.m., with licensed nurse (LN 4), the LN 4 confirmed the facility was alerted to where Resident 1 was on 1/30/24, when Resident 1 ' s sister called around 10:30 p.m., to tell them where Resident 1 was. During a review of the facility ' s policy and procedure titled Elopement and Missing Resident dated 12/17, indicated in part An elopement occurs when a resident leaves the premises or a safe area without authorization or staff notification and/or any necessary supervision to do so.

Dec 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to ensure licensed nurses (LNs) were competent in providing quality of care for two of 2 sampled residents when they failed to: 1...

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Based on observation, interview and record review, the facility failed to ensure licensed nurses (LNs) were competent in providing quality of care for two of 2 sampled residents when they failed to: 1. Complete a comprehensive assessment and individualized care plan related to Resident 1's change of condition (COC), did not report to the attending physician after monitoring the COC for possible further instructions and/or orders. 2. Notify the responsible party on an open lesion documented by LN3 on admission. These failures had the potential for delayed identification of change in health status and implementation of needed healthcare interventions. Findings: 1. During a review of Resident 1's admission Record, dated 11/09/23, this indicated in part that Resident 1 was admitted to the facility with diagnoses that included acute osteomyelitis, venous insufficiency, localized edema, diabetes mellitus (DM) type 2 without complications. During a review of Resident 1's Initial Evaluation, History and Physical Examination dated 11/09/23, Resident 1 has a significant history of seizure disorder who presented to the emergency department for general body aches and lower extremity pain. During a review of Resident 1's Change of Condition (COC), dated 11/11/23, the COC indicated in part shakiness with slight right chest pain without radiating to the arm or neck . Vital signs indicate blood pressure (BP) of 136/72, Pulse Rate (PR) of 76, Temperature of 98 degrees and Oxygen saturation of 97%. The Blood Glucose is 147. Under Provider Notification and Feedback, the clinician was notified 11/11/2023 at 22:06 with recommendation to Monitor. During a review of Follow Up Nurses Notes for Resident 1, dates of 11/11/23;11/12/23; 11/13/23; 11/15/23; 11/17/23; 11/22/23 and 11/23/23, the monitoring of vital signs are documented. Under Section J, Number 10. Describe Current Status regarding COC , entries of no episodes of shakiness and no complaints of slight right chest pain; continue on monitoring for shakiness and arm pain are documented; and 11. Further Comments New MD orders, etc., no evidence of documentation were found. No follow up referral notes, no new orders with attending physician to determine duration of monitoring, cause of COC or if further investigation is warranted if COC recurs. During an interview on 12/1/23 at 2:58 P.M. with licensed nurse (LN)1., LN1 confirmed there was no documentaion of a follow up about the shakiness and no new orders were asked. During a review of Resident 1's Care Plans, no individualized care plans have been developed for the change of condition on shakiness. During a review of Policies and Procedures (P&P) titled Managing Change of Condition dated 01/22, the P&P indicated in part Practice Standards: If the change of condition does not require an immediate 911 transfer the following steps may be followed: 3. Notify the patient and/or responsible party of status, and subsequent actions/orders. 4. Document assessment findings and communications. Update/revise care plan with new interventions. 2. During a review of Resident 2's Wound Evaluation, dated 11/5/23, the wound evaluation indicated in part Open Lesion on Front Left Lateral Lower Leg, New, Present on Admission. Progress notes indicate treatment plan. There was no evidence of documentation that the responsible party was notified of this open lesion. During a review of Policies and Procedures (P&P) titled Managing Change of Condition dated 01/22, the P&P indicated in part Practice Standards: If the change of condition does not require an immediate 911 transfer the following steps may be followed: 3. Notify the patient and/or responsible party of status and subsequent actions/orders.

Nov 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 record review, the facility failed to maintain resident rooms in a clean and homelike envir...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain resident rooms in a clean and homelike environment when: 1. Broken floor tiles observed in two resident rooms. 2. An electrical fan was covered in dust/debris. These facility failures had the potential to negatively impact residents. Findings: During a concurrent observation and interview, on 11/9/23, at 12:12 p.m. with the maintenance director (MTD 1), room [ROOM NUMBER] and room [ROOM NUMBER]'s floors were observed with broken floor tiles. The MTD 1 confirmed both rooms had a broken floor tile and verbalized they needed to be replaced. During a concurrent observation and interview, on 11/9/23, at 12:22 p.m. with MTD 1, in room [ROOM NUMBER], an electrical fan was covered in dust/debris. The MTD 1 acknowledged the electrical fan was dirty and it needed to be cleaned. During a review of the facility's policy and procedure titled Safe and Homelike Environment dated 2/5/20, indicated in part Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment.

CONCERN (D) 📢 Someone Reported This

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

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

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 record review, the facility failed to maintain a bed remote control and call light in safe ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a bed remote control and call light in safe operating conditions. These facility failures had the potential for equipment to be unsafe for use. Findings: During a concurrent observation and interview, on 11/9/23, at 12:06 p.m. with the maintenance director (MTD 1), in room [ROOM NUMBER], a bed remote control and call light were observed with exposed wiring. The MTD 1 confirmed the exposed wiring on the bed remote control and call light and verbalized both needed to be replaced. During a review of the facility's policy and procedure titled Resident Rights, dated 10/22, indicated in part The resident has a right to a safe, clean, comfortable, and homelike environment.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0924 (Tag F0924)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a handrail was in good working order. This fac...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a handrail was in good working order. This facility failure had the potential to place a resident at risk for an avoidable accident. Findings: During a concurrent observation and interview, on 11/9/23, at 12:28 p.m. with the maintenance director (MTD 1), outside room [ROOM NUMBER], a handrail was observed in a state of disrepair and not securely fastened to the wall. The MTD 1 verbalized being unaware of the issue and further verbalized the broken handrail would need to be fixed/replaced. During a review of the facility's policy and procedure titled Resident Rights, dated 10/22, indicated in part Report any unresolved environmental concerns to the Administrator, The policy further indicated The resident has a right to a safe, clean, comfortable, and homelike environment.

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure residents and unauthorized personnel had no access to an open, unlocked supply delivery door. This failure had the potential for resi...

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Based on observation and interview, the facility failed to ensure residents and unauthorized personnel had no access to an open, unlocked supply delivery door. This failure had the potential for residents to go out of the facility unnoticed, into a busy street causing safety issues or for an unauthorized person to enter the facility unnoticed, placing the welfare and safety of residents and staff at risk. Findings: During a facility tour on 9/14/23 at 11:20 AM, a door next to the facility's locked unit (station for residents with memory loss and wandering behavior) marked For deliveries, was observed to be unlocked, with easy access in and out of the facility to a busy street. During a concurrent observation and interview on 9/14/23 at 11:40 AM with a licensed nurse (LN1), the delivery door was observed unlocked. LN1 acknowledged the delivery door was open and unlocked, and indicated the door should always be closed and locked. During a review of the facility policy and procedure (P&P) titled, Instructions. Door, Locks and Alarms, dated 6/2/2023, the P&P indicated, Test doors and hardware for proper operation and condition. During an interview on 9/14.23 at 11:55 AM with the assistant director of nursing (ADON), the ADON indicated the facility door is used for dietary/kitchen supply delivery and dietary plus housekeeping is in charge of ensuring the door is closed at all times post delivery. The ADON indicated the delivery door should be closed and locked at all times when not in use and it was not.

Sept 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide showers for one of two sampled residents (Resident 1) who r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide showers for one of two sampled residents (Resident 1) who required assistance with activities of daily living (ADL). This failure resulted in Resident 1's grooming and personal hygiene not maintained and had a potential to affect Resident 1's quality of life. Findings: During a review of Resident 1's clinical records (CR), this indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including but not limited to multiple fractures of left side ribs, difficulty in walking, and generalized muscle weakness. The admission Minimum Data Set (MDS-an assessment tool) dated 08/10/23, indicated Resident 1 was cognitively intact and required extensive assistance with bathing. During a concurrent record review and interview, on 9/21/23 starting at 11:44 A.M., the bathing record for Resident 1 was reviewed and discussed with the director of nursing (DON); the bathing (ADL documentation) record indicated from 8/11/23 to 8/19/23, the certified nursing assistant (CNA) documented the shower did not occur on 8/14 due to 'resident refused'. Furthermore, on dates 8/16 and 8/18, the CNA documented NA (not applicable or not available) on the PRN (as needed) part of the ADL document. The DON verbally confirmed no showers were provided to Resident 1 for over a week from 8/11/23 through 8/19/23. The DON further stated showers should have been provided two times a week and explained the abbreviation NA should not have been used to document as a resident's response. The facility's undated clinical practice standard titled ADL Documentation indicated, its objective is to enhance the quality and continuity of care, patient safety, access to and communication of plans of care and changes in patient's conditions, and accurate and timely CNA documentation.

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 F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was seen by the physician every 30 days for the first 90 days after admission as stipulated in the regulation. This failure resulted in Resident 1 not able to discuss and not offered to participate in his treatment plans. Findings: During a review of Resident 1's clinical records (CR), this indicated Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS-an assessment tool) dated, 08/10/23 indicated Resident 1 is cognitively intact. During a concurrent record review and interview, on 9/21/23 at 1:40 P.M., the record titled, Physician Visit for Resident 1 was reviewed and discussed with the director of nursing (DON); the History and Physical record indicated the physician handwrote the physical assessment for Resident 1 on 8/4/23. However, the next physician visit did not occur until 48 days later after the first visit as evidenced in the physician's progress note dated, 9/21/23 timestamped 1:32 P.M. No further visit notes were provided. The DON confirmed there was a long gap between the first and second physician visit. The DON further stated the physician visit was to be made every 30 days after admission for the first 90 days after admission. The facility's undated policy and procedure titled Physician Visits indicated, .Monitoring system to assure that physician visits are made and documented every 30 days for the first three visits .

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to demonstrate it offered or provided a shower/bath, for one of two sampled residents (Resident 1). This facility failure had the potential fo...

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Based on record review and interview, the facility failed to demonstrate it offered or provided a shower/bath, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience negative skin outcomes. Findings: During a concurrent interview and record review on 8/23/23, starting at 2:00 p.m., with the Director of Nursing (DON 1) and the Health Information Manager (HIM 1), Resident 1's medical record was reviewed. The DON 1 and HIM 1 confirmed Resident 1's shower schedule was every Monday and Thursday. Resident 1's Documentation Survey Report (a form used by certified nursing assistants to document ADL care) dated 7/23, indicated on Monday 7/17/23 and Thursday 7/20/23, Resident 1 did not receive a shower or bath. The DON 1 and HIM 1 confirmed Resident 1 was at the facility on those dates and acknowledged facility documentation indicated Resident 1 did not receive a shower or bath, while at the facility. The DON 1 and HIM 1 further acknowledged there was no documentation indicating Resident 1 had refused to receive a shower or bath during Resident 1's stay at the facility. During an interview on 8/29/23, at 4:39 p.m., with the DON 1, the DON 1 verbalized the facility did not have a policy and procedure regarding frequency of showers/baths for residents.

Jun 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 F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure podiatry services (medical care and treatment of the human f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure podiatry services (medical care and treatment of the human foot) were provided for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience podiatry complications. Findings: During a review of Resident 1's admission Record, undated, the record indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Type Two Diabetes (a disease that occurs when blood sugar is too high), End Stage Renal Disease (kidneys stop functioning and need dialysis or a transplant to maintain life) and Diabetic Neuropathy (nerve damage that can occur with diabetes). During an interview on 6/15/23, at 10:39 a.m., with the Social Service Director (SSD 1) and the Health Information Manger (HIM 1), the SSD 1 and the HIM 1 verbalized, podiatry care was important for Resident 1, as Resident 1's diagnoses placed Resident 1 at a higher risk for foot infections. During an interview on 6/15/23, at 12:11 p.m., with the Director of Nursing (DON 1), the DON 1 acknowledged, podiatry care was important for Resident 1, due to Resident 1 being at a higher risk for foot complications, because of Type Two Diabetes and Diabetic Neuropathy. During a review of Resident 1's Physician Order Summary Report, dated 6/2/20, the report indicated in part, a physician order, May have Podiatry and Consultation Management As Indicated. During a concurrent record review and interview, on 6/15/23, at 11:03 p.m., with the SSD 1 and the HIM 1, Resident 1's podiatry records, dated 8/18/20 and 1/12/21, were reviewed. Resident 1's podiatry records indicated, on 8/18/20, Resident 1 received podiatry treatment for Onychauxis (a nail disorder that causes toenails to grow abnormally thick), Onychogryphosis (a nail disease that causes one side of the nail to grow faster than the other), and yellow and brittle toenails. The 8/18/20 podiatry record further indicated, Resident 1 received a nail debridement (a procedure that reduces the thickness and length of the nail) and needed a follow up visit in two months. Resident 1's podiatry records indicated, Resident 1's next podiatry visit however, was on 1/12/21. The SSD 1 and the HIM 1 could not produce documentation indicating Resident 1 had refused podiatry services within the time frame of 8/18/20 through 1/12/21, and both the HIM 1 and the SSD 1 acknowledged, Resident 1 did not receive podiatry services as indicated by podiatrist. During a concurrent record review and interview, on 6/15/23, at 11:25 a.m., with the SSD 1 and the HIM 1, Resident 1's podiatry records, dated 9/6/22 and 5/1/23, were reviewed. Resident 1's podiatry records indicated, Resident 1 received podiatry treatment on 9/6/22, which required a follow up visit in two months. Resident 1's podiatry records indicated, Resident 1's next podiatry visit however, was on 5/1/23. The SSD 1 and the HIM 1 could not produce documentation indicating Resident 1 had refused podiatry services within the time frame of 9/6/22 through 5/1/23, and both the HIM 1 and the SSD 1 acknowledged Resident 1 did not receive podiatry services as indicated by Resident 1's podiatrist. During a review of a facility document titled, Podiatry Positive Practice, dated 11/17, indicated in part, Roughly every sixty days the podiatrist will visit and provide routine services to designated individuals. During a review of the facility policy and procure (P&P) titled, Skin Integrity - Foot Care, dated 10/22, the P&P indicated in part, It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health . The facility will provide foot care and treatment in accordance with professional standards of practice, including the prevention of complications, from the resident's medical conditions.

May 2023 1 deficiency

CONCERN (F) 📢 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 F0565 (Tag F0565)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to address residents' concerns, brought to the facility's attention during a Resident Council meeting (a scheduled meeting where residents voi...

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Based on interview and record review, the facility failed to address residents' concerns, brought to the facility's attention during a Resident Council meeting (a scheduled meeting where residents voice concerns and grievances to the facility, to improve residents' quality of life) regarding residents receiving late breakfasts. This facility failure violated resident rights and resulted in the facility not following their own policy and procedures (P&P) pertaining to Resident Council. Findings: During an interview on 4/19/23, at 3:15 p.m., with the Ombudsman (OMB 1- a representative that assists residents in long-term care facilities, with issues related to day-to-day care, health, safety, and personal preferences), the OMB 1 verbalized, they were present at a facility resident council meeting on 4/11/23. The OMB 1 verbalized, during the 4/11/23 resident council meeting, residents voiced their concerns regarding late breakfasts to facility staff, including the Activities Director (AD 1), who was taking notes. During an interview on 4/25/23, at 4:00 p.m., with the Dietary Manger (DM 1), the DM 1 acknowledged, attending the resident council meeting on 4/11/23. The DM 1 verbalized, during the meeting, in a group setting, residents voiced their concerns regarding late breakfasts. During an interview on 4/25/23, at 2:45 p.m., with Resident (Resident 3), Resident 3 confirmed, attending the resident council meeting held on 4/11/23, and acknowledged residents expressed their concerns at the meeting about receiving late breakfasts. During an interview on 4/25/23, at 3:20 p.m., with Resident (Resident 2), Resident 2 verbalized, complaining to staff about receiving late breakfasts. When asked if the facility had addressed the concerns regarding receiving late breakfasts, Resident 2 verbalized, no and stated, If you don't care, you can't give care. During a review of the facility's Resident Council meeting minutes, dated 4/11/23, the minutes indicated, no residents voiced concerns regarding late breakfasts. During a review of the facility P&P titled, Resident Council, dated 11/16, the P&P indicated in part, The facility must listen to the views and act upon the grievances and recommendation of residents and families concerning proposed policy and operational decisions affecting the resident care and life in the facility. The policy further indicated in part Documentation of minutes: a. The minutes will document issues that pertain to the entire group . the facility representative will generate Departmental Response Forms for any new or unresolved concerns . The Department Mangers will be required to respond to the Department Response forms within 10 days and identify a strong plan for prevention. During an interview on 4/25/23, at 3:50 p.m., with the Director of Nursing (DON 1) and AD 1, both DON 1 and AD 1 confirmed there were no notes in the resident council meeting minutes, indicating residents had voiced their concerns regarding breakfasts being served late. When asked if the facility could produce Departmental Response Forms pertaining to the Resident Council concerns of late breakfasts, neither AD 1 or DON 1 could produce the forms.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow their food safety and storage policy and procedure (P&P) when: 1. A can of creamed corn, with multiple dents, was foun...

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Based on observation, interview, and record review, the facility failed to follow their food safety and storage policy and procedure (P&P) when: 1. A can of creamed corn, with multiple dents, was found on dry food storage shelves and not in a designated location labeled Dented cans. 2. A scoop was left in a rice container, in the dry food storage area. These facility failures had the potential for contaminated food items to be served to Residents. Findings: 1. During a concurrent observation and interview, on 4/6/23, at 11:49 a.m., with the dietary manager (DM 1), the facility kitchen and food storage areas were observed. In the facility dry food storage room, a can of cream style corn, with multiple dents, was found on the shelf. The DM 1 acknowledged, the dented can of cream style corn should not be there. The DM 1 verbalized, the facility did not yet set up/have a designated area for dented cans to be stored. 2. During a concurrent observation and interview, on 4/6/23, at 12:00 p.m., with the DM 1, the dry food storage area was observed. In the dry food storage area, a container of rice was observed with a scoop left in it. The DM 1 acknowledged, the kitchen staff should not leave scoops in dry food containers. During a review of the facility's P&P titled, Food Safety in Receiving and Storage, dated 2/9, the P&P indicated in part, . Food will be inspected when it is delivered to the facility and prior to storage for signs of contamination. Examples of signs of contamination include the following .Cans with badly swollen sides or ends, flawed seals or seams, rust, dents, or leaks . If the food cannot be returned immediately, it should be kept away from other food and supplies to prevent contamination. Dented cans are kept in a designated location (labeled dented cans ) until the vendor can pick them up .All food storage bins or containers should be maintained in clean condition .Scoops will not be stored inside bins.

Mar 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow care planned interventions for restorative nursing (therapie...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow care planned interventions for restorative nursing (therapies to help someone with their movement and activities), for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to have a decrease in joint mobility. Findings: During a review of Resident 1's admission Record, undated, the record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses of, but not limited to, pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to both heels and sacral region (lower back), end stage renal disease (a person's kidneys stop working), heart failure, morbid obesity and weakness. During a review of Resident 1's Care Plan, undated, the Care Plan, indicated in part, Resident 1 was At risk for decrease in joint mobility with an intervention, initiated on 2/24/23, of RNA (restorative nurse aid) to assist resident (Resident 1) to perform A/AROM (active range of motion) exercises to BUE (bilateral upper extremity) 3-4 x(times) a week or as tolerated. During a concurrent record review and interview, on 3/17/23, at 5:25 p.m., with the Director of Nursing (DON 1) and the Health Information Manager (HIM 1), Resident 1's Documentation Survey Report, was reviewed. The Documentation Survey Report indicated in part, RNA to assist resident (Resident 1) to perform A/AROM exercises to BLE 3-4x/week or as tolerated. The Documentation Survey Report further indicated, from 2/1/23 through 2/11/23, and from 2/24/23 through 2/28/23, Resident 1 did not receive RNA services. The DON 1 and the HIM 1 confirmed this and acknowledged, if Resident 1 had refused RNA services on those dates, nursing staff should have documented Resident 1 refused, but had not. During a review of the facility's policy and procedure (P&P) tilted, Care Plan, Comprehensive, dated 12/17, the P&P indicated in part, The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life.

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 record review and interview, the facility failed to follow physician orders for wound care treatment and pain managemen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders for wound care treatment and pain management for one of two sampled residents (Resident 1). These facility failures had the potential for Resident 1 to experience negative outcomes. Findings: During a review of Resident 1's admission Record, undated, the record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses of, but not limited to, Pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to both heels and sacral region (lower back), end stage renal disease (a person's kidneys stop working), heart failure, morbid obesity and weakness. During a concurrent record review and interview, on 3/17/23, at 5:35 p.m., with the Director of Nursing (DON 1) and the Health Information Manager (HIM 1), Resident 1's Treatment Administration Record (TAR), dated 1/23, and Medication Administration Record (MAR), dated 1/23 were reviewed. Resident 1's TAR, indicated in part, on 1/1/23, a physician order was initiated for Calazime (a skin protectant), apply to coccyx (tail bone) every shift for skin maintenance, cleanse with soap and water, pat dry, and apply ointment. Resident 1's TAR, for this physician order, had blank entries on 1/6/23, 1/11/23, 1/27/23, 1/31/23, 2/3/23 and 2/12/23. The DON 1 and the HIM 1 acknowledged the blank entries, and could not provide documentation indicating Resident 1 had refused treatment on those dates. Resident 1's MAR indicated, a physician order, initiated on 11/16/23, for Diclofenac Sodium Gel 1% (a pain reliever), apply 1 application transdermally four times a day for pain. Resident 1's MAR, for this physician order, had blank entries on 1/6/23, 1/11/23, 1/27/23, 1/31/23 and 2/26/23. The DON 1 and the HIM 1 acknowledged, the blank entries and could not provide documentation indicating Resident 1 had refused the physician order on those dates. When asked if the facility had a policy regarding nursing staff following physician orders, the DON 1 stated, No and further verbalized, it was a standard of practice for nurses to follow physician orders.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one of two sampled Residents (Res 1's), package was secured when delivered to the facility. This facility failure resulted in Res 1 ...

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Based on interview and record review, the facility failed to ensure one of two sampled Residents (Res 1's), package was secured when delivered to the facility. This facility failure resulted in Res 1 not receiving their package, and the potential for the loss and theft of all Residents' packages. Findings: During an interview on 3/15/23, at 3:05 p.m., with Activity Therapy Director (ATD), ATD stated, Normally, the Receptionist (REC) locks packages in the business office, then when I come in the morning, or my staff, we get them, log them and deliver. ATD further stated, Unfortunately, that was REC 1's first day and they must not have known. ATD confirmed the process was not followed by a head nod. During an interview on 3/15/23, at 3:30 p.m., with the evening receptionist, (REC 1), REC 1 stated, I've been told since that day that I should lock it (delivered package) in the business office, but that day I didn't know that yet and I was going to take it to Res 1, but a Certified Nurse Assistant (CNA), said they would take it to Res 1. REC 1 further stated, Two days later, Res 1 called the front desk and asked about it. I told Res 1 I had signed for it but hadn't seen it since I gave it to a CNA. I didn't know the CNA's name and haven't seen the CNA since. I'm new and that was my first shift alone. During a review of the Theft and Loss Report, dated 2/9/23, the form indicated in part, .Resident 1's name .package with body wash . 2/7/23 at 3 p.m . spoke with REC 1 regarding package. REC 1 gave the package to a CNA (not able to identify) after it was delivered. REC 1 was not able to deliver Res 1's package because REC 1 was attending to calls. During a review of the facility's policy and procedure titled, Resident Rights, dated 10/2022, the P&P indicated in part, .The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility . The P&P had no indication of the facility process for delivering resident packages.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), was repositioned in bed, every 2 hours, as indicated in Resident 1's care plan. This facility failure had the potential to contribute to Resident 1's pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) worsening. Findings: During a review of Resident 1's admission Record, undated, the record indicated in part, Resident 1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Type 2 Diabetes Mellitus (high sugar in the blood, affects wound healing), left sided hemiplegia (paralysis-unable to move) and hemiparesis (weakness), after a stroke and difficulty in walking. During a review of Resident 1's Care Plan, undated, indicated in part, on 11/16/22, Resident 1 had the Potential for impaired skin integrity related to limited mobility . Reposition every two hours in bed. Resident 1's Care Plan further indicated, on 2/9/23, the facility identified a pressure ulcer to Resident 1's coccyx (lower back region) and an open wound on Resident 1's right calf (lower leg region), with a facility intervention of Repositioning q (every) 2 hours and prn (as needed). During a review of Resident 1's Documentation Survey Report, dated 2/23, and 3/23, the reports indicated, Reposition every 2 hours. Document towards the end of shift repositioning task completed. Further review of Resident 1's Documentation Survey Report, the report indicated, Resident 1 was not repositioned the entire a.m. shift (7:00 a.m. to 3:00 p.m.) on 2/3/23, and the entire evening shift (3:00 p.m. to11:00 p.m.) on 3/11/23 and 3/14/23. During a concurrent record review and interview on 3/16/23, at 9:58 a.m., with the assistant director of nursing (ADON 1) and the health information manager (HIM 1), Resident 1's medical record was reviewed. The HIM 1 confirmed, facility documentation indicated, Resident 1 was not repositioned per Resident 1's care plan, the entire a.m. shift on 2/3/23, and on two separate evening shifts on 3/11/23, and 3/14/23. HIM 1 and ADON 1 verbalized, the facility could not produce documentation indicating Resident 1 had refused to be repositioned on those dates. During a review of the facility's policy and procedure (P&P) titled Skin Integrity, dated 8/14, the P&P indicated in part, Care plan implementation of a preventative program to maintain skin integrity will be implemented at time of admission for at risk residents . turn and reposition at least every two (2) hours while in bed or in a chair.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide one of two sampled residents (Resident 1), with functioning equipment in order to receive phone calls in Resident 1's room. This failure had the potential for Resident 1 to feel isolated and cause psychosocial harm. Findings: During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs Positive Practice, dated November 2017, the P&P indicates in part, . The facility's physical environment and staff's behavior will be modified to assist the resident in maintaining independent functioning, dignity, and wellbeing and The facility staff is instructed to meet resident's personal, mental and physical needs. These include personal grooming, socialization, personal clothing of choice, telephone, marriage privileges, home-like environment, and attempting to honor life routines. During a review of resident 1's clinical record, the record indicated, resident 1 was admitted to the facility on [DATE] with very limited mobility and a Stage 4 (Full thickness skin and tissue loss) ulcer on coccyx (tail bone) since 3/23. During a review of Resident 1's Care Plan, dated 1/23, the Care Plan indicates, an intervention for the presence of the Stage 4 pressure ulcer of the coccyx dated 1/25/23, provide offloading of ulcer site (keeping pressure off area). During an interview on 3/13/23, at 9:56 a.m., with a licensed nurse (LN 1), LN 1 verbalized, residents receiving phones calls to the facility would have to take the calls outside their room, as the facility cordless phone was broken. When asked if Resident 1 was being moved from bed to a wheelchair in order to receive a call, LN 1 stated no. LN 1 agreed, Resident 1 had not been able to receive phone calls from their family due to the broken cordless phone. During an interview on 3/13/23, at 10:31 a.m., with the Director of Nursing (DON), the DON agreed, Resident 1 was unable to receive phone calls in Resident 1's room, due to the facility's broken cordless phone.

Mar 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 F0577 (Tag F0577)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to ensure the results of the most recent complaint surveys (surveys conducted due to concerns from residents, their families, or other members...

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Based on record review and interview, the facility failed to ensure the results of the most recent complaint surveys (surveys conducted due to concerns from residents, their families, or other members of the community) were included in the facility's survey results binder. This facility failure had the potential to violate residents' rights to review past survey results. Findings: During a concurrent record review and interview, on 3/8/23, at 1:44 p.m., with the assistant director of nursing (ADON 1), the facility's survey results binder was reviewed. The survey results binder did not contain any complaint survey results from 2023. The ADON 1 reviewed the survey binder, confirmed the binder was outdated, and verbalized the facility needed to update their survey results binder, to include the 2023 findings from complaint investigations. During a review of the facility's Resident [NAME] of Rights, dated 5/11/23, indicated in part, A facility must protect and promote the right of each resident, including each of the following rights .Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination in a place readily accessible to residents, and must post a notice of their availability.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure a call light was within reach, for one of two sampled residents (Resident 2), when Resident 2's call light was underneath Resident 2's...

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Based on observation and interview, the facility failed to ensure a call light was within reach, for one of two sampled residents (Resident 2), when Resident 2's call light was underneath Resident 2's bed. This facility failure had the potential for Resident 2 not being able to call for help, and a delay in receiving care. Findings: During a concurrent observation and interview, on 2/8/23, at 1:20 p.m., with the assistant director of nursing (ADON 1), inside Resident 2's room, Resident 2's call light was on the floor, underneath Resident 2's bed. The ADON 1 acknowledged, Resident 2's call light was on the floor and was out of reach for Resident 2. During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, dated 10/22, the P&P indicated in part, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside . to allow residents to call for assistance .Staff will ensure the call light is within reach of resident and secured, as needed.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on record review, and interview, the facility failed to administer and dispose of a Fentanyl patch (a medication used to treat moderate to severe pain) per physician orders, for one of two sampl...

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Based on record review, and interview, the facility failed to administer and dispose of a Fentanyl patch (a medication used to treat moderate to severe pain) per physician orders, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to experience an increase in pain and resulted in the improper disposal of a class two scheduled drug (a medication that has a high potential for abuse, that is currently accepted for medical use, with severe restrictions). Findings: During a review of Resident 1's Medication Administration Record (MAR) dated, 1/23, indicated in part, the following physician order. Fentanyl patch 50mcg (microgram)/hr (hour) apply 1 patch transdermally every 48 hours for pain . 1st nurse to initial for removal & destruction .2nd nurse to witness and document initials for destruction of old patch on separate order. During a review of Resident 1's MAR, dated 1/23, indicated on 1/7/23, Resident 1 did not receive the physician order for the 50mcg fentanyl patch at 1:00 a.m., due to MN (medication not available). During a review of Resident 1's Controlled Drug Record (a form used by the facility to document narcotic destruction), dated 1/7/23, indicated licensed nurse (LN 3) removed one used 50mcg fentanyl patch from Resident 1 at 1:00 a.m., and destroyed it, without a second nurse to witness the destruction of the used 50mcg fentanyl patch. The Controlled Drug Record further indicated When a patch is removed, it must be immediately destroyed and witnessed with two nurse signatures. During a concurrent interview, and record review, on 1/18/23, at 2:16 p.m., with the assistant director of nursing (ADON 1), and medical records (MR 1), Resident 1's MAR and Controlled Drug Record were reviewed. Both MR 1 and ADON 1 acknowledged Resident 1 did not receive the scheduled 50mcg fentanyl patch on 1/7/23, due to the facility running out of the medication. MR 1 and ADON 1 further acknowledged on 1/7/23, Resident 1's Controlled Drug Record was missing a second nurses signature, for the disposal of Resident 1's used 50mcg fentanyl patch. During a review of the facility's policy and procedure titled Medication Safety Alert ,dated 5/08, indicated in part Disposal of Fentanyl Transdermal Patches .Disposal of wasted patches during medication pass should be witnessed.

Jan 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on interview, and record review, the facility failed to implement a care planned intervention, for one of two sampled residents (Resident 1), who sustained a human bite wound, while in the facil...

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Based on interview, and record review, the facility failed to implement a care planned intervention, for one of two sampled residents (Resident 1), who sustained a human bite wound, while in the facility. This facility failure had the potential for Resident 1 to have wound complications go unnoticed by staff, leading to a potential delay in treatment. Findings: During a review of the facility's policy and procedure titled, Care Plan, Comprehensive dated 12/17, indicated in part The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life . Care plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs .Resident progress is regularly evaluated, and approaches revised or updated as appropriate. During a review of Resident 1's Care Plan dated, 1/3/23, indicated in part, Resident 1 had been bitten by a roommate (Resident 2) on Resident 1's left forearm on 1/3/23, which left a 4x4 inch bite marks with slight bleeding. The care plan further indicated a goal that Resident 1 would not have complications or further skin breakdown from a human bite through the target date of 1/21/23. The Care plan further indicated as an intervention/task to Monitor for signs of infection and further skin breakdown for Resident 1's bite wound. During a concurrent record review, and interview, on 1/12/23, at 4:40 p.m., with the director of nursing (DON 1), the DON 1 was asked to provide documentation indicating the facility monitored Resident 1's bite wound for signs of infection and further skin breakdown on 1/7/23. The DON 1 verbalized and confirmed the facility did not have any documentation indicating facility staff monitored Resident 1's bite wound for signs of infection and further skin breakdown on 1/7/23.

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

Based on record review, and interview, the facility failed to administer Norco (a drug used to treat moderate to severe pain) per physician orders, for one of two sampled residents (Resident 1). This ...

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Based on record review, and interview, the facility failed to administer Norco (a drug used to treat moderate to severe pain) per physician orders, for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to receive inadequate pain medication, and at times, unnecessary pain medication. Findings: During a concurrent record review, and interview, on 1/11/23, at 4:42 p.m., with licensed nurse (LN 1), Resident 1's medication administration record (MAR) was reviewed. Resident 1's MAR indicated in part, a physician order for Norco oral tablet 10-325MG (milligram) Give 1 tablet by mouth every 4 hours as needed for severe pain (Pain scale 7-10). On seven separate occasions, between 1/7/23 through 1/10/23, Resident 1 received one tablet of Norco, when Resident 1 reported a pain level of zero out of ten. LN 1 verbalized Resident 1's MAR indicated Resident 1 received Norco outside of physician orders on seven separate occasions between 1/7/23 through 1/10/23. During a concurrent record review, and interview, on 1/12/23, at 3:20 p.m., with the director of nursing (DON 1), Resident 1's MAR was reviewed. Resident 1's MAR indicated a physician order for Norco oral tablet 10-235mg, give 1, 0.5 tablet, by mouth every 4 hours as needed for moderate pain (Pain scale 4-6). The MAR indicated on two separate occasions on 1/3/23, Resident 1 received a 0.5 tablet of Norco, when Resident 1 pain level was rated at a seven out of ten. The DON 1 acknowledged Resident 1's Norco was administered outside the pain scale parameters, set by Resident 1's physician. During a review of the facility's policy and procedure titled Pain Management Process , dated 6/09, indicated in part It is the responsibility of the licensed nurse to consistently assess, manage, and monitor pain for all residents. The results of the assessment, effectiveness of the pain intervention(s), and monitoring of behaviors are necessary components within the documentation. The policy further indicated in part The objective of the pain management process is to identify resident need and determine potential referrals/interventions to affect positive functional change through pain reduction, modification of the perception of pain, and enhancement of the quality of life.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure two call lights were in operating condition, for two residents (Resident 3 and Resident 4). This facility failure had ...

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Based on observation, interview, and record review, the facility failed to ensure two call lights were in operating condition, for two residents (Resident 3 and Resident 4). This facility failure had the potential for residents to experience a delay in care. Findings: During a concurrent observation and interview, on 1/4/23, at 1:00 p.m., with the interim maintenance director (IMD 1), resident (Resident 3) call light was tested for functionality. The call light indicator outside Resident 3's room, did not illuminate, when the call light button was pressed inside Resident 3's room. The IMD 1 confirmed the call light was broken and verbalized it needed to be replaced and or fixed. During a concurrent observation and interview, on 1/4/23, at 1:02 p.m., with IMD 1, resident (Resident 4) two call lights were tested for functionality. One of the two call light indicators, failed to illuminate above Resident 4's door, when the call light button was pressed, inside Resident 4's room. The IMD 1 verbalized being unsure as to why Resident 4 had two call lights, but confirmed one was not working and it needed to be replaced and or fixed. During a review of the facility's policy and procedure titled, Call Light, Use of , undated, indicated in part For bedside call lights, a light .will appear and be heard over the door of the resident's room and on the board at the nursing station .Notify the maintenance department and enter defective call light location(s) in the maintenance log, if the facility has such a log.

Jan 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment when: 1. A window frame was broken and window screen was partially torn in room [ROOM NUMBER]. 2. A bed control remote had exposed wires in room [ROOM NUMBER]. 3. A television was in disrepair and inoperable in room [ROOM NUMBER]. 4. A television stand was covered in dust/debris in room [ROOM NUMBER]. 5. a missing section of floor tile, a ceiling stain and non-operable television in room [ROOM NUMBER]. 6. Two holes in the wall in room [ROOM NUMBER]. 7. A protruding metal hook and exposed wiring was located next to a handrail in the central wing of the facility. 8. A hole above the windowsill and ceiling in state of disrepair in room three. 9. handrails were in a state of disrepair throughout multiple facility hallways. These facility failures had the potential to negatively effect residents' safety and wellbeing. Findings: 1. During a concurrent observation and interview on 1/4/23, at 1:00 p.m., with the interim maintenance director (IMD 1), inside room [ROOM NUMBER], a broken window frame and torn window screen was observed. The IMD 1 confirmed the window frame was broken and the window screen was torn. IMD 1 further verbalized it needed to be fixed. 2. During a concurrent observation and interview on 1/4/23, at 1:02 p.m., with IMD 1, inside room [ROOM NUMBER], a bed control remote was observed with exposed wiring. The IMD 1 verbalized the bed control remote should not have exposed wires and it needed to be fixed. 3. During a concurrent observation and interview on 1/4/23, at 1:10 p.m., with IMD 1, inside room [ROOM NUMBER], the rooms only television was inoperable with a large circular crack on the display screen. The IMD 1 confirmed the television was broken and further verbalized the television needed to be fixed or replaced with a new one. 4. During a concurrent observation and interview on 1/4/23, at 1:02 p.m., with IMD 1, inside room [ROOM NUMBER], the rooms television stand was covered in dust and debris. The IMD 1 verbalized the television stand needed to be cleaned. 5. During a concurrent observation and interview on 1/4/23, at 1:16 p.m., with IMD 1, inside room [ROOM NUMBER], the floor had a missing section of tile, a brownish yellow stain approximately 4 feet by 4 feet on the ceiling and an inoperable television. The IMD 1 acknowledged the missing tile, ceiling stain and inoperable television. 6. During a concurrent observation and interview on 1/4/23, at 1:20 p.m., with IMD 1, inside room [ROOM NUMBER], two half inch holes in the wall were observed. The IMD 1 confirmed the wall had two holes in it and verbalized the holes should be patched. 7. During a concurrent observation and interview on 1/4/23, at 1:58 p.m., with IMD 1, across the hall from room [ROOM NUMBER], a protruding metal hook and exposed wire was adjacent to the hallways handrail. The IMD 1 removed the metal hook and verbalized he was unaware of the exposed wires but it needed to be fixed. 8. During a concurrent observation and interview on 1/4/23, at 2:05 p.m., with IMD 1, inside room three, a hole was observed above the rooms windowsill. The ceiling in room three was in a state of disrepair with a holes and cracked and bubbling paint. The IMD 1 verbalized being unaware of the hole above the windowsill and acknowledged it needed to be fixed. The IMD 1 further verbalized the ceiling needed to be redone. 9. During a concurrent observation and interview on 1/4/23, starting at 1:22 p.m., with IMD 1, multiple handrails in the facility, were in a state of disrepair. These handrails were located between rooms [ROOM NUMBERS], outside room seven, outside room13, outside room19, outside room four and outside the director of nursing's office. During an interview on 1/4/23, at 2:20 p.m. with the director of nursing (DON 1), the DON 1 was shown photographs of the resident rooms and equipment in disrepair. The DON 1 acknowledged the facility needed to start making repairs and replace any broken equipment. During a review of the facility's policy and procedure titled, Preventative Maintenance dated 8/14, indicated in part .The Maintenance Department will maintain the facility's physical plant .to provide a safe, functional and aesthetically pleasing environment.

Jun 2022 13 deficiencies

CONCERN (D)

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure the indwelling catheter (tube draining urine from bladder) collection bag was covered with a dignity bag (covering for collection bag)...

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Based on observation and interview, the facility failed to ensure the indwelling catheter (tube draining urine from bladder) collection bag was covered with a dignity bag (covering for collection bag), for one unsampled resident (Resident 68). This facility failure had the potential for the Resident 68 to be embarrassed and thus, affect their psychosocial well being. Finding: During an observation on 6/14/22, at 10:11 a.m., Resident 68 was observed in their room, lying in bed, with eyes closed. Resident 68's indwelling urinary catheter's collection bag was hanging below the bed. The collection bag did not have a dignity bag cover. During an interview on 6/14/22, at 10:15 a.m., the licensed nurse (LN 2) acknowledged the indwelling urinary catheter collection bag did not have a dignity bag cover. During an interview on 6/17/22, at 3:46 p.m., the director of nursing (DON) indicated, the facility does not have a policy and procedure regarding a dignity bag, but it is the facility's practice to place a dignity bag to cover on the indwelling urinary catheter collection bag.

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** Based on observation, interview and record review, the facility failed to ensure the resident call light (button to press if a r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident call light (button to press if a resident needs help or assistance) was within reach for two of 32 sampled residents (Resident 13 and Resident 102). This facility failure had the potential for the residents to not be able to call for help or assistance as needed. Findings: During a concurrent observation and interview on 6/14/22, at 10:34 a.m., in Resident 13's room, Resident 13's living area was observed with a Licensed Nurse (LN 2). Resident 13's call light was observed on the floor, under the bed. LN 2 acknowledged, the call light button was on the floor. During an observation on 6/17/22, at 10:30 a.m., in room [ROOM NUMBER] C, the call light for Resident 102 was laying on the floor. During an interview on 6/17/22, at 10:34 a.m., in room [ROOM NUMBER] C, a Certified Nurse Assistant (CNA 1) acknowledged, Resident 102's call light was on the floor. During a review of the facility's policies and procedure (P&P) titled, Call Light, Use of, dated 2006, the P&P indicated, in part .11. Be sure call lights are placed on the bed at all times, never on the floor or bedside stand. During a review of Resident 102's care plan, dated 4/23/22 and 4/27/22, Resident 102's care plan intervention indicated in part, .keep call light within reach.

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

Based on observation, interview, and record review, the facility failed to ensure a care plan intervention for oxygen use was being followed for one of 32 sampled residents (Resident 40). This failur...

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Based on observation, interview, and record review, the facility failed to ensure a care plan intervention for oxygen use was being followed for one of 32 sampled residents (Resident 40). This failure had the potential to result in a decline in Resident 40's physical well being. Findings: During an observation on 06/14/2022, beginning at 10:45 a.m., in Resident 40's room, the oxygen concentrator was set at 4 liters via nasal cannula (oxygen tube placed in nose). During an interview, on 06/14/2022, beginning at 10:45 a.m., with Resident 40, Resident 40 stated, It's always been at 4 liters. During a concurrent interview and record review, on 6/14/2022, at 10:48 a.m., with Licensed Nurse 1 (LN 1), Resident 40's physician order for oxygen administration, dated 9/25/2021, indicated Oxygen at 2 liters per minute via nasal cannula continuously. LN 1 confirmed, that oxygen concentrator was set at 4 liters per minute. LN 1 stated, Oh no, it needs to be changed to 2 liters. During a review of Resident 40's Care Plan for Respiratory Illness (COPD), dated 9/26/2021,the Care Plan indicated in part, .OXYGEN SETTINGS: O2 (oxygen) via nasal cannula at 2 liters continuous. Humidified. During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive, dated December 2017, indicated in part, .Policy: The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life. During a review of the facility's P&P titled, Oxygen Administration, dated August 2014, the P&P indicated in part, .Procedure: 1. Check physician's order for liter flow and method of administration.

CONCERN (D)

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 record review and interview, the facility failed to implement Physician's orders for weekly weights and notify the Phys...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement Physician's orders for weekly weights and notify the Physician of significant weight loss, for one of 32 sampled residents (Resident 4). This failure had the potential to cause Resident 4 a further decline in health status. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe they orders are in error or would harm clients. Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 243 in the section titled, Data Documentation indicates, Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. During a review of Resident 4's clinical records, on 6/15/22, at 10:12 a.m., the Physician's diagnoses included cerebral infarction (stroke), aphasia (loss of ability to speak), anemia (a sign of malnutrition), Gastrostomy (tube inserted through abdomen into stomach for administering tube feeding formula instead of eating by mouth). The Dietary Profile dated 5/25/22 indicated, formula tube feeding discontinued and replaced with oral feeding. Physician Orders dated 3/23/22, included weekly weights every day shift every Wednesday. Continued record review of Resident 4's Weights and Vitals Summary indicated, Resident 4's weekly weights were not performed during the weeks of 3/23/22, 4/3/22, 4/10/22, 4/17/22, and 4/24/22. Further record review indicated, Resident 4's weight declined from 173 pounds on 6/1/22 to 168 pounds on 6/13/22, resulting in a five pound, significant weight loss in twelve days. No documentation from any discipline found notifying the Physician of Resident 4's weight loss. During a concurrent record review and interview, on 6/17/22 at 4:02 p.m., with the director of nursing (DON), Resident 4's health record was reviewed. The DON confirmed, the Physician's orders for Resident 4's weekly weights were not carried out during weeks of 3/23/22, 4/3/22, 4/10/22, 4/17/22, and 4/24/22. The DON also confirmed, Resident 4 had a significant, five-pound weight loss from 6/1/22 to 6/13/22 (twelve days). The DON stated, I received notification on 6/17/22 from the dietary manager [of Resident 4's weight loss on 6/13/22]. The doctor was not notified and should have been. The whole point of carrying out the Physician's order for weekly weights is to notify the Physician of resident's weight loss so nutrition needs are met. The facility's policy and procedure (P&P) titled, Weight Management undated, indicated in part, .Physician and responsible party will be notified of significant weight variances. The facility's P&P titled, Managing Change of Condition within PCC, dated 1/2022, indicated in part, Objective: To appropriately assess, document, and communicate changes of condition (COC) to the primary care provider (Physician). To provide treatment and services to address changes in accordance with patient needs .

CONCERN (D)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure the posted nurse staffing information was current. This facility failure had the potential for residents and visitors to not to be awa...

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Based on observation and interview, the facility failed to ensure the posted nurse staffing information was current. This facility failure had the potential for residents and visitors to not to be aware of the actual nursing hours the facility is providing. Findings: During an observation of the facility's lobby on 6/15/22, at 10:35 a.m., the posted nurse staffing was dated 6/14/22. During an interview on 6/15/22, at 10:38 a.m., the director of nursing (DON) acknowledged the posted nurse staffing was not current. During an interview on 6/17/22 at 3:15 p.m., the DON indicated, the facility does not have a policy regarding posting of nurse staffing. The facility follows the federal regulation for nurse staffing postings.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on record review, and interview, the facility failed to ensure a physician's reason of no action/no change on the pharmacist's recommendation for Cymbalta (medication used to treat depression an...

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Based on record review, and interview, the facility failed to ensure a physician's reason of no action/no change on the pharmacist's recommendation for Cymbalta (medication used to treat depression and anxiety) was documented in the resident's medical record in one of 32 sampled residents (Resident 105). This failure had the potential for over medication and /or ineffective medication administration. Findings: During a concurrent record review, and interview, on 6/17/22, at 2:59 p.m., with the director of nursing (DON 1), Resident 105's Consultation Report (a form used by pharmacists to make drug recommendations to physicians) was reviewed. The Consultation Report, dated 2/14/22, indicated in part, Resident 105 was taking Cymbalta 30 mg QD (every day) for depression. The report further indicated A GDR (gradual dose reduction) should be attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the facility has initiated such medication, and then annually unless clinically contraindicated. If antidepressant therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual. Resident 105's physician on 2/16/22, selected the check box that indicated I decline the recommendation(s) above as GDR is CLINCALLY CONTRAINDICATED for this individual as indicated below. (Note: Please check option # 1or # 2 and provide patient-specific rational in the lines below.) Resident 105's physician did not check option # 1 or option # 2 and did not provide a patient-specific rationale. DON 1 acknowledged, no rational was written by Resident 105's physician on the Consultation Report. During a review of the facility's policy and procedure titled, Psychoactive Medication Management dated 8/14, indicated in part Medications should be prescribed within federal guidelines, unless doses outside these guidelines are clinically indicated to treat psychiatric condition, or when the physician has justified the use by a risk vs. benefit analysis documented in the clinical record. The policy further indicates, Dose reduction attempts are not required if the physician has justified ongoing use of the medication including anti-depressants and mood stabilizers by a risk vs. benefit statement documented in the clinical record.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one of 32 sampled residents (Resident 58's) Lorazepam (medication used for anxiety) ordered as needed (PRN) did not exceed 14 days o...

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Based on interview and record review, the facility failed to ensure one of 32 sampled residents (Resident 58's) Lorazepam (medication used for anxiety) ordered as needed (PRN) did not exceed 14 days of therapy unless renewed. This facility failure had the potential for Resident 58 to be over medicated or have no assessment for renewal use. Findings: During a review of the health record for Resident 58's on 6/16/22, at 12:12 p.m., the health record indicated orders for: 1. Lorazepam 0.5mg by mouth twice a day as needed for anxiety for 90 days, ordered on 2/15/22 2. Lorazepam 0.5mg by mouth twice a day as needed for anxiety for 120 days ordered on 5/25/22. During a concurrent interview and record review, on 6/16/22 at 12:41 p.m., with the nurse supervisor (RNSUP), Resident 58's health record was reviewed. Resident 58's pharmacy recommendation indicated, on 1/18/22 the pharmacist commented on Lorazepam as PRN (as necessary) order for anxiolytic, which has been greater for 14 days without a stop date. Pharmacy recommendation - please discontinue prn Lorazepam, tapering as necessary, if medication cannot be discontinued at this time current regulation require that prescriber document the indication for use, the intended duration of therapy and the rationale for the extended time period of the prn order. The RNSUP verbalized, the Lorazepam order is over 14 days. Rationale for the extended order for Lorazepam was not located. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Review, dated 12/01/07, the P&P indicted, Facility should encourage Physician/Prescriber to either (a) accept and act upon the recommendations contained within the MRR, or (b) reject all or some of the recommendation is contained in the MRR and provide an explanation as to why the recommendation was rejected.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a standardized recipe for tuna salad, and no sys...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a standardized recipe for tuna salad, and no system in place to acknowledge food allergies. This facility failure had the potential to negatively impact the health and safety of residents with known food allergies. Findings: A review of the facility policy and procedure (P&P) titled, Resident Food Preferences, dated 2/09, indicated in part, .The food and dining services staff will avoid serving products that contribute to food allergies and make every attempt to meet the resident's food preferences. During an observation on 6/14/22, at 8:55 a.m., during a tour of the kitchen, in the walk- in refrigerator, a container of tuna salad was observed. The tuna salad container indicated it was made on 6/13/22 and use by date was 6/18/22. During an interview on 6/15/22, at 2:07 p.m., with the cook (Cook 2), [NAME] 2 was asked how tuna salad was made. [NAME] 2 verbalized, the tuna comes from a can that is taken from dry storage. [NAME] 2 verbalized, the tuna water is drained and then mixed with other ingredients, lemon, celery, onion, mayonnaise, sometimes relish, sometimes hard-boiled eggs, salt, and pepper. When asked if [NAME] 2 followed a recipe, [NAME] 2 verbalized, there is no recipe, staff make tuna salad by taste. During an interview on 6/15/22, at 2:44 p.m., with the cook (Cook 3), [NAME] 3 verbalized, the tuna salad was made on 6/13/22. [NAME] 3 verbalized, the tuna comes from dry storage, staff opens can, drains water and adds the cold ingredients. [NAME] 3 verbalized, using mayonnaise, green onions, mustard, salt, and pepper. When asked how you know what ingredients go into the tuna salad, and do you follow a recipe, [NAME] 3 verbalized, there is no recipe for tuna salad and tuna salad is made by taste. During a review of the Academy of Nutrition and Dietetics current Nutrition Care Manual (NCM), the NCM indicated in part, . Food allergies are an abnormal immunologic response to a harmless food protein, include [NAME] (immunoglobulin E)-mediated and non-[NAME]-mediated allergic responses. An allergic reaction is caused by the immune system responding to what it perceives as an invader; physiologic responses to food allergies vary widely but can be life-threatening in some cases (FARE, 2017). A food intolerance, on the other hand, does not involve the immune system (AAAAI, 2016). A physician can help differentiate whether a patient has an intolerance or an allergy. Both food allergies and intolerances require that foods be eliminated from the diet. The eight foods that account for 90% of significant allergies in adults were identified in the Food Allergen Labeling and Consumer Protection Act (FALCPA), which passed in 2004: milk, eggs, wheat, soy, fish, crustacean shellfish, peanuts, and tree nuts (FDA, 2015). Vigilance is required in monitoring food ingredients to prevent a reaction to a food allergen or intolerance, as it only takes a trace amount to trigger a reaction in some people (CDC, 2015) .responsibilities of the health care facility: read labels of ingredients used to prepare food .prior to preparing and serving the product, the staff should confirm the ingredient information on the actual label of the product . During an interview on 6/16/22, at 2:15 p.m., with the registered dietician (RD) and dietary supervisor (DS), The RD and DS were asked about a standardized recipe for tuna salad, both the RD and DS verbalized, there is no recipe for tuna salad. The RD and DS both verbalized, tuna salad is a snack and not a meal on the menu. The RD and DS verbalized, if the food item is part of the menu, then a standardized recipe is used. When asked what if the resident wants a tuna salad sandwich as a meal alternative, The DS verbalized, a tuna sandwich is a snack and not a meal. When asked what if a resident has a food allergy, how do you know what ingredients are in the tuna salad if a recipe is not followed, the RD and DS did not answer. The RD was asked, if not following a recipe, is this a safe practice, the RD stated, I see what you mean. The RD acknowledged, without standardized recipes the facility failed to have a system to ensure food allergies are acknowledged. A review of the facility policy titled, Menus, dated 2/17, indicated in part . To ensure food/fluid variety, adequate nutrition, and allow for effective planning of food and dining service .menus are planned in advance to meet the nutritional needs of the residents .the food and dining services manager may modify the menus to meet the preferences of the resident .the registered dietician approves menus .if items on the menu are not available and substitutions are made, documentation of substitutions must be recorded on the menu for the day .recipes are available for use and will be utilized.

CONCERN (D)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow the physician's prescribed therapeutic diet order for one of 32 sampled residents (Resident 78) during lunch on 6/16/2...

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Based on observation, interview, and record review, the facility failed to follow the physician's prescribed therapeutic diet order for one of 32 sampled residents (Resident 78) during lunch on 6/16/22. This failure resulted in Resident 78 receiving the wrong prescribed lunch meal and had the potential to result in decreased food intake or unplanned weight loss, further compromising the nutritional and medical status of Resident 78. Findings: During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, dated 2/09, the P&P indicated in part .Ensure therapeutic diets are written and available as ordered .therapeutic diets (also known as special diets) and mechanically-altered diets are ordered by the physician and planned by a registered dietician .the facility prepares and serves all special diets as planned. During an interview on 6/14/22, at 10:38 a.m., with Resident 78, Resident 78 stated, Food portions have become smaller. I am still hungry at the end of meals. Resident 78 verbalized, the food portion sizes I am receiving are small and stated, I call them kindergarten sized meals. During a concurrent observation and interview, on 6/16/22, at 11:45 a.m., during the lunch tray line (meal plating), the cook (Cook 1) served a regular portion of 4 oz (ounces) of pineapple pork, ½ cup of potatoes, and ½ cup of baby carrots, for Resident 78. When asked if Resident 78 should get an extra-large portion of meat, [NAME] 1 said no. Resident 78's lunch meal tray ticket indicated, Diet: CCHO (a diabetic diet), Regular, Lactose Intolerant. During a review of Resident 78's Order Summary Report, dated 6/17/22, the physician's diet order indicated, CCHO diet, regular texture, regular/thin consistency, lactose intolerant, double portion protein/meat TID (three times a day) with meals. During a concurrent interview and record review, on 6/16/22, at 2:15 p.m., with the dietary supervisor (DS) and registered dietician (RD), Resident 78's Physician Orders and Meal Tray Ticket were reviewed. The Physician Orders indicated, Resident 78 should have a CCHO diet, regular texture, regular/thin consistency, lactose intolerant, and double portion protein/meat TID (three times a day) with meals. The Meal Tray Ticket indicated, Diet: CCHO, Regular, Lactose Intolerant. The DS and RD both acknowledged, the Meal Tray Ticket was not accurate and did not match the physician orders. The DS and RD acknowledged, Resident 78 did not receive the double portion of meat protein the lunch tray. During an interview on 6/16/22, at 4:28 p.m., with Resident 78, Resident 78 was asked if he received the large lunch portion and asked if Resident 78 received enough food on the lunch tray. Resident 78 stated, Well, the portion of meat was a little bit bigger than before, probably because you guys (state surveyors) are here. The portion still was not big and there was not enough food on my lunch tray. I was still hungry after eating the lunch meal. During a review of the facility's P&P titled, Processing Physician Orders, dated 8/17, the P&P indicated in part, .To verify and maintain accuracy of physician orders to provide appropriate care and services .

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 and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) were reflected as signed and ordered by the attending physician on the resident's electronic medical record (EMR) for one of 32 sampled residents (Resident 28). This failure had the potential to cause a delay or violate resident's rights as to wishes on administering life-sustaining treatments during an emergency. Findings: During a concurrent interview and record review, on [DATE], at 10:51 a.m., with the minimum data set nurse (MDS 1) Resident 28's POLST, dated [DATE], was reviewed. Resident 28's POLST indicated .Do Not Attempt Resuscitation (DNR), provide Comfort-Focused Treatment- relieve pain and suffering with medication, use oxygen, suctioning, and manual treatment of airway obstruction, and No artificial means nutrition, including feeding tubes. Resident 28's Physician Orders (PO) in the EMR, with the run date of [DATE], indicated . Full Cardiopulmonary Resuscitation (CPR), Full Treatment, and a Trial period of artificial nutrition. MDS 1 acknowledged, the PO in the EMR did not reflect the signed orders on the POLST, dated [DATE]. MDS 1 verbalized, Resident 28's EMR should be updated to match the current POLST. During a review of the facility's policy and procedure (P&P) titled, Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives, dated 11/2016, the P&P indicated in part, .To provide guidelines and principles to assist residents and/or legal healthcare decision maker, physicians and facility personnel in implementing decisions concerning a residents' preferred intensity of care and the process for creating and implementing advanced healthcare directives including the withholding of life support and the foregoing or withdrawal of life sustaining treatment .Standing physician order form (POLST) are physician orders, typically on bright colored paper and clearly identifiable, that specify the types of medical treatment that a patient wishes to receive towards the end of life .decisions documented on these orders include choices for CPR, antibiotics and IV fluids, use of intubation and mechanical ventilation, and artificial nutrition .the form is to be used to compliment an Advanced Directive or Living Will and is not intended to replace those documents .a completed, fully executed form is a legal physician order and is immediately actionable .if the physician has completed a standing physician order form (POLST), it should be copied and maintained as part of the resident's medical chart.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment w...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and homelike environment when: 1. A wall was in a state of disrepair in room six. 2. The floor was in disrepair in room two. 3. Missing section of handrail in the north wing of the facility. 4. Ill fitting closet drawer in room five. 5. Used equipment were stored outside the building of the south wing in view of the residents, staff, and visitors. 6. A toilet seat was in disrepair and peeling paint was on the door jams in room [ROOM NUMBER]. 7. A wall behind the bathroom sink was in disrepair, a faucet knob was not in good working order, limescale buildup was on the faucet, and a vent cover was missing on the bathroom ceiling in room [ROOM NUMBER]. 8. Two rooms with torn loose wall paper, stripped down to the dry wall. These facility failures had the potential to negatively effect residents' safety and wellbeing. Findings: 1. During an observation on 6/14/22, at 11:00 a.m., in room six, a section of wall, measuring approximately five feet in length, was scraped and had missing paint. During an interview on 6/17/22, at 10:10 a.m., with the Maintenance Director (MD 1), MD 1 verbalized, the wall had been gouged and further verbalized, the section of the wall that was damaged spanned five feet in length. 2. During an observation on 6/14/22, at 3:29 p.m., in room two, a section of flooring was missing measuring approximately one square foot. During an interview on 6/17/22, at 10:12 a.m., with MD 1, MD 1 acknowledged, the missing floor in room two and verbalized, the missing piece was approximately one square foot. 3. During a concurrent observation, and interview, on 6/17/22, at 10:08 a.m, with MD 1, the north wing of the facility was toured. A section of hand railing around the corner from room [ROOM NUMBER], had a section of railing missing. MD 1 confirmed, the missing section of hand railing and acknowledged it needed to be repaired. 4. During a concurrent observation and interview, on 6/17/22, at 10:11 a.m, with MD 1, Resident 150's closet was inspected. Resident 105's closet drawer was not able to be fully closed. MD 1 acknowledged, the closet drawer needed to be fixed so it could close completely. 8. During a concurrent observation and interview, on 6/14/22, at 9:38 a.m., room [ROOM NUMBER] was observed with CNA 2. room [ROOM NUMBER]'s wall, at the head of beds A, B, and C had torn, loose, hanging wall paper exposing dry wall below. CNA 2 stated, The wallpaper should not be loose and tearing away from the wall. During an observation on 6/14/22, at 11:18 a.m., room [ROOM NUMBER]'s wall at the head of bed A had torn and loose wallpaper exposing the dry wall below. During a concurrent observation and interview, on 6/17/22, at 4:41 p.m., with MD 1, room [ROOM NUMBER] beds A, B, C and room [ROOM NUMBER], bed A was observed. MD 1 confirmed, the walls at head of beds A, B, and C in room [ROOM NUMBER] and bed A in room [ROOM NUMBER] had torn and loose wallpaper stripped down to dry wall. MD 1 stated, That is not a homelike environment. The wallpaper and damaged walls should be repaired and are not. 5. During the initial tour of the facility on 6/14/22, at 8:58 a.m., on the south wing, used equipment, including a mattress, hoyer lift (equipment used to lift and move residents who cannot move themselves), wheelchairs, and scrap building materials were stored outside the building in view of the residents, staff, and visitors. During an interview on 6/17/22, at 8:45 a.m., MD 1 acknowledged, the equipment and scrap building materials needed to be thrown away. During an interview on 6/17/22, at 9:50 a.m., the Director of Nursing (DON) acknowledged, the equipment and building materials should be cleared from the south wing. 6. During an observation on 6/14/22, at 10:58 a.m., in Resident 28's bathroom, in room [ROOM NUMBER], peeling paint was observed on the door jams and a rough brown patch, about 4 inches long and 2 inches wide, was on the left side of the toilet seat. During a concurrent observation and interview, on 6/14/22, at 11:00 a.m., with MD 1, Resident 28's bathroom, in room [ROOM NUMBER] was observed. MD 1 acknowledged, the toilet seat was in disrepair and verbalized, MD 1 needed to replace the toilet seat. MD 1 further acknowledged, there was peeling paint on the door jams. When asked about the facility's process for maintenance and upkeep in residents' rooms, MD 1 verbalized, there is no process. MD 1 verbalized, MD 1 was new to the facility. MD 1 verbalized, this a large 193 bed facility and there are only two maintenance personnel, MD 1 and one other employee. MD 1 stated, When someone calls that something is broken, I go and fix it. When asked if there was any kind of daily rounding, MD 1 verbalized, there is no process. During a review of the facility's policy and procedure (P&P) titled, Maintenance Manual Policy & Procedures-Functions, dated 8/14, the P&P indicated in part, .As part of the Safety Committee and/or Performance Improvement Committee, the Maintenance Department is responsible for performing periodic surveys of each department within the facility to identify and correct potential problems and to perform preventative maintenance or repairs . 7. During an interview on 6/14/22, at 10:55 a.m., with Resident 88, in room [ROOM NUMBER], Resident 88 verbalized, the building is old and needs repairs. Resident 88 verbalized, the bathroom is shared between four residents. Resident 88 verbalized, her neighbor in room [ROOM NUMBER] went to the bathroom in the middle of the night and the water faucet was left on. Resident 88 further verbalized, the water was running all night and was almost overflowing out of the sink. During an observation on 6/14/22, at 10:57 a.m., in Resident 88's bathroom, in room [ROOM NUMBER], the bathroom sink was observed. The wall behind the sink faucet had peeling paint and was in disrepair. White, crusty substance was observed on the faucet. The hot water knob was turned on. After a minute, the hot water knob was attempted to be turned off. The knob kept twisting several times and the water was still flowing out of the faucet. The knob was slowly twisted backwards to shut the water off. The water was difficult to turn off. The ceiling in the bathroom was also observed. The air duct vent cover was missing. During a concurrent observation and interview, on 6/14/22, at 3:30 p.m., with the DON and MD 1, in Resident 88's bathroom, in room [ROOM NUMBER], MD 1 turned on the hot water faucet knob. MD 1 acknowledged, the knob was not working properly and needed to be fixed. The DON and MD 1 both acknowledged, the peeling paint on the wall behind the sink and it needed to be repaired. MD 1 verbalized, the white crusty substance was lime or calcium scaling from the old water system. The DON acknowledged, the white, crusty scaling is difficult to clean and can harbor bacteria and further acknowledged, housekeeping would be informed. The DON and MD 1 both acknowledged, the air duct vent cover was missing and MD 1 verbalized, getting a new vent cover for the airduct. During a review of the facility's P&P titled, Maintenance Manual Policy & Procedures-Scope of Services, dated 8/14, the P&P indicated in part . The Maintenance Department is responsible for the condition and function of the facility's physical plant, including all utilities, grounds, and equipment .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation and concurrent interview, on 6/14/22, at 11:03 a.m., Resident 78's room was observed with Certified Nur...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation and concurrent interview, on 6/14/22, at 11:03 a.m., Resident 78's room was observed with Certified Nursing Assistant 2 (CNA 2). Resident 78's nebulizer had an undated and unprotected oxygen tubing and face mask attached and ready for use. CNA 2 acknowledged the undated and unprotected tubing and mask and stated, No, the oxygen mask and tubing connected to the Nebulizer is not dated, is not properly stored in the bag to prevent cross contamination and is not stored properly. This is against infection control. The tubing and mask should be stored properly in the bag and dated properly and is not. During a follow-up observation and interview, on 6/17/22, at 3:24 p.m., with licensed nurse 3 (LN 3), Resident 78's room was observed. An unlabeled and undated oxygen tubing and face mask attached to Resident 78's Nebulizer was laying inside of the bedside cabinet drawer and ready for use. LN 3 stated, The face mask and tubing should be dated and are not. That is against infection control. During a concurrent interview and record review, on 6/17/22 at 3:44 p.m. with the director of nursing (DON), the facility's P&P titled, Nebulized Medication/Hand-Held Nebulizer, dated 2008 was reviewed. The DON confirmed, the P&P and the DON stated, For [a] Nebulizer, the oxygen tubing and breathing treatment face mask should be replaced every week and whenever soiled. Yes, the tubing and mask should be dated with the date the tubing and mask placed onto the nebulizer. 3. During an observation and interview on 6/14/22, at 10:23 a.m., the shared bathroom between rooms [ROOM NUMBERS] was observed with with CNA 3. The bathroom contained an unlabeled large basin and emesis (vomit) basin on the floor next to the toilet. CNA 3 confirmed and stated, The basin and emesis basin on floor next to toilet not labeled, not properly contained and should not be [there]. That is against infection control. During an observation and interview on 6/14/22, at 11:03 a.m., the shared bathroom between rooms [ROOM NUMBERS] was viewed with CNA 2. The bathroom contained an unlabeled and not enclosed large basin and bedpan on the floor next to the toilet. CNA 2 confirmed the above and stated, There should not be an unlabeled and not properly contained bed pan and basin on the floor next to the toilet in the bathroom. That's against infection control. The facility was unable to provide a policy and procedure for the storage and labeling of resident equipments. Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Hand hygiene was not performed in the kitchen. 2. Oxygen tubing and face mask connected to a Nebulizer (breathing treatment machine) was not dated and stored in a plastic bag for one resident (Resident 78). 3. Residents' shared bathrooms (rooms 23, 24 and 25, 26) had unlabeled and uncovered resident supplies, (large basins, bedpan, and emesis basin [small container used to collect vomit]) and were stored on the floor next to the toilet. These facility failures had the potential to result in food borne illness, cross-contamination (the transfer of harmful bacteria) of resident equipment and supplies that could impact residents' health and safety. Findings: 1. During a review of the facility's policy and procedure (P&P) titled, Dietary Services, dated 2/12, the P&P indicated in part, .To prevent contamination of food products and therefore prevent foodborne illness .Personal Hygiene: D. Adequate numbers of handwashing sinks with soap dispensers and single-use towels are provided .wash hands carefully with soap and water whenever they become soiled, immediately before work in the morning, after using the bathroom, after coughing, sneezing, blowing your nose, after touching the hair, mouth, or cigarettes, after handling raw unwashed food and dirty dishes; before touching food, clean dishes, and silverware . During a concurrent observation and interview, on 6/16/22, at 10:00 a.m., with the cook (Cook 1), in the kitchen, [NAME] 1 was observed preparing pureed potatoes in the food processor. [NAME] 1 finished using the food processor and went to the dirty dish sink, which contained other dirty dishes, and washed the food processor with bare hands. [NAME] 1 then proceeded to continue to prepare food without washing hands in between the tasks. When asked about washing hands in between tasks, [NAME] 1 acknowledged, [NAME] 1 should have washed hands in between washing the dirty dishes and preparing food. Review of the APIC website, https://infectionpreventionandyou.org/infographic/ppe-dos-and-donts/ accessed on 6/22/2022, the website indicated, Do clean hands and change gloves between each task (e.g., after contact with a contaminated surface or environment).

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to ensure: 1. The temperature was monitored in the dry food storage room; 2. The ice machine's preventative maintenance (PMs) an...

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Based on observation, interview, and record review, the facility failed to ensure: 1. The temperature was monitored in the dry food storage room; 2. The ice machine's preventative maintenance (PMs) and cleaning schedule was performed and documented according to the manufacturer's instruction for use (MIFU's) manual; 3. The ice machine floor drain was clean, free of debris, and trash. These failures had the potential to place residents at risk for developing foodborne illness. Findings: 1. During an observation on 6/14/22, at 9:20 a.m., in the dieticians office, the office was observed to also be used as the dry food storage room. The room was divided by a caged wall. One side of the room was the office, and the other side was food storage. The food was stored on shelves. The room felt warm and not well ventilated and no thermometer was seen. During a concurrent observation and interview, on 6/15/22, at 3:30 p.m., with the dietary supervisor (DS), in the dry food storage room, it was observed there was a thermometer hanging on the wall behind the door. The thermometer was reading 78°F. When asked if the temperature was being monitored in the dry food storage room, The DS verbalized, we just look at the thermometer. The DS verbalized, we do not record the temperature and do not have a temperature log. When asked what the normal temperature range should be for dry food storage, the DS verbalized, the DS did not know. During a concurrent observation and interview, on 6/16/22, at 2:15 p.m., with the registered dietician (RD) and the DS, in the dry storage room, a fan was observed on a shelf. The fan was turned on and circulating the air. The thermometer was still reading 78°F. Both the RD and the DS acknowledged, the temperature should be logged daily in the dry storage room. During a review of the facility's policy and procedure (P&P) titled, Food Safety in Receiving and Storage, dated 2/09, the P&P indicated in part, .Food is received and stored by methods to minimize contamination and bacterial growth .food will be stored in a manner to allow air circulation around food .dry storage areas should be well-ventilated, and pest free, and range in temperatures from 50-70 degrees F. 2. During a review of the facility's P&P titled, Ice Machine Sanitation, dated 2/09, indicated in part, .Maintain sanitary and clean ice machines and ensure proper service of ice .ice machines are properly maintained and ice is served in a safe and sanitary manner .filters will be changed monthly. During a review of the MIFU's manual for the ice machine PMs indicated in part, .The ice system requires three types of maintenance: remove the build up of mineral scale from the ice machine's water system and sensors .sanitize the ice machine's water system and the ice storage bin and dispenser .clean or replace the air filter and clean the air cooled condenser. During a concurrent observation and interview, on 6/15/22, at 11:40 a.m., with the maintenance director (MD 1), the ice machine was observed. MD 1 verbalized, the ice machine is maintained quarterly by a contracted company. MD 1 verbalized, the contracted company does part of the suggested preventative maintenance (PM's) per MIFU's, which is the descaling, cleaning and sanitizing of the ice machine. MD 1 verbalized, the MD 1 changes the air filter once a month and cleans out the ice bin before the contracted company comes. MD 1 pulled out the air filter and gray, fluffy substance was observed all over the air filter. When asked if the air filter changes are documented, MD 1 verbalized, MD 1 does not document the air filter changes and MD 1 does not have a log. MD 1 further acknowledged, MD 1 should document the air filter changes and bin cleaning. During a concurrent interview and record review, on 6/15/22, at 11:42 a.m., with MD 1, the MIFU's manual for the ice machine cleaning schedule was reviewed. The MIFU's manual indicated in part, .The interior of this bin is in contact with a food product: ice .the storage bin must be cleaned and sanitized regularly to maintain a sanitary environment .suggested schedule: weekly: clean and sanitize the door liner, door gasket and door frame .monthly: clean the exterior .semi-annually: clean and sanitize the entire interior of the bin. MD 1 acknowledged, the weekly cleaning schedule was not being performed per MIFU's. 3. During a review of the facility's P&P titled, Maintenance Manual Policy & Procedures-Scope of Services, dated 8/14, the P&P indicated in part . The Maintenance Department is responsible for the condition and function of the facility's physical plant, including all utilities, grounds, and equipment . During a concurrent observation and interview, on 6/15/22, at 11:44 a.m., with the maintenance director (MD 1), the floor drain from the ice machine was observed. The drain was observed to have dark brown flaky (rust) substance around the drain, white crusty (lime/calcium scaling) substance and black (mold) substance on the tile flooring and grout. Two dirty plastic cups (trash) were also observed sitting inside the drain. MD 1 acknowledged, the rust, scaling, mold substances, debris, and trash and further acknowledged, should not be there. MD 1 verbalized, the drain should be cleaned. During a review of the FDA U.S. Food & Drug Administration: Food Code dated 2017, the food code indicated in part, .4-204.120 Equipment Compartments Drainage: EQUIPMENT compartments that are subject to accumulation of moisture due to conditions such as condensation, FOOD or BEVERAGE drip, or WATER MELTING FROM ICE shall be sloped to an outlet that allows complete draining .FDA Food Code Annex: 4-202.16 NONFOOD-CONTACT SURFACES: Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. Well-designed equipment enhances the ability to keep nonfood-contact surfaces clean .Equipment. (1) Equipment means an article that is used in the operation of a FOOD ESTABLISHMENT such as a freezer, grinder, hood, ICE MAKER, meat block, mixer, oven, reach-in refrigerator, scale, sink, slicer, stove, table, temperature measuring device for ambient air, vending machine, or warewashing machine .4-601.11 Equipment, Food-Contact Surfaces, NON FOOD- CONTACT SURFACES, and Utensils. (A) Equipment and food contact surfaces and utensils shall be clean to sight and touch. Pf (B) The food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NON FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, food residue, and other debris .FDA Food Code Annex: Objective 4-601.11 Equipment, Food-Contact Surfaces, NON FOOD-CONTACT SURFACES, and Utensils. The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean FDA Food Code Annex: 4-204.17 ICE UNITS, Separation of Drains. Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines. Liquid drain lines passing through the ice bin are, themselves, difficult to clean and create other areas that are difficult to clean where they enter the unit as well as where they abut other surfaces. The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin.

May 2019 3 deficiencies

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 record review, the facility failed to ensure used spoons were not stored in fiber and liquid thickening storage containers. This facility failure had the potentia...

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Based on observation, interview, and record review, the facility failed to ensure used spoons were not stored in fiber and liquid thickening storage containers. This facility failure had the potential to result in residents developing a foodborne illness from cross-contamination. Findings: During an observation and concurrent interview with licensed nurse (LN1) on 5/7/19, at 9:47 AM., at medication cart one north wing, the fiber storage container had a used spoon stored inside the container. LN1 acknowledged used spoons should not be stored in fiber containers. During an observation and concurrent interview with LN2 on 5/7/19, at 10:19 AM., at medication cart two north wing, the Thick and Easy powder (liquid thickening) storage container had a used spoon stored inside the container. LN2 stated this is the normal practice and confirmed that used spoons should not be stored inside liquid thickening storage container. During an observation and concurrent interview with LN3 on 5/7/19, at 11:09 AM., at medication cart one central wing, the Thick and Easy powder (liquid thickening) storage container had a used spoon stored inside the container. LN3 acknowledged that used spoons should not be stored inside liquid thickening storage container. During an interview with the director of nursing (DON) on 5/5/19, at 11:35 AM., the DON confirmed used spoons should not be stored in fiber or liquid thickening storage containers. Review of the Food Code 2017 section 3-304.11 indicated in part . food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. The handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination. Review of the facility policy titled Infection Prevention Program Overview dated 2012, indicated in part Prevention of spread of infections is accomplished by use of hand hygiene, standard precautions and other barriers

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to ensure the menu approved by the registered dietitian and/or directions on the meal tray card was followed related to; 1. A foo...

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Based on observation, interview and record review, the facility failed to ensure the menu approved by the registered dietitian and/or directions on the meal tray card was followed related to; 1. A food preference (Resident 100), 2. Fortified diet (Resident 138), 3. CCHO (consistent carbohydrate diet for diabetes) (Resident 89), 4. Renal diet (for kidney disease) (Resident 127, 76, 91), 5. Small portions (Resident 52). Failure to follow written menus may result in individualized nutrition needs not being met which could compromise medical status. Findings: 1. On 05/08/19 at 11:35 AM, during observation of the lunch meal trayline, navy beans were served on Resident 100's lunch meal plate that was placed on the meal delivery cart. The Dietary Manager (DM) was asked to review Resident 100's lunch meal tray. Concurrently, the DM reviewed Resident 100's meal tray ticket that listed beans under the dislikes. The DM proceeded to inform the dietary staff that Resident 100's known food dislike was not honored when navy beans were placed on her plate. The facility's policy and procedure (Effective: 2/09) titled Resident Food Preferences indicated, Purpose: Satisfy resident's tastes and appetites by determining and providing their food preferences at meals ., These are documented on tray tickets . 2. On 05/08/19 at 11:36 AM, during observation of the lunch meal trayline, a dietary aide (DA 1) placed the lid over Resident 138's lunch meal to be placed on the meal delivery cart. DA 1 was asked if Resident 138 was served a fortified diet as listed on Resident 138's meal tray ticket. Concurrently, the dietary manager (DM) stated the fortified item for the noon meal was extra butter. DA 1 and DM reviewed Resident 138's meal and verified the fortified diet was not honored as extra butter had not been served. Resident 138's meal tray ticket indicated the prescribed diet order was soft, chop, fortified diet. The facility's policy and procedure, undated, titled Nutrition Care; Fortification indicated, Policy: This diet is intended for persons with significant weight loss, pressure sores, decreased appetite, decreased ability to handle normal volume of food items, underweight residents, and any resident who may requires increased concentrated calories to maintain or improve nutritional status . 3. On 05/08/19 at 11:37 AM, during observation of the lunch meal trayline, Resident 89 was observed to have been served a ham glaze sauce over the ham. Resident 89's lunch meal tray was placed on the meal delivery cart. Resident 89's lunch meal tray ticket indicated the diet order was soft, fine chpd [chopped], CCHO, fortified. Concurrently, the dietary manager (DM) was asked to review Resident 89's lunch meal tray for accuracy. The DM verified that ham glaze sauce was served over the ham which was not planned to be served for the CCHO diet. Accordance to the planned menu approved by an RD, the ham glaze sauce should not have been served to the CCHO therapeutic diet. The facility's policy and procedure (Effective: 2/09) titled Therapeutic Diets indicated, Purpose: Ensure therapeutic diets are written and available as ordered ., Policy: Therapeutic diets .are ordered by the physician and planned by a Registered Dietitian ., 7. The facility prepares and serves all special diets as planned . 4. On 05/08/19 at 11:39 AM, during observation of the lunch meal trayline, Resident 127's meal tray ticket indicated a diet order of renal, CCHO. According to the planned menu for the renal diet the entrée was 3 oz [ounce] pork roast. Resident 127's lunch meal plate was observed to be served pork roast with gravy on top. On 05/08/19 at 11:46 AM, Resident 76's lunch meal tray ticket indicated a diet order of renal and dislikes pork. Resident 76 was observed to be served meatballs with gravy on the lunch meal tray, which was placed on the meal delivery cart. On 05/08/19 at 11:54 AM, Resident 91's lunch meal tray ticket indicated a diet order of renal. Pork roast with gravy was observed to be placed on Resident 91's lunch meal plate. On 05/08/19 at 11:56 AM, the registered dietitian (RD) was in the kitchen and was asked if gravy was planned to be served on top of the main entrée for lunch that day for the renal diet orders. The RD reviewed the therapeutic menu and then informed the cooks that gravy should not be served for the renal diet. The facility's approved diet manual for the renal diet indicated, .the foods that are typically restricted in the Renal Diet are the high potassium foods and high sodium foods . The facility's recipe for the gravy indicated, beef soup base .285 mg (milligrams) NA (sodium) per 2 oz [ounce] ladle . The facility's policy and procedure titled Therapeutic Diets dated 2/09, indicated Purpose: Ensure therapeutic diets are written and available as ordered ., Policy: Therapeutic diets .are ordered by the physician and planned by a Registered Dietitian ., 7. The facility prepares and serves all special diets as planned . 5. On 05/08/19 at 11:50 AM, Resident 52 was observed to be served a half cup of navy beans and two slices of glazed ham. Resident 52's meal tray ticket indicated a diet order of CCHO, small PT [portions]. A dietary aide (DA 1) placed Resident 52's lunch meal tray onto the meal delivery cart. The planned menu for small portions indicated 3.5 ounces of ham and a quarter of a cup of navy beans. Concurrently, DA 1 and the dietary manager (DM) was asked to remove Resident 52' lunch meal delivery cart and review it for accuracy. The cooks (Cook 1 and [NAME] 2) stated, Only the beans are small portion. The cooks verified the wrong portion size of the navy beans were served and corrected it. Resident 52's lunch meal tray remained with two slices of ham. (For reference, the regular diet was planned for 4.5 oz of ham and ½ cup navy beans.) Concurrently, the DM acknowledged Resident 52's meal tray was not served in accordance with the planned menu for small portions. The facility's policy and procedure titled Portion Size undated, indicated, Policy: Appropriate portion size will be determined based on estimated nutritional needs .or per resident preference ., Portions size will be designated on resident tray ticket if it varies from regular portion size on menu spreadsheet ., .small portions will be served as indicated on menu spreadsheet .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review, the facility failed to ensure: 1. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth ...

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Based on observation, interview and record review, the facility failed to ensure: 1. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were consistently and accurately cooled down to ensure food safety. 2. The ice-machine was sanitized in accordance with manufacturer's guidelines. These deficient practices had the potential to cause foodborne illness to the highly susceptible residents currently residing in the facility. According to the FDA (Food and Drug Administration) Food Code 2017, A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; .or older adults; and (2) Obtaining food at a facility that provides services such as .health care . Findings: 1. During an observation and concurrent interview on 05/07/19, at 08:00 AM, inside the walk-in freezer was a pan covered with tin foil labeled as corned beef dated 5/6 and a pan of sausage covered and labeled as sausage 5/6. The Assistant Dietary Manager (ADM) stated the corned beef and sausage were cooked at the facility yesterday and were left overs. On 05/07/19 at 08:09 AM, the Dietary Manager (DM) reviewed the facility's Time/Temperature Log and stated there was no documentation on the log that the leftover corned beef or sausage were cooled down safely. The DM verified the sausage and corned beef were heated at the facility yesterday and should have been on the Time/Temperature log. Concurrently, the DM reviewed the Time/Temperature Log for an entry listed as 5/2/19, Soup, time 3:00 [PM] 198 [degrees Fahrenheit (F)}, 6:00 [PM} 70 [degrees F], 8:00 [PM] 40 [degrees F]. The DM stated the cool down was not done correctly as the temperature of the soup should have been checked two hours after the initial cool down started, not three hours later. A review of the facility's Time/Temperature Log included incorrect and unsafe cool down practices as, per the log, on 2/13/19 roast beef temperature was checked three hours after the initial cool down process began, as well as soup, dated 4/18/19. On 05/07/19 at 08:19 AM, the registered dietitian (RD) verified that the Time/Temperature Log was not consistently done accurately and safely. The facility's policy and procedure titled Safe Food Temperatures dated 2/09, indicated, Purpose: Limit the risk of food-borne illness through proper temperature control ., 10.c. Foods should be cooled to 70 degrees F within 2 hours, and then to 41 degrees F or below within an additional 4 hours . According to the 2017 FDA Food Code, .(A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 degrees F to 70 degrees F, and (2) Within a total of 6 hours from 135 degrees F to 41 degrees F or less. (3-501.14 Cooling) According to the 2017 FDA Food Code Annex, Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness .,The initial 2-hour cool is a critical element of this cooling process . (3-501.14 Cooling) 2. On 05/08/19 at 09:53 AM, in the presence of the Administrator (Admin), the maintenance supervisor (MS) stated he was responsible for cleaning the ice-machine. The MS was asked to show the products that he used to clean the ice-machine. The MS showed a bottle of the manufacturer's scale remover for ice-machine cleaner. The MS stated he used a detergent to clean the bin of the ice-machine. Concurrently, the MS went into the kitchen and pointed to a bottle of detergent labeled for pots and pans. The MS was asked if there were any products he used to sanitize the internal components of the ice-making apparatus, and he pointed to the bottle of scale remover. The MS repeated the only products used on the ice-machine was the scale remover and the pots and pans detergent. The MS showed the manufacturer's guidelines that indicated, Cleaning, Sanitation and Maintenance, This ice system requires three types of maintenance: Remove the build up of mineral scale from the ice machine's water system and sensors. Sanitize the ice machine's water system and the ice storage bin ., Clean or replace the air filter ., 16. Mix a solution of sanitizer. Note: A possible sanitizing solution may be made by mixing 1 ounce of liquid household bleach with 2 gallons of warm (95-115 degrees F.) potable water .21. Circulate the sanitizer solution for 10 minutes . On 05/08/19 at 10:02 AM, the above was reviewed with the Admin. The Admin acknowledged the ice-machine had not been sanitized in accordance with the ice-machine's manufacturers guidelines. The facility's policy and procedure titled Ice Machine Sanitation dated 2/09, indicated, Purpose; Maintain sanitary and clean ice machines and ensure proper service of ice .

Shoreline Care Center

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