Does NORTH BAY POST ACUTE have any serious inspection findings?

Yes, NORTH BAY POST ACUTE has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 85 total deficiencies from recent inspections.

What are the staffing levels at NORTH BAY POST ACUTE?

NORTH BAY POST ACUTE has a four-star staffing rating from CMS with 0.55 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 NORTH BAY POST ACUTE located?

NORTH BAY POST ACUTE is located in PETALUMA, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does NORTH BAY POST ACUTE have?

NORTH BAY POST ACUTE has 98 certified beds.

Who owns NORTH BAY POST ACUTE?

NORTH BAY POST ACUTE is a for profit - limited liability company facility and operates independently (not part of a chain).

What questions should families ask when visiting NORTH BAY POST ACUTE?

Families visiting NORTH BAY POST ACUTE should ask about what corrective actions were taken after fines, 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 NORTH BAY POST ACUTE compare to other nursing homes?

NORTH BAY POST ACUTE 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.

NORTH BAY POST ACUTE

Name: NORTH BAY POST ACUTE
Address: 300 DOUGLAS STREET, PETALUMA, CA, 94952, US
Telephone: (707) 763-6887
Rating: 1.0

300 DOUGLAS STREET, PETALUMA, CA 94952 · (707) 763-6887

For profit - Limited Liability company 98 Beds Independent Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

3/100

#1076 of 1155 in CA

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Last Inspection: January 2025

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

Overview

North Bay Post Acute has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. Ranked #1076 out of 1155 facilities in California, it falls in the bottom half of nursing homes in the state, and at #16 out of 18 in Sonoma County, only one local option is better. The trend is worsening, with issues increasing from 11 in 2024 to 37 in 2025. While staffing is a relative strength with a rating of 4 out of 5 stars, indicating good staffing levels, the overall quality measures score just 2 out of 5, suggesting below-average care. Additionally, the facility has faced concerning fines totaling $132,836, which is higher than 94% of California facilities, pointing to repeated compliance problems. Specific incidents include a serious rat infestation in the kitchen that contaminated food for residents, as well as failures in providing proper care for residents with critical medical needs, leading to serious health risks. Overall, while there are some strengths in staffing, the facility has significant weaknesses that families should carefully consider.

Trust Score: F
In California: #1076/1155
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 42% turnover. Near California's 48% average. Typical for the industry.
Penalties: $132,836 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
Violations: 85 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 11 issues

2025: 37 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (42%)
6 points below California average of 48%

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 42%

Near California avg (46%)

Typical for the industry

Federal Fines: $132,836

Well above median ($33,413)

Significant penalties indicating serious issues

The Ugly 85 deficiencies on record

1 life-threatening 2 actual harm

Jul 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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observations, interviews and record reviews, the facility failed to ensure the provision of a sanitary environment that would prevent the development and transmission of infections for one out of four residents (Resident 2) when:1. Resident 2's foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine also known as a urinary catheter) bag (a drainage bag connected to the FC) was touching the floor.2. Staff did not wear a gown, in accordance with enhanced barrier precautions (EBP, an infection control intervention, that involves the use of gowns and gloves during high-contact care activities to reduce the transmission of Multidrug-Resistant Organisms [MDRO, microorganisms (germs), that are resistant to one or more antibiotics]) while handling Resident 2's FC.These failures had the potential to cause and spread infections among residents and staff. Findings:1. During a concurrent observation and interview on 7/15/25 at 1:44 p.m. Unlicensed Staff A verified Resident 2's FC drainage bag was touching the floor. Unlicensed Staff A stated the FC drainage bag should not be touching the floor, for infection control purposes, as Resident 2 could get sick with an infection.During an interview on 7/15/25 at 1:58 p.m., Licensed Nurse (LN) B stated FC drainage bags should not touch the floor because the floor was dirty. LN B further explained, bacteria (germs) could contaminate the FC drainage bag and Resident 2 could end up with an infection.During an interview on 7/15/25 at 2:30 p.m., the Director of Nursing (DON) stated the FC drainage bag should not touch the floor, for infection control, as it increases the risk of a resident acquiring an infection.A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised 8/2022, the P&P indicated, . be sure the catheter tubing and drainage bag are kept off the floor.2. During a concurrent observation and interview on 7/15/25 at 1:53 p.m., outside Resident 2's door a poster indicated Resident 2 was on EBP. Unlicensed Staff A was observed handling Resident 2's FC drainage bag while not wearing a gown. Unlicensed Staff A verified Resident 2 was on EBP and that she had not followed the EBP when she had not worn a gown when she handled Resident 2's FC drainage bag. Unlicensed Staff A acknowledged EBP was expected to be followed to prevent spreading infections to other residents.During an interview on 7/15/25 at 1:58 p.m., LN B stated residents who had a FC were placed on EBP, and all staff were expected to follow the EBP when caring for these residents. LN B stated anytime a staff touched a residents' FC, staff must wear gloves and a gown to prevent cross contamination (transfer of germs from one place to another with harmful effect) and infection. During a concurrent interview and record review on 7/15/25 at 2:45 p.m., with the DON, the Centers for Disease Control (CDC, the national public health agency of the United States) EBP poster was reviewed, the DON verified Resident 2 had a foley catheter and was on EBP. The DON verified the facility followed the CDC's EBP guidelines which indicated when staff handled a resident's FC, they should wear gloves and gown. The DON stated it was important to follow EBP to prevent or reduce the spread of infections.A review of the CDC document titled Enhanced Barrier Precaution, undated, indicated, . everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and gowns for the following high contact resident care activities.device care or use:.urinary catheter.

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

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Based on observation, interviews and record review, the facility failed to ensure a call light (a communication tool used in healthcare settings to allow patients/residents to request assistance from staff) was provided to one out of three sampled residents (Resident 2) when the call light was not within Resident 2's reach.This failure could result in late provision of care, unmet needs and increases the risk of accidents.Findings:During a concurrent observation and interview on 7/15/25 at 1:38 p.m., Resident 2's call light was tangled with a red string by the wall and near the foot of his bed. Resident 2 stated when he needed help he would use his call light but added, it was not where he could reach as it was too far [away].During a concurrent observation and interview on 7/15/25 at 1:44 p.m., in Resident 2's room, Unlicensed Staff A verified Resident 2's call light was tangled with red string by the wall, near the foot of his bed, and was not within Resident 2's reach. Unlicensed Staff A stated Resident 2's call light should be within his reach so he could ask for assistance when he needed it. Unlicensed Staff A verified Resident 2's call light had a clip to ensure it could be clipped on his clothes or pillowcase to ensure the call light was within his reach. During an interview on 7/15/25 at 1:58 p.m. Licensed Nurse (LN) B stated residents' call light should be clipped to their clothing and be within residents' reach at all times. LN B stated residents used the call light to alert staff when they need assistance. LN B stated if a resident could not reach his call light easily, then it was a safety issue, as it could lead to unmet needs, and accidents. During an interview on 7/15/25 at 2:30 p.m., the Director of Nursing (DON) stated residents' call light should be within residents' reach at all times. The DON verified it was the facility's policy to place the call light within reach of the resident. A review of the facility's policy and procedure (P&P), titled Call light, revised 6/26/2024, the P&P indicated, .place the call light within reach of the resident .

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement its abuse policy when Certified Nursing Assistant B (CNA B) was allowed to return to work after a physical and sexual abuse allegation was made against him, and prior to the facility completing their abuse investigation. This failure caused Resident 1 to feel unsafe, and potentially placed other residents, who were cared for by CNA B, at risk of abuse. Findings: During an interview on 4/25/25 at 2:50 p.m., the Administrator stated Resident 1 had reported that CNA B had pushed her and had jumped on her roommate. The Administrator stated the facility's investigation into the incident was in process (not finished). The Administrator stated Resident 1's roommate (Resident 2) screamed when CNAs provided ADL (Activities of Daily Living; care such as eating, dressing, bathing, and toileting) care and Resident 1 may have inferred she was being abused. When asked how Resident 1 and Resident 2 were being protected during the investigation, Administrator stated he had immediately suspended CNA B. Review of Resident 1's MDS (Minimum Data Set - a federally mandated resident assessment tool) dated 2/10/25, her BIMS (Brief Interview for Mental Status; an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 13 (cognitively intact). During an interview on 4/25/25 at 3:15 p.m., Resident 1 stated the previous night (4/24/25), CNA B had not fed Resident 2 (the roommate) her meal; she stated CNA B also pushed her (Resident 1) shoulder. Resident 1 stated two months earlier, CNA B was on top of Resident 2 on the bed; she stated the curtains were pulled around the bed but she could see through an opening in the material. Resident 1 stated if CNA B returned to the facility, she would not feel safe. During an interview on 4/25/25 at 4:20 p.m., the Social Worker (SW) stated Resident 1 reported to them that she was giving Resident 2 a sandwich, but CNA B took it away and pushed her. The SW also stated Resident 1 had alleged staff had grabbed Resident 2, threw her on the bed, men had sex with Resident 2, and she heard Resident 2 screaming. SW stated the facility suspended CNA B. During an interview on 4/28/25 at 3:10 p.m., Resident 1 stated she had seen CNA B in the building over the weekend (4/26-4/27/25) but he was not taking care of the three women in her room. When asked if she felt safe, Resident 1 stated, hell no! Review of CNA B's Employee Timesheet (dated 04/16/2025 - 04/30/2025) indicated on, Sat [Saturday] 04/26/2025, CNA B worked from approximately 2:23 p.m. to 11:07 p.m. and Sun [Sunday] 04/27/2025, CNA B worked from approximately 2:29 p.m. to 11:04 p.m. During an interview on 4/28/25 at 3:50 p.m., the Administrator stated the abuse investigation was not yet completed but CNA B had returned to work over the weekend. The Administrator stated staff could return to work prior to the facility abuse investigation's completion as long as there was no truth to the allegation. A review of facility's document title, Summary-Staff-to-Resident Allegation, sent to the California Department of Public Health on 4/30/25, indicated the investigation continued through 4/30/25. Review of facility policy titled, Alleged or Suspected Abuse and Crime Reporting, subtitled, 7. Protection, dated 2/21/2025, indicated, To protect residents . from harm or retaliation during an investigation, the facility shall: .Suspend staff member(s) believed to be involved, pending the outcome of an investigation .

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of three sampled residents received care which met services provided to meet professional standards when nursing assessments related to changes in Resident 1's skin integrity (skin health) was not documented in Resident 1's medical record. This failure resulted in inaccurate assessment documentation which had the potential to prevent Resident 1's skin integrity from further impairment. Findings: A review of Resident 1's admission record indicated admission to the facility in April 2024 with diagnosis of syncope (fainting or passing out) and collapse, muscle weakness, abnormalities of gait (a manner of walking) and mobility, presence of right and left artificial knee joint (knee replacement), and schizophrenia (a mental illness that is characterized by disturbances in thought). A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 4/9/25, indicated Resident 1: · No memory impairment, · Risk of developing pressure ulcers/injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence), · Impairment on one side lower extremity (hip, knee, ankle, foot), · Substantial/maximal assistance (helper does more than half the effort) sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, · Unable to walk 10 feet, · Wheelchair independent and, · Always incontinent (lack of voluntary control over urination or defecation) of urinary and bowel. A review of Resident 1's discontinued orders 3/25-4/25, indicated a phone order was received on 4/10/25 at 3:19 p.m., by License Nurse 1 (LN 1). The order summary indicated, LAL (low-air loss mattress [a medical-grade mattress designed to prevent and treat pressure injuries]) mattress. A review of Resident 1's discontinued orders 3/25-4/25, indicated a phone order was receive on 4/10/25 at 6:07 p.m., by LN 1. The order summary indicated, Apply barrier cream (skincare product designed to protect and support the skin's natural barrier function) to bilateral buttocks redness every shift. A review of Resident 1's shower sheet, dated 4/14/25, indicated two open areas on Resident 1's body map. One circle described open on Resident 1's coccyx (tailbone), and one circle described open on Resident 1's left buttocks. If new skin problem observed, was nurse notified? , indicated, Yes. Nurse intervention for new findings, indicated, No new findings. The shower sheet included Certified Nurse Assistant 1 (CNA 1) signature, and a Nurse signature. During an interview on 4/24/25 at 3:30 p.m., Resident 1 stated he received incontinence care at the facility. Resident 1 stated he can wait up to thirty minutes to be changed when wet or soiled. In regard to bed mobility, Resident 1 stated, I can participate a little bit, but it's getting harder. During a concurrent observation and interview on 4/24/25 at 3:41 p.m., CNA 1 stated, Oh yea, he (Resident 1) had a wound on his coccyx area before he went to the hospital. CNA 1 described the wound as a small opening, gesturing with her thumb and index finger by bringing them together with a gap approximately measuring 3 centimeters (cm, a unit of measure) in-between. Additionally, CNA 1 stated Resident 1 had redness on his bilateral buttocks. CNA 1 stated Resident 1 was treated with barrier cream to the wound and buttocks and was being repositioned. CNA 1 stated a LAL mattress was started this month. During an interview on 4/25/25 at 10:58 p.m., LN 1 stated changes in skin condition are reported to the Medical Director (MD), Director of Nursing (DON), nurses, and Wound Specialist (WS), as soon as they are discovered. LN 1 stated the WS will evaluate and give new orders. LN 1 stated WS notes are emailed to her, and she enters the WS notes into the resident's electronic record. LN 1 stated prior to Resident 1's recent admission to the hospital, Resident 1 had redness to the left buttocks and was treated with barrier cream. LN 1 stated a LAL mattress was ordered 4/10/25 to prevent skin injury. During an interview on 4/25/25 at 11:19 a.m., the CNA 2 stated, He (Resident 1) can't really help anymore with shifting in bed. He is a 2-person assist (a patient or resident requires two caregivers to safely assist with mobility, transfers, or other daily living activities) for incontinence care. During an interview on 4/25/25 at 11:37 p.m., the DON stated his expectations for reporting changes in skin condition is for staff to initiate a change in condition (COC) form, and notify the MD, and family if resident is not own representative. DON stated the treatment nurse, and the Director of Staff Development (DSD) are expected to review shower sheets daily. DON stated any changes in skin should be reported to the treatment nurse and charge nurse for assessment. DON stated alert charting for changes in skin is completed for two days, stating, The treatment nurse would continue to chart skin assessments. DON reviews the shower sheet dated 4/14/25, and stated it is not the CNA's scope of practice to assess wounds. During an interview on 4/25/25 at 1:50 p.m., the DON stated the shower sheet dated 4/14/25 was reported to a treatment nurse by CNA 1. The DON confirmed there is no documentation of the assessment, and stated, The only documentation we have is of the barrier cream and dressing. During an interview on 4/25/25 at 2:14 p.m., the DSD stated, The charge nurse or treatment nurse should be completing the assessment if changes to skin are reported. Changes should be documented in SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents). The DSD stated, CNA's are expected to document the location and a description of what they see on the body map of the shower sheet. The DSD confirms the interpretation of open on the body map would indicate the skin is no longer intact (not damaged, or impaired in any way). During a review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention, Management and Documentation, dated 2024, the P&P indicated, Licensed nurses will conduct a pressure injury risk assessment .Whenever the resident's condition changes significantly Findings will be documented in the medical record. During a review of the facility's P&P titled, Skin Care, dated 2024, the P&P indicated, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse .The assessment may also be performed after a change of condition or after any newly identified pressure injury .Documentation of skin assessment .Document observations (e.g. skin conditions .) .Document type of wound .Document wound (measurements, color .). During a review of the facility's P&P titled, Resident Showers, dated 2024, the P&P indicated, The CNA will assess the skin for any changes while performing bathing .

Apr 2025 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0658 (Tag F0658)

A resident was harmed · This affected 1 resident

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Based on interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 1), who had a history of COPD (chronic obstructive pulmonary disease; a chronic lung disease causing difficulty in breathing) and cancer in her lungs received care consistent with nursing professional standards of quality and the resident's individualized nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes). Resident 1 experienced a medical emergency (a serious and sudden situation that requires immediate medical attention to prevent serious injury, disability, or death) on the morning of 3/23/25 that included respiratory distress (difficulty breathing associated with inadequate oxygenation) and critical hypoxia (low level of oxygen in the blood), but licensed nursing staff: 1) Did not physically assess Resident 1 by listening to her lung sounds (using a stethoscope [medical instrument used to detect sounds produced in the body] to assess airflow through the respiratory tract/lungs) or by assessing her use of accessory muscles (use of neck or intercostal [between the ribs] muscles when breathing is an indication of respiratory distress); 2) Did not administer oxygen (medical treatment that provides extra oxygen to the body when the lungs cannot oxygenate the blood sufficiently) to meet her needs; licensed staff attempted to titrate (adjust) the oxygen down while she had critical hypoxia; 3) Did not administer Albuterol (a rescue medication that opens the airways and can ease breathing) as ordered by her physician; 4) Did not document Resident 1's oxygen saturation levels (percent of oxygen in a person's blood; normal range is approximately 95% - 100%) throughout her medical emergency; 5) Did not ensure Resident 1 was promptly transferred to the hospital when her emergent condition was discovered on 3/23/25 at approximately 10:30 a.m.; the ambulance company was contacted at 11:20 a.m. (reflecting a timespan of approximately 50 minutes); 6) Did not document contacting Resident 1's physician immediately upon discovery of her critical condition; nursing staff documented they contacted Physician F at 11:20 a.m., approximately 50 minutes after her hypoxia was discovered; and, 7) Did not document nursing interventions implemented to treat Resident 1's emergency. These failures: 1) Impaired Physician F from knowing the extent of Resident 1's condition and ordering medication to treat her declining respiratory status; 2) Potentially exacerbated (to make worse or more severe) Resident 1's critical hypoxia by decreasing her oxygen administration, when she required additional oxygen administration; 3) Potentially contributed to Resident 1's respiratory distress by failing to administer medication (Albuterol) designed to treat COPD and the resulting hypoxia; and, 4) Delayed Resident 1's transportation to the Emergency Department, thereby delaying life-saving respiratory treatments (Resident 1's was ultimately admitted to the Intensive Care Unit - specialty unit providing round-the-clock monitoring and treatment for critically ill patients). Findings: During a telephone interview on 4/1/25 at 12:46 p.m., Registered Nurse C (RN C), who worked at Hospital E, stated a nurse from the facility called report (nurse to nurse communication regarding important patient health status details) to her on the morning of 3/23/25, prior to Resident 1's hospital transfer. RN C stated the facility nurse told her Resident 1's oxygen saturation was 78% and she was struggling (to breathe), but the facility nurse was weaning (decreasing) Resident 1 off her oxygen. RN C stated she instructed the facility nurse to go back to the patient and increase her oxygen, because she needed the oxygen. RN C stated she was concerned because the facility nurse lacked knowledge of how to treat hypoxia. RN C stated if a patient had hypoxia, you give them oxygen; if 5 liters (of oxygen) is not working, she stated you put on a mask (oxygen is measured in liters [L] per minute and delivered via mask or nasal cannula [small plastic tube, which fits into the person ' s nostrils for providing supplemental oxygen]). During the same telephone interview on 4/1/25 at 12:46 p.m., RN C stated Emergency Responders (ER's) determined Resident 1's physical status required Code 3 transport (driving using lights and sirens) and they administered an Albuterol treatment in route to the hospital. RN C stated Code 3 transportation was utilized with someone who was dying. RN C stated Resident 1 was critical upon arrival to the Emergency Department (ED) and she was classified as an ESI 2 (Emergency Severity Index; high risk of deterioration; ESI 1 is the most urgent/ESI 5 is the least urgent) and she was close to coding (code blue; an emergent situation when a patient's breathing or heart has stopped). RN C stated Resident 1 was also struggling (to breathe), unable to speak, and weak as a noodle when she arrived and was subsequently transferred to the Intensive Care Unit. RN C stated Resident 1's hypoxia (at the facility) contributed to her respiratory distress and bumped her into a more critical presentation in the ED and came close to killing her. Online review of the Cleveland Clinic's website indicated, .Hypoxia is when the tissues of your body don't have enough oxygen .Hypoxia can be life-threatening .prolonged hypoxia can cause organ damage. Brain and heart damage are particularly dangerous and can lead to death . (https://my.clevelandclinic.org/health/diseases/23063-hypoxia) Review of the Ambulance Trip Sheet (ER's documentation of Resident 1's care), dated 3/23/2025 at 11:21 a.m., indicated on 3/23/25, the facility called for an ambulance at 11:20 a.m. and the emergency responders arrived at approximately 11:27 a.m. (seven minutes later). The ER's documented upon their arrival at the facility, Resident 1's respiratory rate was increased (a sign of respiratory distress), her breathing was labored (abnormal breathing; increased effort to breathe; may include use of accessory muscles), and her oxygen saturation was 74%. The ER's also documented Resident 1 had decreased tidal volume (the amount of air inhaled or exhaled during a normal breath ), had retractions (indicating use of accessory muscles) around her neck area, her lung sounds were diminished in the bases (reduced air flow in the lower part of the lungs) and she had mild wheezing (high-pitched sound caused by narrowed airways). Continued review of the Ambulance Trip Sheet, dated 3/23/2025 at 11:21 a.m., indicated on 3/23/2025 at approximately 11:29 a.m., the ER's gave Resident 1 a respiratory treatment with Albuterol and placed her on 6 liters of oxygen; they documented Resident 1's response to their interventions was improved. At approximately 11:42 a.m., prior to arrival at Hospital 3, the ER's documented Resident 1's breathing was still labored but her oxygen saturation had increased to 92%. Oxygen saturation is measured by a pulse oximetry devise at the bedside. According to the National Library of Medicine, pulse oximetry is a quick, non-invasive technique to measure/monitor oxygen saturation in the blood. Normal pulse oximeter readings (oxygen saturation) range from 95% to 100%. Hypoxemia (hypoxia) is an oxygen saturation of less than 90%. Critical findings prompting intervention for most patients would be oxygen saturation in the mid to high 80%. [https://www.ncbi.nlm.nih.gov/books/NBK470348/] During an interview on 4/3/2025 at 1:58 p.m., RN A stated she worked on 3/23/25 but did not remember Resident 1 being sent out to Hospital 3. RN A described the process she would follow if a resident had SOB (shortness of breath): RN A stated she would check the resident's vital signs (temperature, heart rate, blood pressure and respirations/breathing), check the oxygen saturation, listen to the lungs, look at medication (for possible administration), and call the physician. She stated the physician may order labs (laboratory blood work; draw the resident's blood to run tests) and order a chest X-ray (medical imaging of the lungs and heart). RN A stated if a resident's oxygen saturation was below 90%, she would increase the oxygen up to the maximum (ordered by the physician) and would call the physician. She stated if the saturation was in the 80's or 70's (percentile), she would send the resident out (to the hospital) by calling 911 (request for emergency assistance; emergency responders). RN A stated if a resident's saturation was 68%, that would be a very critical situation and she would send the resident to the hospital ASAP (as soon as possible). During an interview on 4/3/2025 at 3:13 p.m., Licensed Nurse B (LN B) stated she would follow the following process if her resident had SOB: check the oxygen saturation, if it was below 90% she would start oxygen and notify the physician; she would elevate the head of the bed, give medication via the nebulizer (medical equipment that administers medication directly and quickly to the lungs via mist) and check the saturation level again; if there was no improvement, she would call 911. LN B stated normal oxygen saturation levels were between 92% - 96%. LN B stated if a residents oxygen saturation was in the 60's or 70's (percentile), they were at risk of dying and she would call 911. During an interview on 4/7/2025 at 1:58 p.m., RN D stated on the morning of 3/23/25 at approximately 10:30 a.m., Resident 1's daughter came out of the room and told her something was wrong with her mother. RN D stated she checked Resident 1's vital signs, her oxygen saturation was 68%, and she was short of breath. RN D stated she turned Resident 1's oxygen up to 5 L (via nasal cannula) and her oxygen saturation increased to 88%. RN D stated she instructed a nursing assistant to stay with the resident while she called Physician F. When questioned if these interventions were documented in Resident 1's medical record, RN D confirmed that she had not documented them. RN D stated she had not listened to Resident lungs during the morning of 3/23/25. When asked why she had not assessed her lung sounds, RN D stated she did not think of it. Review of facility policy titled, Oxygen Administration subtitled, Assessment (revised 10/2010) indicated, . while the resident is receiving oxygen therapy, assess for the following: .5. Lung sounds . Under subtitle, Documentation, the policy indicated, After completing the oxygen . adjustment (dose change), the following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed . 3. The rate of the oxygen flow, route (delivery method, nasal tubing or mask), and rationale. 4. The frequency and duration of the treatment . 6. All assessment data obtained before, during, and after the procedure . Review of facility Registered Nurse job description (dated 08/2015) indicated, . A. Safety discussions: . 17. Reports change of condition to physician . in timely manner . Under subtitle, A. Provision of Nursing Care, the document indicated, 1. Performs nursing care consistent with resident needs . Under subtitle, B. Demonstrates Knowledge and Understanding of Physical Evaluations, the document indicated, 1. Respiratory a. Breath Sounds . During the same interview on 4/7/2025 at 1:58 p.m. RN D reviewed Resident 1's MAR (medication administration report; daily record used by a licensed nurse to document medications and treatments given to a resident), dated March 2025, and confirmed she had a physician order for PRN (as needed) Albuterol inhaler (handheld device that delivers a measured amount of medication as a mist the patient can inhale). RN D confirmed Albuterol was not documented as given on 3/23/25. When asked why she had not given Resident 1 Albuterol, RN D stated Resident 1 was too weak to take it (inhalers require a person to inhale deeply and hold their breath). RN D confirmed Resident 1 had a medication nebulizer (device that converts liquid medication into a mist the patient can inhale easily) at her bedside for administration of other respiratory (lung) medication. When asked if she could have gotten an Albuterol vial (liquid form of the medication to be used with a nebulizer and mask) from the E-kit (emergency kit; facility supply of emergency medication) and given Resident 1 a dose via the nebulizer (does not require deep inhalation or breath-holding), RN D stated she did not know if Albuterol was in the E-kit. Review of Resident 1's MAR (dated March, 2025) revealed a physician order, dated 2/27/2025 at 2:19 p.m., that indicated, ProAir .Inhalation Aerosol Solution . (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for COPD . During the same interview on 4/7/2025 at 1:58 p.m. RN D reviewed Resident 1's SBAR (situation, background, assessment, recommendation; a communication tool used by healthcare workers when there is a change of condition in the resident), dated 3/23/2025 at 3 p.m., and stated it indicated Resident 1's oxygen saturation was 78%. RN D stated the reading of 78% occurred at approximately 11:20 a.m., prior to Resident 1's hospital transfer. RN D was asked if she had attempted to wean Resident 1 to a lower level of oxygen administration and she stated, yes. When asked why she tried to lower the amount of oxygen administered, RN D stated she was not sure why she had done that. Review of Resident 1's SBAR, dated 3/23/25 at 3 p.m., indicated RN D documented the following: .Resident reported difficulty breathing as well as chest congestion . This started on: 03/23/2025 (no time documented) . RN D documented she increased the oxygen from 3L (the increased amount was not identified). RN D documented Resident 1's oxygen saturation was 78% at 11:30 p.m. and, The problem is respiratory due to COPD . She appears with shortness of breath . The SBAR indicated RN D called Physician F one time at 11:20 a.m., prior to her hospital transfer. RN D documented, . Updated MD at 1120. O sat (oxygen saturation) was 78 on NC (nasal cannula) at 4 L SBAR indicated RN D called an RN at Hospital E and gave her report at 11:24 a.m. Review of Resident 1's MAR (dated March, 2025) revealed a physician order that indicated, Titrate (adjust) oxygen from 2L-4L (2 to 4 liters) to maintain (oxygen) saturation of > (greater than) 90% every shift . RN D documented on the MAR that Resident 1's oxygen saturation during the day shift of 3/23/25 was 78%; no specific time was indicated. Review of Resident 1's RN D's nursing progress notes (nurse's documentation of resident care), dated 3/23/25 at 11:30 a.m. indicated, Resident (1) sent to (Hospital E) via 911 (emergency responders). During an interview on 4/7/25 at 2:07 p.m., the DON (Director of Nursing) stated an oxygen saturation of 68% was considered low-low and the nurse should assess the resident's vital signs, increase the oxygen dose level, to increase the oxygen saturation, listen to lung sounds and give a breathing treatment if a PRN medication was ordered. The DON stated if the resident did not improve, the physician should be called (notified). When the DON was asked if a nurse should attempt to wean a hypoxic resident's oxygen administration down, the DON stated, that doesn't make sense. The DON asked why would a nurse wean oxygen down when staff were trying to increase their oxygen (saturation) level. During the same interview and concurrent medical record review on 4/7/25 at 2:07 p.m., the DON stated he advised nursing staff to document their interventions. The DON reviewed Resident 1's SBAR and nurse progress notes from the incident on 3/23/25; he confirmed neither contained documentation that Resident 1's oxygen saturation was 68%, RN D turned up the oxygen to 5L and the resident's saturation increased to 88%, or that RN D listened to Resident 1's lung sounds. When asked about emergency supplies of Albuterol, the DON confirmed Albuterol for nebulizer administration were located in the E-kits. During an interview on 4/7/2025 at 3:15 p.m., Physician F was asked if Resident 1's oxygen saturation level from 68% to 78% was a medical emergency and she stated, yes. She stated staff needed to get the resident to the hospital. Physician F stated a saturation of 68% could indicate the resident was going to crash (code blue; an emergent situation when a patient's breathing or heart has stopped). She stated staff should keep the resident talking (to keep them awake) and not leave them alone. She stated staff should listen to the lungs; if the resident was wheezing, she would use that information to decide on a medication to treat them. Physician F stated she could have ordered oral Prednisone (anti-inflammatory medication) that could be given under the tongue and Albuterol; she stated these medications would give the Emergency doctors a head start (on treatment). Review of Resident 1'a physician notes from Hospital E titled, admission History & Physical , dated 3/23/25 at 11:57 a.m., indicated, . presenting (came to the hospital) from (the facility) for shortness of breath, patient found to be labored (difficulty breathing), with low oxygen saturation . Today in the ED (emergency department) found to have . respiratory failure (condition were a person does not have enough oxygen or too much carbon dioxide [chemical compound in the blood] in their body), started on Bipap (treatment that uses mild air pressure to keep the airways open), also given . abx (antibiotics to fight infection) . CT (computed tomography scan; imaging that produces detailed images of the inside of the body) shows diffuse (spread out) metastatic disease/infiltrate (cancer that spread to the lungs) . Under the subtitle of Assessment/plan, the physician note indicated . Admit to ICU . Review of Resident 1's physician progress note from Hospital E, dated 3/24/2025 at 9:46 a.m. indicated after coming to the hospital, Resident 1 was, .eventually intubated (a tube is inserted through the windpipe and into the lungs; medical procedure that helps patients who cannot breathe on their own) [on] 3/23/ (2025) . Review of Resident 1's physician's notes from Hospital E titled, Hospitalist Discharge Summary (dated 3/28/2025) indicated, . decision was made for patient (Resident 1) to transition to hospice on discharge . Review of Resident 1's Nursing Care Plan dated 2/27/25 indicated Resident 1 had, .altered respiratory status/difficulty breathing r/t (related to) COPD, metastatic . cancer (cancer that spread to her lungs) . The nursing interventions identified in the care plan indicated, Administer medication/puffers (Albuterol) as ordered. Monitor for effectiveness . Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (physician) . Decreased Pulse oximetry .cough . Accessory muscle usage . Monitor/document/report abnormal breathing .use of accessory muscles .Oxygen settings: (oxygen) via nasal prongs (nasal cannula)/mask 2-4L/min (2 to 4 liters per minute) . Review of facility job description titled, Charge Nurse subtitled, Charting and Documentation (undated), the document indicated, . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well and the resident's response to the care . Under subtitle, Care Plan and Assessment Functions, the document indicated, Review care plans daily to ensure that appropriate care is being rendered . Review resident care plans for appropriate resident goals, problems, approaches and revisions . Review of facility policy titled, Change in a Resident's Condition or State (revised 2/2021) indicated, Our facility promptly notifies the . attending physician . of changes in the resident's medical .condition and/or status . Under subtitle, Policy Interpretation and Implementation, the policy indicated, . 2. A significant change of condition is a major decline . in the residents status . 3. Prior to notifying the physician . the nurse will make detailed observations and gather relevant and pertinent information for the provider (physician) . Review of facility policy titled, Transfer of Discharge, Facility-Initiated, subtitled, Documentation of Facility-Initiated Transfer or Discharge (dated 10/2022) indicated, When a resident is transferred or discharged from the facility, the following information is documented in the medical record: . a.(1) If the resident is being transferred or discharged because his or her needs cannot be met . documentation will include: a. the specific resident needs that cannot be met; b) this facility's attempt to meet those needs; . f. A summary of the resident's overall medical, physical, and mental condition . Review of facility document titled, Competency (demonstration of appropriate knowledge/skills) Validation Checklist (undated) for licensed nurses indicated, Respiratory Assessment . Observe respiratory rate, pattern, work of breathing . Auscultate (listen via stethoscope) anterior (front), lateral (side) and posterior (back) chest comparing one side to the other; .Ability to determine the following Breath sounds: 1. Wheezing - .usually a sign that something is making your airways narrow or keeping air from flowing through them. Two of the most common causes of wheezing are lung disease . COPD .lung cancer . Online review of the National Library of Medicine indicated the brain is the most sensitive organ, and visual, cognitive, and electroencephalographic (EEG - recording of the spontaneous electrical activity of the brain) changes develop when the oxygen saturation is less than 80% to 85%. (https://www.ncbi.nlm.nih.gov/books/NBK525974/)

Jan 2025 32 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure resident hand-outs (weekly menu, activities calendar, guide for translation services) were provided in Resident's preferred language for two of 23 sampled residents (Resident 342 and Resident 8). This failure resulted in Resident 342 and Resident 8 being uninformed on menu options, activities, and how to obtain a translator. Findings: a. During a concurrent observation and interview on 1/13/25 at 3:22 p.m. with Resident 342, through the translation services provided from the facility, in Resident 342's room , posted on the walls were the weekly menu, activity calendar, interpretive services-reference guide and instructions for accessing interpreter, all written in English. Resident 342 stated he did not understand the signage because it was written in English. Resident 46 further stated he only spoke and read in Spanish. During an interview on 1/14/25 at 10:48 a.m. with Registered Nurse (RN) 2, RN 2 stated she has not seen any papers or forms in other languages. The forms were all written in English. RN 2 further stated, Doesn't make sense why it's in English when he can't read it, and it was important for signage to be in Resident's primary language so he could be informed. During an interview on 1/14/25 at 10:59 a.m. with the Registered Dietician (RD), the RD stated the facility did not offer menus in different languages. RD stated it would be important to have the menu in different languages so the Resident knew what they were eating and if they wanted to request a food alternative. During an interview on 1/14/25 at 11:03 a.m. with the Activities Director (AD), the AD stated the facility did not offer activity calendars in a different language. During a review of Resident 342's Minimum Data Set (MDS-an assessment tool), dated 12/26/24, the MDS indicated, Resident 342's preferred language was Spanish, and an interpreter was needed for communication. During a review of [facility name] Facility Assessment, dated 1/6/25, the Facility Assessment indicated, .The facility can provide or accommodate most activities, food and nutrition services, languages . according to resident preference . During a review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, dated November 2020, the P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information . b. During an observation on 01/14/25 at 3:58 p.m. in Resident 8's Room, the weekly menu for January 13-19, 2025, and the facility monthly activity schedule for January 2025 posted on Resident 8's wall was in English only. Translation services posted on the wall next to bed was in English only. During an interview on 01/14/25 at 03:43 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that Resident 8 spoke only Chinese. During an interview on 01/14/25 at 03:52 p.m. with Certified Nurse Assistant (CNA) 8, CNA 8 stated that Resident 8 only spoke Mandarin. CNA 8 stated, I haven't seen the menu or activity paper in other languages. During a review of Resident 8's Face Sheet (demographics), dated 2/29/24, the Face Sheet indicated Chinese was listed as Resident 8's primary language. During a review of Resident 8's Minimum Data Set (MDS-an assessment tool), dated 11/15/24, the MDS indicated, Resident 8's preferred language was Mandarin, and an interpreter was needed for communication. During a review of [facility name] Facility Assessment, dated 1/6/25, the Facility Assessment indicated, .The facility can provide or accommodate most activities, food and nutrition services, languages . according to resident preference . During a review of the facility's policy and procedure (P&P) titled, Translation and/or Interpretation of Facility Services, dated November 2020, the P&P indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information .

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for Resident 46. This failure resulted in Resident 46 being unable to contact staff for assistance. Findings: During a review of Resident 46's Face Sheet (demographics) dated 1/16/25, the Face Sheet indicated Resident 46 was admitted to the facility on [DATE] with diagnoses of hemiplegia (complete paralysis to one side of the body) following cerebral infarction (stroke- serious condition that occurs when blood flow to the brain is blocked) affecting right dominant side, aphasia (unable to communicate verbally) and weakness. During an observation on 1/14/25 at 4:02 p.m. in Resident 46's room, Resident 46 was reclined in a geriatric chair (padded chair that is designed to help seniors with limited mobility) in the middle of the room without a call light. Resident 46 threw one pillowcase, in the direction of the door, and waved multiple times. Resident 46 grunted and pointed at the call light, on the floor. During an interview on 1/14/25 at 4:05 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 46 was non-verbal and required maximum assistance for all Activities of Daily Living (ADL). CNA 2 stated Resident 46 call light was not within resident's reach. During an interview on 1/16/25 at 11:25 a.m. with the Director of Nursing (DON), the DON stated that the call light should have been within Resident 46's reach at all times. It is important for all the residents to be able to use the call light for assistance. During a review of Resident 46's Minimum Data Set (MDS-an assessment tool), dated 4/29/24, MDS indicated Resident 46 had absence of spoken words and rarely/never understood for ability to verbally express ideas or wants. During a review of Resident 46's Care Plans, dated 10/31/24, the Care Plans indicated, [Resident 46] has a communication problem r/t [related to] Expressive Aphasia (unable to communicate verbally) . Ensure/provide a safe environment: Call light in reach . During a review of the facility's policy and procedure (P&P) titled, Call Light, Answering, dated 4/1/19, the P&P indicated, .Make sure call cords are placed within the resident's reach at all times .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 83) and/or their legal representatives were informed and/or provided written information about Advance Directives (AD, legal document that provides instructions regarding medical care according to the resident's wishes and only goes into effect if the resident can no longer communicate their wishes). This failure had the potential to result in lack of knowledge regarding care and treatment decision making for Resident 83. Findings: During a review of Resident 83's admission Record (AR), the AR indicated the facility admitted Resident 83 on 11/12/2024 with multiple diagnoses including hypertension (high blood pressure) and muscle weakness. The AR indicated Resident 83 had a Responsible Party 1 (RP) 1 as the emergency contact. During a review of Resident 83's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment dated 11/19/24, indicated Resident 83's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 12 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 83 had moderate cognitive impairment. During a concurrent interview and record review on 1/14/25 at 3:57 p.m. with Minimum Data Set Coordinator (MDSC), Resident 83's Physician Orders for Life-Sustaining Treatment (POLST), dated 11/12/24 was reviewed. The POLST indicated Section D, Information and Signatures was incomplete. MDSC stated RP 1 did not sign the Advance Directive Acknowledgment form. MDSC stated there was no documented evidence RP 1 was provided information regarding AD and written information on AD formulation. During a concurrent interview and record review on 1/16/25 at 10:32 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Residents' Rights Regarding Treatment and Advance Directives dated February 2023 was reviewed. The P&P indicated, .Advance Directive is a written instruction, such as a living will or durable power of attorney .On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive . Any decision making regarding the residence choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . The DON stated it was the physician's and the nurses' responsibility to ensure that information regarding the advanced directive was discussed and documented. The DON stated the purpose of the advanced directive was to meet the wishes and desires of the individuals living will.

CONCERN (D)

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

Employment Screening (Tag F0606)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure proper screening and follow-up for Registered Nurse (RN) 3 who had been found guilty of neglect by a court of law. This finding had the potential to compromise the safety of all residents, staff, and visitors. The facility census was 94. Findings: During a review of RN 3's employee files titled, CALIFORNIA BOARD OF REGISTERED NURSING- BRN (Board of Registered Nursing) LICENSING DETAILS, dated 1/16/25 and 12/19/23, the documents indicated RN 3 had an administrative disciplinary action against RN 3's license posted on 12/12/23. During a review of a public court document (legal document available to the public and is part of the court record) titled, BEFORE THE BOARD OF REGISTERED NURSING DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA, dated 11/30/23, the document indicated, .[RN 3] was convicted by a plea of guilty to: (1) child endangerment . felony . During an interview on 1/17/25 at 8:31 a.m. with the Administrator (ADMIN), the ADMIN identified himself as the facility's abuse coordinator (designated staff member within a nursing home responsible for overseeing and coordinating the facility's efforts to prevent resident abuse). The ADMIN stated it was the responsibility of the facility to check a registered nurse's license when up for renewal for the expiration date and if anything was added to the license, like a DUI. The ADMIN stated an employee with a disciplinary action against their nursing license meant the facility had to investigate the issue and go from there. The facility was unable to provide documentation that the administrative disciplinary action against RN 3's license was investigated and addressed by the facility. During a review of Registered Nurse (RN) 3's Job Description, dated 1/25/24, the document indicated, .Specific Requirements- Must possess a current, unencumbered (a license that's free of disciplinary limitation), active license to practice as an RN . During a review of the California Penal Code (a legal document that compiles a jurisdiction's criminal laws, defining various crimes), dated 1/1/23, the PENAL CODE Section 11165.2 indicated, .'Severe neglect' also means those situations of neglect where any person having the care or custody of a child willfully causes or permits the person or health of the child to be placed in a situation such that their person or health is endangered . During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, the P&P indicated, .Conduct employee background checks and not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law . a disciplinary action in effect against his or her professional license by a state licensure body as a result of finding of abuse, neglect, exploitation .

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the resident's transfer notification to the Office of the State Long-Term Care Ombudsman (resident advocacy agency) for two of 23 sampled residents (Resident 77 and 84) when: 1. Resident 77 was transferred to General Acute Care Hospital (GACH) on 11/10/24, and a transfer notification was not sent to the Ombudsman. 2. Resident 84 was transferred to General Acute Care Hospital (GACH) on 11/15/24, and a transfer notification was not sent to the Ombudsman. These failure resulted in the Office of the State Long-Term Care Ombudsman not being aware of Resident 77 and 84's transfers to GACH. Findings: 1. During a review of Resident 77's Face Sheet (demographics), the Face Sheet indicated Resident 77 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (lung disease that makes it difficult to breathe). During a review of Resident 77's Progress Notes, dated 11/10/24, the notes indicated .running high temp (temperature) with irregular HR (heart rate). MD (medical doctor) notified of the vitals and was recommended to send him to the hospital . During a concurrent interview and record review on 1/15/25 at 12:28 p.m. with the Medical Records Director (MRD), Resident 77's Medical Record was reviewed. The MRD stated Resident 77 was sent to the hospital on [DATE], and that the Notice of Transfer or Discharge was not sent to the Office of the State Long-Term Care Ombudsman. During an interview on 1/15/25 at 2:28 p.m. with Registered Nurse (RN) 6, RN 6 stated the purpose of the notice of transfer and discharge was to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge of resident. RN 6 stated it was the licensed nurse's responsibility to complete and send the notice of transfer or discharge form. During a concurrent interview and record review on 1/16/25 at 10:30 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated October 2022, was reviewed. The P&P indicated, .The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge, including the basis .A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer is provided to the resident and representative . The DON stated it was the licensed nurses' responsibility to send the notice of transfer or discharge at the time it was initiated. The DON stated the notice of transfer or discharge should be sent to the Office of the State Long-Term Care Ombudsman. 2. During a review of the Resident 84's provider note from [hospital name], dated 11/15/24, the note indicated Resident 84 was admitted to the hospital for osteomyelitis of great left toe (swelling that occurs in the bone). During a review of the Resident 84's [hospital name] History and Physical (H&P), dated 11/15/24, the H&P indicated Admit [Resident 84] to hospital service. During a concurrent interview and record review on 1/15/25 at 2:44 p.m. with the Medical Records Director (MDR), Resident 84's Medical Record was reviewed. The MRD stated Resident 84 was sent to the hospital on [DATE], and that the Notice of Transfer or Discharge to the Office of the State Long-Term Care Ombudsmanwas was not in Resident 84's Medical Record. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated October 2022, the P&P indicated .The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge, including the basis . A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer is provided to the resident and representative .

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to identify a mental illness (MI- medical disorder that affects a person's thinking, emotions, or behavior) and subsequently failed to refer one of 23 sampled residents (Resident 71) for a Level II PASRR (Preadmission Screening and Resident Review- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) screening. This failure resulted in Resident 71 not receiving specialized mental health services to meet her needs. Findings: During a review of Resident 71's PASRR, dated 7/14/23, the PASRR indicated Level 1 screening was negative. PASRR indicated Resident 71 was not diagnosed with a mental disorder such as anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms) and panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), and not prescribed psychotropic (a drug that affects how the brain works and causes changes in mood, thoughts, feelings and behaviors) medications for mental illness. During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 7/20/23, the MDS indicated Resident 71's active diagnoses were anxiety disorder and post-traumatic stress disorder (a condition of persistent mental and emotion stress occurring because of injury or severe psychological shock). The MDS indicated Resident 71's Level II PASRR Conditions were not checked. During a review of Resident 71's CAA [Care Area Assessment] Worksheet (a tool used to further investigate specific areas of concern identified during MDS assessment), dated 7/20/23, the CAA Worksheet indicated Resident has had thoughts that she would be better off dead, or thoughts of hurting herself, and she was on medication for PTSD and psychosis (symptoms that can cause a person to lose touch with reality such as hallucinations). The CAA Worksheet further indicated Resident 71 had severe depression and was recommended for a Referral . PsyD (doctor of psychology) . During a concurrent interview and record review on 1/16/25 at 9:52 a.m. with Social Services Director (SSD), Resident 71's Medication Administration Record (MAR), dated 1/16/25 was reviewed. Resident 71's MAR indicated Resident received three different medications for post-traumatic stress disorder, panic disorder and depression. SSD stated it was her responsibility to arrange the referral for a PASRR evaluation. SSD stated if a resident had psychosis, depression, anxiety or other mental health related diagnoses, the resident would be referred for clarification for PASRR evaluation. SSD stated Resident 71 was never evaluated or referred for PASRR clarification, but she should have been. During a review of the facility's policy and procedure (P&P) titled, Preadmission Screen and Resident Review (PASRR), dated July 2016, the P&P indicated, It is the policy of this facility to complete and submit a PASRR screening . If facility is dissatisfied with the recommendations in the PASRR determination letter, they can request a reconsideration . the facility will update the existing PASRR on file for either of the following reasons . there is a significant change in a resident's physical or mental condition .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to reduce the risk of injuries from falls for one of 23 sampled residents (Resident 25). This failure resulted in the potential for the resident to suffer an injury during a fall. Findings: Review of Resident 25's admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of the temporal lobe (brain tumor). During an interview on 1/13/25 at 10:50 a.m. with Resident 25's Responsible Party (RP) 1, RP 1 stated facility staff called her on 1/12/25 and informed her that Resident 25 had rolled out of his bed. During an observation on 1/13/25 at 9:00 a.m. in Resident 25's room, Resident 25 was in bed asleep. No fall mat was observed on the floor at his bedside. During an observation 1/13/25 11:58 a.m. in Resident 25's room, Resident 25 was in bed asleep. No fall mat observed at bedside. During an interview on 1/15/25 at 8:45 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 25 required assistance to get out of bed. CNA 1 stated he was aware that the resident was found on the floor. CNA 1 confirmed there was not a fall mat at Resident 25's bedside. During an interview on 1/14/25 at 9:11 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 25 fell on 1/12/25 and was found crawling on the floor. RN 1 stated that a fall mat should have been placed next to Resident 25's bed. During an interview on 1/15/25 at 9:15 a.m. with Charge Registered Nurse (CRN) 1, CRN 1 stated that Resident 25 recently had a fall on 1/12/25. CRN 1 stated that Resident 25 becomes agitated and scoots around in bed. CRN 1 stated that Resident 25 required a fall mat and that it may have been removed for cleaning. During an interview on 1/15/25 at 12:30 p.m. with the Director of Nursing (DON) 1, DON 1 stated that the fall mat should be used as an intervention for Resident 25 because he was prone to crawling or rolling out of bed. During a review of Resident 25's Care Plan, dated 10/15/24, the Care Plan indicated, Resident 25 had been found crawling out of bed and interventions included keep floor mat at bedside. During a review of the facility's policy titled, Falls and Fall Risk, managing, dated March 2018, the policy indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise and implement a person centered comprehensive care plan for one of 23 sampled residents (Resident 28), when Resident 28 fell on 1/12/25 and care plan interventions were not revised and updated. This failure placed Resident 28's health and safety at risk when fall care plan interventions were not revised. Findings: During a review of Resident 28's Face Sheet (demographics), the Face Sheet indicated Resident 28 was admitted to the facility on [DATE] with diagnoses including repeated falls, muscle weakness and dementia (impaired ability to remember, think, or make decisions). During an observation on 1/14/25 at 8:56 a.m. in Resident 28's room, Resident 28 was observed seated in his wheelchair self-propelling himself out of his room. During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) Assessment, dated 12/19/24, the MDS indicated Resident 28's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 3 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment, 99 severely impaired). The BIMS assessment indicated Resident 28 had severe cognitive impairment. During a review of Resident 28's Progress Notes, dated 1/12/25, the notes indicated, . Resident had unwitnessed fall and sustained on left elbow skin tear on upper extremities . Resident found on lying position by a [Certified Nurse Assistant] CNA .confusion as baseline . During a concurrent interview and record review on 1/14/25 at 3:40 p.m. with Licensed Vocational Nurse (LVN) 4, Resident 28's Care Plan (CP), dated 9/7/24 was reviewed. The CP indicated, .is at risk for falls R/T [related to] deconditioning, gait/balance problems . LVN 4 reviewed Resident 28's CP and stated there were no updated interventions after the fall on 1/12/25. LVN 4 stated care plan interventions should be updated after a fall, but was not. LVN 4 stated the fall care plan should have been updated and that it was the nurses' responsibility to update it. LVN 4 stated the purpose of the CP was to implement interventions and measure what was working or not. During a concurrent interview and record review on 1/16/25 at 10:26 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated March 2018 was reviewed. The P&P indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . In conjunction with the attending physician, staff will identify and implement relevant interventions . to try to minimize serious consequences of falling . The DON stated the CP should be updated after a fall to prevent a serious injury. The DON stated the purpose of the care plan was to identify problems and implement interventions to maintain or improve conditions.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when Licensed Vocational Nurse (LVN) 2 prepared two unsampled residents' (Resident 39 and Resident 193) medications and did not observe Resident 39 and Resident 193 ingest medications. This failure had the potential to result in Resident 39 and Resident 193 receiving the wrong medications. Findings: During an observation on 1/15/25 at 12:35 p.m. in the hallway of Station 1, LVN 2 was standing in front of the medication cart. LVN 2 had two medicine cups on top of the medication cart with unidentified pills: the first medicine cup, labeled 22A in black marker, had one long yellow pill. The second medicine cup, labeled 22C in black marker, had one round blue pill and one round white pill. LVN 2 went into the medication cart and dispensed a third pill into the medicine cup labeled 22C. LVN 2 then walked down the hallway, approximately 65 feet, holding the two medicine cups. LVN 2 entered Resident 39 and 193's room and placed the medicine cup labeled 22A on the bedside table for Resident 39. LVN 2 then walked over and placed the medicine cup labeled 22C on the bedside table for Resident 193. LVN 2 did not observe Resident 39 and Resident 193 ingest the medications that were placed on their bedside tables, and did not inform the residents of what medications were in the cups . During an interview on 1/15/25 at 12:41 p.m. with LVN 2, LVN 2 stated she was supposed to push the medication cart to the resident's room and prepare medications one resident at a time. LVN 2 confirmed she did not follow expectations. LVN 2 further stated she did not observe Resident 39 and Resident 193 ingest the medications because They always take those meds [medications]. During an interview on 1/15/25 at 12:47 p.m. with the Director of Nursing (DON), the DON stated the expectation was the medication cart goes to each room with the nurse during medication administration. DON stated nurses should not prepare multiple residents' medications at one time to avoid the possibility of medication error. DON further stated residents should be observed while taking medications by the nurse. During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered at the time they are prepared. Medications are not pre-poured . The resident is always observed after administration to ensure that the dose was completely ingested .

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that Resident 290 received an assistive device for his vision needs when Resident 290 did not receive assistance with making an appointment to get new eyeglasses. This failure resulted in negatively affecting Resident 290's ability to enjoy his favorite hobbies such as crossword puzzles. Findings: During a review of Resident 290's Face Sheet (demographics), the Face Sheet indicated Resident 290 was admitted on [DATE] with diagnoses including diabetic retinopathy (eye condition that damages the eye's blood vessels due to high blood sugar). The Face Sheet included a picture of Resident 290 wearing eyeglasses. During a concurrent observation and interview on 1/14/25 at 4:25 p.m. with Resident 290 in his room, Resident 290 was holding up the crossword puzzle very close to his face. Resident 290 stated that he has been unable to do his crossword puzzles which he loved to do because he did not have eyeglasses for more than two weeks. Resident 290 stated that he reported his eyeglasses missing and requested getting new eyeglasses from the Social Services Director (SSD). During an interview on 1/14/25 at 4:32 p.m. with the SSD, the SSD stated that she remembered talking to Resident 290 about needing to send him out for a consultation if he needed help with getting eyeglasses, but she did not document the interaction or follow-up afterwards. The SSD stated that if residents brought up issues to her when she was not in the office, she would sometimes forget to chart them. The SSD stated that she was responsible for helping residents with setting up an appointment to get new eyeglasses. The SSD stated that Resident 290 not having his glasses would negatively affect his quality of life by a lot. During a review of Resident 290's Nursing admission Screening, dated 12/27/24, the document indicated, Resident 290 wears glasses. The facility was unable to provide a policy and procedure regarding ensuring that residents received the proper assistive devices, such as eyeglasses, to maintain vision abilities.

CONCERN (D)

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

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure physician visits were conducted once every thirty days for Resident 25. This failure had the potential to result in an undetected decline in Resident 25's health and/or potential delays in treatment or services. Findings: During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the temporal lobe (brain tumor), iron deficiency anemia (fewer red blood cells in the body due to a lack of iron), type 2 diabetes mellitus (condition that causes the level of sugar in the blood to become too high), and dysphasia (difficulty swallowing). During an interview on 1/15/25 at 3:20 p.m. with Medical Director (MD), MD stated she visited the facility daily and saw the residents who need medication changes. MD stated she was unaware of the requirements for physician's visits, but she tried to see all residents monthly. MD stated, Sometimes I just pop in and see how they are doing and I don't document that. When I do an examination, I document it. During a concurrent interview and record review of Resident 25's Medical Record on 1/15/25 at 4:00 p.m. with the Director of Nursing (DON), DON stated he was unsure how often the MD visited Resident 25. DON confirmed there was no documentation in the record which indicated that Resident 25 was seen by MD between 9/20/24 and 11/28/24 (58 days). DON stated, [MD] must not have visited Resident 25 during that timeframe. During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April 2013, the P&P indicated, The Attending Physician must visit his/her patients at least once every thirty days for the first ninety days . physician must perform relevant tasks at the time of each visit including a review of the resident's total program of care and appropriate documentation.

CONCERN (D)

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

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide mental health services to Resident 71. This failure had the potential to negatively affect Resident 71's psychosocial (the mental, emotional, social and spiritual effects of a disease) well-being. Findings: During a review of Resident 71's Face Sheet (demographics) dated 1/16/25, the Face Sheet indicated Resident 71 was admitted to the facility on [DATE], with diagnoses of depression, panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), generalized anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms), and chronic post-traumatic stress disorder (a condition of persistent mental and emotion stress occurring because of injury or severe psychological shock). During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 7/20/23, the MDS indicated, Resident 71's active diagnoses are anxiety disorder and post-traumatic stress disorder. During multiple observations on 1/13/25 to 1/17/25 at various times in room [ROOM NUMBER], Resident 71 was always in her room isolated and lying in bed most of the day. During an interview on 1/14/25 at 10:39 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 71 had depression, and she was sad often because her son passed away. RN 2 stated since admission, Resident 71 has laid in bed and rarely left her room. During an interview on 1/15/25 at 5:14 p.m. with the Medical Director (MD), the MD stated, Resident 71 definitely had depression and sometimes aggression. During an interview on 1/16/25 at 9:16 a.m. with Resident 71, Resident 71 stated the facility had not provided behavioral health services. Resident 71 further stated she had informed the Social Services Director (SSD) that she wanted counseling. Resident 71 stated she had been dealing with so much mentally for 10 years, I'm sad mostly all day. During an interview on 1/16/25 at 9:52 a.m. with the SSD, the SSD stated Resident 71 had not been evaluated or seen by any mental health professional. During a concurrent interview and record review on 1/16/25 at 4:02 p.m. with the Administrator (ADMIN), Resident 71's CAA [Care Area Assessment] Worksheet (a tool used to further investigate specific areas of concern identified during MDS assessment), dated 7/20/23 was reviewed. The CAA Worksheet indicated Resident has had thoughts that she would be better off dead, or thoughts of hurting herself, and she was on medication for PTSD and psychosis (symptoms that can cause a person to lose touch with reality such as hallucinations). The CAA Worksheet further indicated Resident 71 had severe depression and was recommended for a Referral . PsyD (doctor of psychology) . The ADMIN confirmed Resident 71 did not have any mental health services and stated, I'm very surprised, she should have had help. During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Services,' undated, the P&P indicated, The facility will provide, and residents will receive behavioral health services .

CONCERN (D)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. follow up on facility transfer for one of 23 sampled residents (Resident 54) 2. properly screen for Preadmission Screening and Resident Review (PASARR- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) for one of 23 sampled residents (Resident 71) 3. arrange and provide mental/psychosocial counseling services for one of 23 sampled residents (Resident 71) These failures resulted in the delay of Resident 54 and Resident 71's care to maintain their well-being. Findings: 1.During a concurrent observation and interview on 1/13/25 at 9:03 a.m. with Resident 54 in room [ROOM NUMBER], Resident 54's privacy curtain was drawn, Resident 54 was sitting on edge of the bed, and watching television. Resident 54 stated she was involved in a resident-to-resident altercation on 12/13/24 and had been trying to leave the facility and stated, I don't feel safe here. During an interview on 1/16/25 at 9:26 a.m. with Resident 54, Resident 54 stated she did not feel safe at the facility and still wanted to transfer to a different facility. Resident stated she had not heard any update in a month. During an interview on 1/16/25 at 10:01 a.m. with the Social Services Director (SSD), the SSD stated she did not call any facilities to follow up on transferring Resident 54 since 12/18/24. The SSD stated it was very important for residents to feel safe at the facility and she should have seen here more frequently and followed up with transferring Resident 54 to a different facility. During an interview on 1/16/25 at 11:06 a.m. with the Director of Nursing (DON), the DON stated after Resident 54 stated she did not feel safe, Social Services should have followed up daily to address any psychosocial needs. During a review of Resident 54's Summary- Resident-to-Resident Incident, dated 12/13/24, Resident 54's Summary- Resident-to-Resident Incident indicated, When asked if she feels safe in the facility, [Resident name] stated, No.When asked if she would like to be place in another facility . [Resident name] stated, yes. During a review of Resident 54's Social Services Note, dated 12/17/24, the Social Services Note indicated, she said she was doing well but did not fell safe . when she was asked if she felt safe here she replay no was and discus other placement options and she said to was okay, Referral was fax . During a review of Resident 54's Social Services Note, dated 12/18/24, the Social Service Note indicated, .[facility name 1] has been called to see if they have reviewed referral have called and have asked for them to call back awaiting response, [facility name 2] was called to see if they have reviewed referral they have not called back at this time. During a review of Resident 54's Social Services Note, dated 12/19/24, the Social Service Note indicated, [facility name 1] have called have not been able to speech with admission. Will f/u (follow up) as needed. During a review of Resident 54's Psychiatric Visit Progress Report, dated 12/23/24, the Psychiatric Visit Progress Report indicated, Patient reports feeling depressed because of this place and how they're running this place. Facility was unable to provide policy and procedure for Social Services. 2. During a review of Resident 71's PASRR, dated 7/14/23, the PASRR indicated Level 1 screening was negative. PASRR indicated Resident 71 was not diagnosed with a mental disorder such as anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms) and panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), and not prescribed psychotropic (a drug that affects how the brain works and causes changes in mood, thoughts, feelings and behaviors) medications for mental illness. During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 7/20/23, the MDS indicated, Resident 71's active diagnoses are anxiety disorder and post-traumatic stress disorder (a condition of persistent mental and emotion stress occurring because of injury or severe psychological shock). The MDS indicated, Resident 71's Level II Preadmission Screening and Resident Review (PASRR) Conditions were not checked. During a review of Resident 71's CAA [Care Area Assessment] Worksheet (a tool used to further investigate specific areas of concern identified during MDS assessment), dated 7/20/23, the CAA Worksheet indicated Resident has had thoughts that she would be better off dead, or thoughts of hurting herself, and she was on medication for PTSD and psychosis (symptoms that can cause a person to lose touch with reality such as hallucinations). The CAA Worksheet further indicated Resident 71 had severe depression and was recommended for a Referral . PsyD (doctor of psychology) . During a concurrent interview and record review on 1/16/25 at 9:52 a.m. with Social Services Director (SSD), Resident 71's Medication Administration Record (MAR), date 1/16/25 was reviewed. Resident 71's MAR indicated Resident received three different medications for post-traumatic stress disorder, panic disorder and depression. SSD stated if a resident had psychosis, depression, anxiety or other mental health related diagnoses, the resident would be referred for clarification for PASRR evaluation. SSD stated Resident 71 was never evaluated or referred for PASRR clarification and she should have been. During a review of the facility's policy and procedure (P&P) titled, Preadmission Screen and Resident Review (PASRR), dated July 2016, the P&P indicated, It is the policy of this facility to complete and submit a PASRR screening . If facility is dissatisfied with the recommendations in the PASRR determination letter, they can request a reconsideration . the facility will update the existing PASRR on file for either of the following reasons . there is a significant change in a resident's physical or mental condition . 3. During multiple observations on 1/13/25 to 1/17/25 at various times in room [ROOM NUMBER], Resident 71 was always in her room isolated and lying in bed mostly all day. During an interview on 1/14/25 at 10:39 a.m. with Registered Nurse (RN) 2, RN 2 stated Resident 71 had depression, and she was sad often because her son passed away. RN 2 stated since admission, Resident 71 has laid in bed and rarely left her room. During an interview on 1/15/25 at 5:14 p.m. with the Medical Director (MD), the MD stated Resident 71 definitely had depression and sometimes aggression. During an interview on 1/16/25 at 9:16 a.m. with Resident 71, Resident 71 stated the facility had not provided behavioral health services and she further stated she had informed the Social Services Director that she wanted counseling. Resident 71 stated she had been dealing with so much mentally for 10 years, I'm sad mostly all day. During an interview on 1/16/25 at 9:52 a.m. with the Social Services Director (SSD), the SSD stated Resident 71 had not been evaluated or seen by any mental health professional. During a concurrent interview and record review on 1/16/25 at 4:02 p.m. with the Administrator (ADMIN), Resident 71's CAA [Care Area Assessment] Worksheet (a tool used to further investigate specific areas of concern identified during MDS assessment), dated 7/20/23 was reviewed. The CAA Worksheet indicated Resident has had thoughts that she would be better off dead, or thoughts of hurting herself, and she was on medication for PTSD and psychosis (symptoms that can cause a person to lose touch with reality such as hallucinations). The CAA Worksheet further indicated Resident 71 had severe depression and was recommended for a Referral . PsyD (doctor of psychology) . The ADMIN confirmed Resident 71 did not have any mental health services and stated, I'm very surprised, she should have had help. During a review of Resident 71's admission Record, dated 1/16/25, the admission Record indicated, Resident 71 was admitted to the facility on [DATE], with diagnoses of depression, panic disorder (mental health condition that experiences unexpected and repeated episodes of intense fear accompanied by physical symptoms like chest pain), generalized anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness that can cause physical symptoms), and chronic post-traumatic stress disorder (a condition of persistent mental and emotion stress occurring because of injury or severe psychological shock). During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 7/20/23, the MDS indicated, Resident 71's active diagnoses are anxiety disorder and post-traumatic stress disorder. During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Services,' undated, the P&P indicated, The facility will provide, and residents will receive behavioral health services .

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Monthly Medication Reviews (MMR- a comprehensive review of all medications a resident receives) were conducted for Resident 61. This failure resulted in the potential for Resident 61 to receive unnecessary medications. Findings: During a review of Resident 61's Face Sheet (demographics), the Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including Lewy body dementia (brain disease that causes a gradual decline in thinking, movement, and behavior) and major depressive disorder (a mental disorder causing low mood, lack of interest and feelings of hopelessness). During an interview on 1/16/25 at 3:14 p.m. with Pharmacist (PHARM), PHARM stated that he should conduct a MMR every month to look for any medication concerns such as duplicate therapy or medication interactions and email the results to the Director of Nursing (DON) so that any issues with the resident's medications could be addressed. During a concurrent interview and record review of Resident 61's MMRs on 1/16/25 at 3:50 p.m. with DON, there were no documentation of MMRs found in Resident 61's Medical Record for the months of January and August 2024. DON confirmed MMRs were not conducted. During a review of the facility's policy and procedure (P&P) titled, Consultant Pharmacist Reports, dated December 2016, the P&P indicated, The consultant pharmacist performs a comprehensive medication regimen review at least monthly . to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy . the findings are documented and stored within 72 hours.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to attempt a Gradual Dose Reduction (GDR- an attempt to reduce the dose of medications which affect the nervous system to treat mental illness to achieve the lowest dose possible) for one of 23 sampled residents (Resident 61). This failure had the potentialto result in Resident 61 receiving psychotropic medications which were unnecessary and in excessive dose. Findings: During a review of Resident 61's Face Sheet (demographics), the Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included Lewy body dementia (brain disease that causes a gradual decline in thinking, movement, and behavior) and major depressive disorder (a mental disorder causing low mood, lack of interest and feelings of hopelessness). During an interview on 1/15/25 at 8:45 a.m. with Certified Nurse Assistant (CNA) 6, CNA 6 stated Resident 61 has shown no aggression to staff or other residents. During an interview on 1/15/25 at 9:00 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 61 was very polite and calm and did not have any issues with the staff or cause trouble with the other residents. LVN 2 confirmed Resident 61 did not have any aggressive behaviors. During a review of Resident 61's Medical Record on 1/15/25 at 3:53 p.m., the Medical Record indicated: On 4/13/24, Medical Director (MD) renewed the order for, escitalopram oxalate (Medication used to treat depression [Mood disorder that causes a persistent feeling of sadness and loss of interest] and anxiety [Intense, excessive, and persistent worry and fear about everyday situations]) 20 milligrams (mg, measurement of weight) once daily for anxiety and pacing. MD ordered staff to monitor Resident 61 for signs of depression and excessing pacing every shift. On 5/24/24, the MD renewed the order for quetiapine (medication used to treat mental disorders and regulate mood, thought, and behaviors) 50 mg every night and quetiapine 25 mg twice a day, at 8 a.m. and 1 p.m. for angry outbursts, aggressive behavior, and striking out. MD ordered staff to monitor Resident 61 for aggressive behavior and striking out every shift. Resident 61's Medication Administration Records (MAR), dated April 2024 through 1/13/25, indicated Resident 61 had no documented aggressive behaviors, striking out, depression, or excessive pacing during the timeframe (9 ½ months). Resident 61's Minimum Data Set (MDS - a resident assessment tool), dated 3/22/24, 6/19/24, 9/9/24. and 11/29/24, indicated, Section E - No behaviors. On 11/5/24, the Executive Mental Health Doctor's (EMH) 1 Progress Note indicated, Please discontinue [quetiapine] 25 mg twice a day for GDR trial and will continue to consider reducing [quetiapine] dose as tolerated. Please decrease escitalopram to 10 mg, due to [resident's] older age the max dose is 10 mg for escitalopram. On 11/25/24, EMH 1's Progress Note indicated, Discontinue [quetiapine] for GDR. Please decrease escitalopram to 10 mg due to patient's older age the max dose is 10 mg for escitalopram. On 12/23/24, EMH 1's Progress Note indicated, Proceed with [quetiapine] GDR. No behavioral concerns reported. There was no documentation in Resident 61's medical record which indicated a GDR was attempted for Resident 61 from 1/4/24-1/13/25 (1 year). During an interview on 1/15/25 at 3:20 p.m. with Medical Director (MD), MD stated Resident 61 had not exhibited any behaviors. MD further stated she was aware of the Mental Health Physician's recommendations to discontinue quetiapine and decrease escitalopram. MD confirmed she did not attempt a GDR over the past year for either medication. MD stated she did not discuss a GDR with Resident 61's Responsible Party over the past year. During an interview on 1/16/25 at 3:14 p.m. with Pharmacist (PHARM), PHARM stated he made a recommendation regarding Resident 61 for a GDR of quetiapine on 4/11/24, and the recommendation was declined by MD. PHARM stated he made a recommendation for a dose reduction for escitalopram in May of 2024 as 10 mg was the maximum recommended dose for the elderly, and the recommendation was declined by MD. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication (medications that affect how the brain works and cause changes in mood, awareness, thoughts, feelings, or behavior) Use, dated October 2017, the P&P indicated, Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted Annually, unless clinically contraindicated. During a review of the FDA (Food and Drug Administration) instructions for use and black box warning for escitalopram oxalate, revised January 2017, the instructions indicated, 10 mg per day is the recommended dose for most elderly patients . elderly may be at greater risk for hyponatremia (low salt in the blood).

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the correct dosage of insulin (medication that lowers the level of glucose [sugar] in the blood) was in the prefilled pen injector per physician's sliding scale order for Resident 291. This failure had the potential to result in hypoglycemia (medical condition where blood sugar level is too low) and death for Resident 291. Findings: During a review Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars). During a review of Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars). During a concurrent observation and interview on 1/15/25 at 4:15 p.m. with Registered Nurse (RN) 3 in Resident 291 ' s room, RN 3 checked Resident 291's blood sugar with a glucometer (handheld device that measures the amount of sugar in the bloodstream) and stated the result was 205 milligram/deciliter (mg/dL, unit of measurement). RN 3 went to the medication cart and documented 305 mg/dL into Resident 291's Medication Administration Record (MAR) for the blood sugar result. RN 3 stated the sliding scale for blood sugar result of 305, was to administer 8 units of insulin (medication that manages blood sugar levels). RN 3 turned the dial to 8 units of insulin and confirmed the prefilled pen injector was turned to 8 units. RN 3 stated, Yes, I'm ready to give, and began to walk towards Resident 291. RN 3 was then stopped and was asked to show the history on the glucometer results. RN 3 recalled the history on the glucometer and stated the value was 205! Oh, my god! That would have been so bad. RN 3 reviewed Resident 291's MAR and confirmed the correct dose of insulin should have been 4 units. During a review of Resident 291's Physician's Order, dated 1/8/25, the Physician's Orders indicated, insulin injected per sliding scale (increasing administration of the insulin dose based on blood sugar levels) was for blood sugar value of 0-149= 0 units to be given, 150-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, and 401-500= 12 units and call physician. During an interview on 1/15/25 at 4:54 p.m. with the Medical Director (MD), MD stated, It's always life threatening to give too much insulin. During an interview on 1/16/25 at 3:30 p.m. with the Pharmacist (PHARM), the PHARM stated if double the dose of insulin was administered, that would be quite a jump, and significant damage could be caused to Resident 291. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide routine dental services for Resident 71 for 16 months. This failure had the potential to result in a decline in oral health for Resident 71. Findings: During a concurrent observation and interview on 1/16/25 at 9:35 a.m. with Resident 71, Resident 71 had multiple teeth missing. Resident 71 stated she had only seen the dentist one time since admission. Resident 71 further stated she verbally requested a dental visit multiple times. During an interview on 1/16/25 at 9:46 a.m. with Social Services Director (SSD), SSD stated Resident 71 was admitted on [DATE] and was not seen by dental until 11/14/24. SSD stated the resident should have been seen every 6 months and as needed. During a review of Resident 71's Minimum Data Set (MDS-an assessment tool), dated 12/26/24, the MDS indicated, Resident 71's Oral/Dental Status is no natural teeth or tooth fragment(s) (edentulous-lacking teeth). The MDS indicated Care Area Triggered was Dental Care. The facility was unable to provide a policy and procedure regarding dental services.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to protect equipment from contamination via dust and grease. This failure posed the risk for food borne illness in a medically fragile resident population of 98 facility residents who received food prepared in the kitchen. Findings: During a concurrent observation and interview on 1/13/25 at 8:21 a.m., with the Dietary Supervisor (DS) a white powdery (dusty) substance was noted on top of the dishwasher. The dishwasher was also noted to have a thick greasy buildup up on the bar going across the bottom of the equipment. The DS agreed that the equipment was dirty and needed to be cleaned. During a review of the facility's policy and procedure (P&P) titled, Shelves, Counters, and Other surfaces Including Sinks (Handwashing, Food Preparation, ETC.), dated 2023, the P&P indicated, Remove any large debris and wash surface with warm detergent solution .Rinse with clear water using a clean sponge or cloth. Wipe dry with a clean cloth.

CONCERN (D)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide three of five sampled residents (Resident 54, 56, and 341) a designated refrigerator to store personal, perishable food items. This failure resulted in Resident 56, unsafely storing perishable personal food items in her bedside drawer, which had the potential to result in a foodborne illness for Resident 56. This failure resulted in a non-homelike environment for Residents 54 and 341. Findings: During a concurrent observation and interview on 1/13/25 at 10:57 a.m., in Resident 56's room, Resident 56 was observed opening her bedside bottom drawer and pulling out a container of butter and jar of pickled beets. Resident 56 stated she knew the food items needed to be refrigerated but there was no available refrigerator. During an interview on 1/14/25 at 2:54 p.m. with Dietary Manager (DM), DM stated residents were encouraged to eat food brought from outside within two hours. DM stated the facility did not have a separate refrigerator to store food for residents. During an interview on 1/14/25 at 3:21 p.m. with Registered Nurse (RN) 5, RN 5 stated the facility did not have a refrigerator to store perishable foods for the residents, and there should be a refrigerator for residents. During an interview on 1/14/25 at 4:14 p.m. with Resident 56, Resident 56 stated, I wish they had a fridge for us to use but I know it's not going to happen. During an interview on 1/15/25 at 8:22 a.m. with Resident 54, Resident 54 stated she would like the facility to have a refrigerator to store food for her. Resident 54 stated approximately a year ago the facility did have a refrigerator for residents but was unsure why it was taken away. During an interview on 1/15/25 at 8:25 a.m. with Resident 341, Resident 341 stated at home he stored tea in the refrigerator to drink throughout the day. Resident 341 stated he wished the facility had a refrigerator because he had to rely on drinking the tea with ice. During an interview on 1/16/25 at 10:08 a.m. with Social Services Director (SSD), SSD stated the facility used to have a refrigerator for resident use but was unsure why the facility no longer had one. During a concurrent interview and record review on 1/16/25 at 10:22 a.m. with the Director of Nursing Services (DON), the facility's policy and procedure (P&P) titled, Foods Brought by Family/Visitors, dated March 2022, was reviewed. The P&P indicated, . Food brought to the facility by visitors and family is permitted .Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable . Potentially hazardous food that are left out then for the resident without a source of heat or refrigeration longer than 2 hours are discarded . The DON stated since he had started working at the facility there was no refrigerator for resident use available. The DON stated residents have the right to store food brought in from outside.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Physician's Progress Notes were documented in the medical record for 3 of 23 sampled residents (Resident 25, 61, and 75). This failure resulted in the potential for communication delays and potential delays in coordination of care. Findings: 1. During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the temporal lobe (brain tumor) and urinary tract (organs that make urine) infection. During a concurrent interview and record review of Resident 25's medical record on 1/14/25 at 4 p.m. with the Director of Nursing (DON), the medical record review indicated there were no documented Physician's Progress Notes. DON stated he was unaware how often the Medical Director (MD) examined the residents and confirmed there were no documented Physician's Progress Notes. DON stated MD had her own charting system and did not document progress notes at the facility; instead MD documented from home and faxed her notes later. DON stated it was important for the Physician's Progress Notes to be readily available in the residents' medical records. During an interview on 1/15/25 at 3:20 p.m. with MD, MD confirmed Resident 25's Physician Progress Notes were not in the medical record. MD stated she documented her progress notes at her office and faxed them to the facility at a later date. MD stated the facility requested Physician's Progress Notes for multiple residents for the survey team and she would be faxing them later. MD confirmed she did not have remote access to the progress notes and could not provide them. During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), ADMIN confirmed MD did not document Physician's Progress Notes while at the facility. ADMIN further stated the facility did not have access to Physician's Progress Notes for multiple residents, and staff were unable to review the notes if needed. ADMIN stated if a resident required transfer to a higher level of care, then the facility would need to contact MD and request to fax the progress notes. During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April 2013, the P&P indicated, The Attending Physician must perform all relevant tasks at the time of each visit, including .appropriate documentation. 2. During a review of Resident 61's Face Sheet (demographics), Face Sheet indicated Resident 61 was admitted to the facility on [DATE] with diagnoses which included Lewy body dementia (brain disease that causes a gradual decline in thinking, movement, and behavior). During a concurrent interview and record review of Resident 61's medical record on 1/14/25 at 4 p.m. with the Director of Nursing (DON), the medical record review indicated there were no documented Physician's Progress Notes. DON stated he would request MD fax the Physician's Progress Notes for the medical record. During an interview on 1/15/25 at 1 p.m. with the Director of Nursing (DON), DON stated he was waiting for MD to send the progress notes. DON stated, We do not have the progress notes at the facility. MD does not complete her progress notes when she assesses the residents; she faxes them to us- she is old school. DON stated he expected MD to document progress notes in the record while she was at the facility so that the notes were readily available. During an interview on 1/15/25 at 3:20 p.m. with MD, MD confirmed Resident 25's Physician Progress Notes were not in the medical record. MD stated she documented her progress notes at her office and faxed them to the facility at a later date. MD stated the facility requested Physician's Progress Notes for multiple residents for the survey team and she would be faxing them later. MD confirmed she did not have remote access to the progress notes and could not provide them. During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), ADMIN confirmed MD did not document Physician's Progress Notes while at the facility. ADMIN further stated the facility did not have access to Physician's Progress Notes for multiple residents, and staff were unable to review the notes if needed. ADMIN stated if a resident required transfer to a higher level of care, then the facility would need to contact MD and request to fax the progress notes. During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April 2013, the P&P indicated, The Attending Physician must perform all relevant tasks at the time of each visit, including .appropriate documentation. 3. During a review of Resident 75's Face Sheet (demographics), the Face Sheet indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (disorder wherein body is unable to regulate blood sugar). During a concurrent interview and record review of Resident 75's medical record on 1/14/25 at 4 p.m. with the Director of Nursing (DON), the medical record review indicated there were no documented Physician's Progress Notes. DON stated he would request MD to fax the Physician's Progress Notes for the medical record. During an interview on 1/15/25 at 1 p.m. with the Director of Nursing (DON), DON stated he was waiting for MD to send the progress notes. DON stated, We do not have the progress notes at the facility. MD does not complete her progress notes when she assesses the residents; she faxes them to us- she is old school. DON stated, he expected MD to document progress notes in the chart while she was at the facility so that the notes were readily available. During an interview on 1/15/25 at 3:20 p.m. with MD, MD confirmed Resident 25's Physician Progress Notes were not in the medical record. MD stated she documented her progress notes at her office and faxed them to the facility at a later date. MD stated the facility requested Physician's Progress Notes for multiple residents for the survey team and she would be faxing them later. MD confirmed she did not have remote access to the progress notes and could not provide them. During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), ADMIN confirmed MD did not document Physician's Progress Notes while at the facility. ADMIN further stated the facility did not have access to Physician's Progress Notes for multiple residents, and staff were unable to review the notes if needed. ADMIN stated if a resident required transfer to a higher level of care, then the facility would need to contact MD and request to fax the progress notes. During a review of the facility's policy and procedure (P&P) titled, Physician Visits, dated April 2013, the P&P indicated, The Attending Physician must perform all relevant tasks at the time of each visit, including .appropriate documentation.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS- a standardized assessment and care planning tool) were accurate for two of 23 sampled residents (Residents 25 and Resident 391). This failure had the potential to adversely affect the provision of care for Residents 25 and Resident 391. Findings: 1. During an interview on 01/15/25 at 3:26 p.m. the Medical Record Director (MRD), MRD stated Resident 391 was discharged home. During a concurrent interview and record review on 01/16/25 at 9:25 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 391's MDS, dated [DATE], was reviewed. Resident 391's quarterly MDS Section A2105 indicated Resident 391 was discharged to a Short-Term General Hospital. MDSC stated Resident 391's MDS was inaccurate because she went home, not to the hospital. During a review of Resident 391's Discharge Summary, dated 11/27/24, the Discharge Summary indicated Resident 391 was to be discharged to home on [DATE]. During a review of Resident 391's Nursing Progress Note, dated 11/29/24, the Nursing Progress Note indicated, On 11/29/2024, the patient was successfully discharged from the skilled nursing facility . is expected to continue at her new setting, home . During a review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, dated October 2024, the RAI Manual indicated, The assessment accurately reflects the resident's status . 2. During a review of Resident 25's Face Sheet (demographics), the Face Sheet indicated Resident 25 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the temporal lobe (brain tumor), iron deficiency anemia (a condition in which blood lacks healthy red blood cells), type 2 diabetes mellitus (a disease resulting in body's inability to regulate blood sugar), and dysphasia (difficulty swallowing). During a concurrent interview and record review on 1/14/25 at 4:00 p.m. with Director of Nursing (DON), Resident 25's Weight Measurements was reviewed. Resident 25's weights were documented as: 9/23/24- 153 lbs. (pounds) 10/7/24- 148 lbs. 11/2/24- 144 lbs. 11/26/24- 139 lbs. 12/10/24- 135 lbs. 12/24/24- 120 lbs. 12/30/24- 120 lbs. 12/31/24- 113 lbs. 1/2/25- 120 lbs. 1/6/25- 119 lbs. DON confirmed Resident 25 lost 34 pounds which was a 22.22% weight loss since his admission. During an interview on 1/14/25 at 2:14 p.m. with Registered Dietitian (RD), RD confirmed Resident 25 had a 22.22% weight loss since admission. During a concurrent interview and record review on 1/15/25 at 11:14 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 25's MDS, dated [DATE], was reviewed. Under Section K 300, Weight Loss of 5% or more in the last month or loss of 10% or more in the last 6 months, MDSC coded a response of no. MDSC confirmed she did not code the MDS accurately. MDSC stated it was important to code the MDS correctly because the MDS triggered the resident's plan of care. During a review of the Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, dated October 2024, the RAI Manual indicated, The assessment accurately reflects the resident's status . During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated March 2022, the P&P indicated, A comprehensive assessment of every resident's needs . which includes admission assessments, quarterly assessment, annual assessment, Significant change in status assessments, and completion of the MDS .

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident's 191's Face Sheet (demographics), the Face Sheet indicated Resident 191 was admitted on [DATE], with diagnoses including cellulitis of right lower limb (swelling and skin infection of the lower leg); unspecified fracture of shaft of right tibia (a break in the lower leg bone below the knee); initial encounter for closed fracture (the first time a resident is seen by a healthcare provider for a broken bone where the skin is intact), and burn of unspecified degree of right lower leg (the burn cannot be definitely determined at the time of assessment). During a concurrent observation and interview on [DATE] at 9:00 a.m. with Resident 191 in room [ROOM NUMBER] C, there was one collagenase (Santyl) ointment tube located on top of Resident 191's bedside cabinet. Resident 191 was alert and oriented. Resident 191 stated he has had the Santyl ointment tube stored in the bedside cabinet since [DATE]. During a concurrent interview and record review on [DATE] at 8:59 a.m. with Infection Preventionist (IP), Resident 191's Physician's Orders, dated [DATE], was reviewed. IP stated there was no physician order for bedside storage of collagenase (Santyl) ointment tube. The IP also stated the ointment should not be stored on the bedside cabinet without a physician's order. During a review of the facility's policy and procedure (P&P) titled, Bedside Medication Storage, dated [DATE], the P&P indicated, . A written order for the bedside storage of medication is present in the residents' medical record . Based on observation, interview, and record review, the facility failed to safely store and label drugs and supplies in accordance with acceptable standards of practice when: 1a. A yellow-colored tablet was on the floor under the bed in room [ROOM NUMBER]. 1b. One of two Treatment Carts was left unlocked and unattended. 2. In room [ROOM NUMBER]C, one 1 collagenase (Santyl) ointment tube (used to remove damaged skin tissue from burns and wounds- [broken skin]) was on top of Resident 191's bedside cabinet. 3. One of four medication carts was left unlocked and unattended. 4. Three insulin pens (hormone medication that helps manage blood sugar levels preloaded into a device that injects the medication into the body) were not dated when opened for two of 23 sampled residents (Resident 90 and Resident 192). These failures had the potential to result in residents and staff obtaining unauthorized access to medications and supplies that could lead to adverse effects. In addition, Resident 90 and Resident 192 were at risk for receiving expired insulin. Findings: 1a. During a concurrent observation and interview on [DATE] at 10:06 a.m. with Licensed Vocational Nurse (LVN) 4 in Resident 240's room, a yellow-colored tablet was under the bed. LVN 4 stated she could not identify the type of medication that was underneath Resident 240's bed. LVN 4 stated the medication should not be left on the ground to prevent improper use which could lead to adverse effects. During a concurrent interview and record review on [DATE] at 10:15 a.m. with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023 was reviewed. The policy indicated, . The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls .Medications and biologicals are stored in the packaging, containers or dispensing systems in which they are received . The DON stated medication should not be left on the ground because someone could potentially consume it. 1b. During an observation on [DATE] at 9:37 a.m., Station 2's Treatment Cart was located against the wall next to the nurses' station. The treatment cart was unlocked and unattended. During an observation on [DATE] at 9:55 a.m., Station 2's Treatment Cart remained unlocked and unattended. During a concurrent observation and interview on [DATE] at 9:59 a.m. Licensed Vocational Nurse (LVN) 5 was observed walking towards Station 2's Treatment Cart. LVN 5 acknowledged the Treatment Cart was left unlocked and unattended. LVN 5 stated the Treatment Cart should be locked when unattended to prevent unauthorized access. During a concurrent interview and record review on [DATE] at 10:15 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023 was reviewed. The policy indicated .Compartments (including, but not limited to, .carts .containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . The DON stated the Treatment Cart should be locked when unattended to prevent unauthorized access. 3. During an observation on [DATE] at 8:41 a.m. outside of room [ROOM NUMBER], a medication cart was unattended and unlocked. In the top drawer of the medication cart, there was a medicine cup with one unidentified pill that was white, round, and labeled G785. During a concurrent observation and interview on [DATE] at 8:51 a.m. with Registered Nurse (RN) 6, outside of room [ROOM NUMBER]. RN 6 walked towards the medication cart and moved the medication cart to room [ROOM NUMBER] to administer medication. RN 6 confirmed the medication cart was unlocked and unattended. RN 6 stated, Sorry, I forgot. RN 6 further stated it ' s important to lock the medication cart, so a patient or anyone else doesn't get access to medications. During an interview on [DATE] at 11:18 a.m. with Director of Nursing (DON), DON stated all medication carts need to be locked when left unattended. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated February 2023, the P&P indicated .Compartments (including, but not limited to . carts . containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others . 4 a. During a review of Resident 90's Face Sheet (demographics), the Face Sheet indicated Resident 90 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (condition that causes the level of sugar in the blood to become too high). During a concurrent observation and interview on [DATE] at 2:10 p.m. with Registered Nurse (RN) 7, the Station Three medication cart was observed. RN 7 removed one insulin pen from the medication cart. The insulin pen was labeled with Resident 90's name, and instructions to inject insulin glargine (long-acting insulin used to control high blood sugar), 35 units (measurement of the amount of insulin in a liquid medication) one time daily. The insulin pen was missing the opened date. The label indicated, Discard unused portion after 28 days. RN 7 confirmed the insulin pen was opened and had been used. RN 7 was unaware when the insulin pen was opened and unaware of when it should be discarded. RN 7 confirmed the insulin pen should have been labeled with the date it was opened. During an interview on [DATE] at 3:15 p.m. with Pharmacist (PHARM), PHARM stated insulin injector pens should be dated when they are opened. PHARM stated, Insulin pens are generally good for 28 days. PHARM further stated it was important to label the insulin pen with the opened date because insulin would start to breakdown after 28 days. During a review of the facility's policy and procedures (P&P) Medication Labeling and Storage, dated February 2023, P&P indicated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days . 'If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items'. 4 b. During a review of Resident 192's Face Sheet (demographics), Face Sheet indicated, Resident 192 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (condition that causes the level of sugar in the blood to become too high) with diabetic neuropathy (nerve damage caused by diabetes). During a concurrent observation and interview on [DATE] at 2:10 p.m. with Registered Nurse (RN) 7, the Station Three medication cart was observed. RN 7 removed two insulin injector pens (hormone medication that helps manage blood sugar levels preloaded into a device that injects the medication into the body) from the medication cart 3. One insulin pen was labeled with Resident 192's name, and instructions to inject insulin glargine, 20 units (measurement of the amount of insulin in a liquid medication) one time daily. The insulin pen was missing the opened date. The label indicated, Discard unused portion after 28 days. A second insulin pen was labeled with Resident 192's name, and instructions to inject insulin lispro (rapid-acting insulin used to control blood sugar) seven units three times a day before meals. The insulin pen was missing the opened date. The label indicated, Discard unused portion after 28 days. RN 7 confirmed both insulin pens were opened and had been used. RN 7 was unaware when Resident 192's insulin pens were opened and unaware of when they should be discarded. RN 7 confirmed the insulin pens should have been labeled with the opened date. During an interview on [DATE] at 3:15 p.m. with Pharmacist (PHARM), PHARM stated insulin injector pens should be dated when they are opened. PHARM stated, Insulin pens are generally good for 28 days. PHARM further stated it was important to label the insulin pen with the opened date because insulin would start to breakdown after 28 days. During a review of the facility's policy and procedures (P&P) Medication Labeling and Storage, dated February 2023, P&P indicated, Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days . 'If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items'.

CONCERN (E)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the antibiotic stewardship (monitors the effective use of antibiotics) monitored the effective use of Amoxicillin-Pot Clavulanate (antibiotic to treat urinary tract infections-[UTI- infection in your urinary system]) for the month of October 2024 and November 2024 for Resident 84. This failure had the potential to result in an inappropriate use of antibiotics for Resident 84. Findings: During a review of Resident 84's Face Sheet (demographics), the Face Sheet indicated Resident 17 was admitted on [DATE] with diagnoses to include a UTI. During a review of Resident 84's Physician Orders, dated 10/27/24, the Physician Order indicated, Amoxicillin-Pot Clavulanate tablet 875-125 milligram (unit of measurement), give 1 tablet by mouth two (2) times a day for urinary tract infection for 14 days. During a concurrent interview and record review on 1/15/25 at 10:48 a.m. with Infection Preventionist (IP), the facility's binder of Monthly Infection Control Log, dated 2024 was reviewed. IP stated there was no documentation that the antibiotic stewardship monitored the effective use of Amoxicillin-Pot Clavulanate for urinary tract infection in October 2024 and November 2024 for Resident 84. IP also stated the IPs should have monitored for the effective use of antibiotics monthly. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 2001, the P&P indicated, The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents .

CONCERN (E)

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

Deficiency F0912 (Tag F0912)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate space for all 24, three residents residing rooms. This failure resulted in 23 Residents (Resident 1, 5, 11, 21, 23, 31, 51, 54, 56, 59, 61, 64, 65, 68, 69, 70, 74, 79, 81, 190, 191, 193, and 345) not having the required amount of usable living space and had the potential to compromise the safety of residents due to limited space. Findings: During a concurrent observation and interview on 1/13/25 at 9:03 a.m. with Resident 54 in room [ROOM NUMBER], the room had three residents residing in it. Bed C's individual living space was visibly smaller than Bed A and B's living spaces. Resident 54 in Bed C, stated, Look how small this is; I can't even get by. Resident 54 used a walker for an assistive device. During a concurrent observation and interview on 1/15/25 at 4:06 p.m. with Maintenance (MAIN) in room [ROOM NUMBER], MAIN measured Bed C's individual living space, the result was 11.5 feet by 6.5 feet, the Maintenance Director calculated living space was 74.75 square footage (sqft.). MAIN stated, Oh, too small! She needs at least 80. During a concurrent observation and interview on 1/15/25 at 6:01 p.m. with the Administrator (ADMIN), in room [ROOM NUMBER], the ADMIN had the MAIN measure Bed C's individual living space, 11.5 feet by 6.5 feet, the ADMIN calculated living space was 74.75 sqft. The ADMIN confirmed Bed C's individual living space was under 80 sqft. During a concurrent interview and record review on 1/16/25 at 12:01 p.m. with the ADMIN, [facility name] Resident Room Measurements, was reviewed. The [facility name] Resident Room Measurements indicated rooms labeled 1-24, in red ink, had three residents in one room. The ADMIN stated all 24 rooms with a Bed C had an individual living space below 80 sqft. Facility was unable to provide policy and procedure for adequate resident living space.

CONCERN (F)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a sanitary (clean manner that prevents the spread of diseases), safe, and comfortable environment when: 1. All 21 residents' bathrooms were in disrepair. 2. Resident 54's privacy curtain (curtain used as divided between residents' beds) was not kept in a sanitary manner. 3. Comfortable water temperatures were not maintained in the bathrooms for 5 Residents' rooms (room [ROOM NUMBER], 114, 141, 143 and 146). These failures violated the residents' rights to live in a sanitary, safe, comfortable, homelike environment and had the potential to result in injury and illness in a medically compromised population. The facility census was 94. Findings: 1. During a concurrent observation and interview on 1/13/25 at 12:46 p.m. with Resident 23 in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], the flooring going into the shower had an uneven surface with multiple large multilayer cracks, exposing old cement and flooring underneath. The cracks had lifted sharp jagged edges and were covered in rough and grimy dark black brownish moist substances. Resident 23 stated that he did not like using the bathroom because of the black stuff on the floor that looks like mold. Resident 23 stated he felt like the bathroom was not cleaned enough and not cleaned properly. During an interview on 1/14/2025 at 10:15 a.m. with Resident 56, Resident 56 stated she purchased her own disinfectant because the showers were not being cleaned regularly. Resident 56 stated, in the past, she slipped going into the shower due to the flooring condition. Resident 56 stated the bathrooms looked and felt dirty and unsafe so she had to put towels down on the floor everywhere so that her bare feet would not touch the floor. During an interview on 1/14/25 at 10:41 a.m. with Resident Council (gathering of residents who work together to improve their living conditions) Members, a consensus of six out of 11 Resident Council Members (Residents 23, 56, 83, 84, 341, and 343) stated that the bathrooms did not feel or look clean. A consensus of nine out of 11 Resident Council Members (Residents 6, 21, 23, 56, 79, 83, 84, 341, and 343) stated that the bathrooms did not feel safe to use. During a concurrent observation and interview on 1/14/25 at 4:30 p.m. with the Housekeeping Manager (HKM) in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were black, gunky, moist substances in the cracks, on the baseboards on the shower, and around the toilet. HKM stated that she thought the substance was mold, and that it would not come off even after deep cleaning. HKM stated, the black substance looks dirty, like [the staff] aren't cleaning. During an interview on 1/15/25 on 8:23 a.m. with the HKM, the HKM stated that housekeeping staff were reporting the poor state of the bathrooms to the previous Director of Maintenance (DOM), but the previous DOM never addressed the issues. During an observation on 1/15/25 at 8:29 a.m. in the bathroom for room [ROOM NUMBER], there were cracks at the edges of the shower and between the shower ramp and the tiles. The cracks had jagged uneven edges and a grimy black and gray substances. There was a gap on floor between the toilet and the tiles that was filled in with gunky black substances. During a concurrent observation and interview on 1/15/25 at 8:31 a.m. with the HKM in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], the flooring going into the shower had multilayered cracks exposing black grimy fuzzy substances. The cracks had sharp uneven edges. There was a gap between the toilet and the linoleum flooring covered with moist fuzzy gunky dark brown substances. There were multiple cracks along the baseboards and the linoleum flooring with uneven sharp edges. HKM stated the cleaning solution that housekeeping staff used could not remove the substances and discolorations. During an observation on 1/15/25 at 8:31 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were big dark black fuzzy stains around and behind the toilet. There were cracks between the shower ramp and the flooring. The cracks had jagged edges and exposed a rough black grainy surface. On the doorway between the bathroom and into room [ROOM NUMBER], the whole flooring was missing, exposing an uneven, rough surface with a brown and gray grimy substance. During an observation on 1/15/25 at 8:36 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were long gray discolorations under the sink and by the toilet. On the flooring going into the shower, there were large multilayer cracks with ragged, uneven edges, The cracks exposed a rough and grainy surface with black and gray grimy substances. During an observation on 1/15/25 at 8:38 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were scratched, silver discolorations on the rim of the toilet bowl. There was a gap between the linoleum floor and the toilet covered in a black grimy substance. There were cracks with jagged sharp edges on the linoleum floor by the toilet. There was a large deep crack on the flooring going into the shower. The crack had sharp jagged edges and exposed a hard gray grimy substance. There were gaps along the edges of the flooring going into the shower. The gaps were filled with black and gray gunky substances. During an observation on 1/15/25 at 8:41 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were cracks with jagged uneven edges on the flooring going into the shower. The cracks exposed a grimy rough black surface. There was a gap between the toilet and the flooring that was covered with a gunky moist black substance. During an observation on 1/15/25 at 8:43 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were cracks with jagged edges all over the floor, exposing a black grimy rough surface. There was a gap between the flooring and the toilet which was covered with a dark brown gunky substance. During an observation on 1/15/25 at 8:52 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were gaps between flooring and the toilet covered with black, dark brown gunky substances and surrounded by large black fuzzy discolorations on the floor. There was a large crack on the flooring by the doorway to room [ROOM NUMBER]. The crack had jagged sharp edges and moist thick grimy black substances. During an observation on 1/15/25 at 8:55 a.m. in the bathroom for room [ROOM NUMBER], there were peeling paint on and above the baseboards by the shower. There were long dark cracks on the wall above the showerhead. The baseboard next to the toilet was peeling off. During an observation on 1/15/25 at 8:58 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were cracks on the shower flooring with uneven edges and exposed dark grimy substances. There were gaps on the baseboards along the shower walls. The gaps had black and dark gray grimy substances. There were gaps between the toilet and the flooring covered in dark brown and fuzzy moist gunky black substances, surrounded by a thin layer of dark gray stains. During an observation on 1/15/25 at 9:00 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were multiple cracks with uneven edges on the shower ramp with black and gray grimy substances. There was a gap between the flooring and the toilet which was covered with a dark brown gunky substance. There was a multilayer crack on the flooring by the doorway to room [ROOM NUMBER]. The crack had jagged sharp edges and thick gunky black substances. During an observation on 1/15/25 at 9:04 a.m. in the bathroom for room [ROOM NUMBER], there were cracks on the shower flooring covered with black and dark gray grimy substances. There was a long crack running along the edge of flooring going into the shower covered with a black gunky substance. During an observation on 1/15/25 at 9:05 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there was multiple cracks with ragged, uneven edges on the flooring going into the shower. The cracks had black and gray grimy substances. There were cracks with jagged and uneven edged on the linoleum flooring by the toilet. During an observation on 1/15/25 at 9:08 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were cracks with jagged uneven edges on the flooring going into the shower. The cracks exposed a grimy rough black surface. There was a gap between the flooring and the toilet which was filled with a dark brown gunky substance. There were cracks with jagged and uneven edged on the linoleum flooring by the toilet. There were dark gray and black stains on the doorway leading into room [ROOM NUMBER]. During an observation on 1/15/25 at 9:12 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were cracks on the shower flooring with uneven edges and exposed dark grimy substances. There were long dark gray stains across the floor and around the toilet. During an observation on 1/15/25 at 9:14 a.m. in the bathroom for room [ROOM NUMBER], there were cracks with jagged edges on the linoleum flooring next to toilet. There were multiple cracks with uneven edges on the shower ramp with black and gray grimy substances. During an observation on 1/15/25 at 9:15 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were cracks with jagged sharp edges on the linoleum floor behind the toilet. There were multiple cracks with ragged, uneven edges on the flooring going into the shower. The cracks had black and gray grimy substances. During an observation on 1/15/25 at 9:29 a.m. in the bathroom for room [ROOM NUMBER], there was a gap between the flooring and the toilet which was filled with a dark brown gunky substance. There were cracks with ragged, uneven lifted edges on the flooring going into the shower. The cracks had multiple gray grimy substances. During an observation on 1/15/25 at 9:43 a.m. in the shared bathroom for room [ROOM NUMBER] and room [ROOM NUMBER], there were cracks on the shower flooring with uneven edges and exposed dark grimy substances. There were gaps on the baseboards along the shower walls. The gaps were filled with a black and dark gray grimy substance. There were gaps between the toilet and the flooring were filled with dark brown and fuzzy moist gunky black substances. During an interview on 1/15/24 at 9:56 a.m. with the Administrator (Admin), the Admin confirmed the poor condition of the flooring in the bathrooms, and it needed to be replaced. During an interview on 1/15/24 at 3:49 p.m. with Resident 83, Resident 83 stated the bathrooms sucked and looked like a mess. Resident 83 stated the bathrooms were scummy and uncomfortable to be in. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated February 2021, the P&P indicated, residents are provided with a safe, clean, comfortable and home like environment . During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated December 2009, the P&P indicated, Functions of maintenance personnel include . Maintaining the building in good repair. 2. During a concurrent observation and interview on 1/16/25 at 9:30 a.m. with Resident 54 in room [ROOM NUMBER], a dark brown substance was observed smeared on the curtain divider between bed B and bed C, facing bed C. Resident 54 stated, It looks like poop and it has been there for a while. During an interview on 1/16/25 at 9:32 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, I don't know what that is. It's dirty for sure. LVN 1 stated maintenance only changes the curtains after a request is put in and no request had been put in. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, dated February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment . 3. During an interview on 1/13/25 at 10:53 a.m. with Resident 33, Resident 33 stated, The showers are always cold. During a concurrent observation and interview on 1/16/25 at 12:17 p.m. with Maintenance (MAIN) in room [ROOM NUMBER]'s bathroom, MAIN checked the shower's hot water temperature with a digital thermometer and it read 97.3 degrees Fahrenheit after waiting six minutes. MAIN stated the digital thermometer was calibrated on 1/16/25. MAIN stated, It feels cold, it's supposed to be at least 109. During a concurrent observation and interview on 1/16/25 at 12:27 p.m. with MAIN in room [ROOM NUMBER]'s bathroom, MAIN checked the shower's hot water temperature with a digital thermometer and it read 95.6 degrees Fahrenheit after waiting six minutes. MAIN stated the digital thermometer was calibrated on 1/16/25. MAIN checked the sink's hot water temperature and it read 106.3 degrees Fahrenheit after waiting six minutes. MAIN stated it was too cold to shower in and the sink temperature should have been at least 109 degrees Fahrenheit. During a concurrent observation and interview on 1/16/25 at 12:32 p.m. with MAIN in room [ROOM NUMBER]'s bathroom, MAIN checked the shower's hot water temperature with a digital thermometer and it read 95.3 degrees Fahrenheit after waiting six minutes. MAIN stated the digital thermometer was calibrated on 1/16/25. MAIN checked the sink's hot water temperature, it read 91.7 degrees Fahrenheit after waiting six minutes. MAIN stated, Yeah, that's not right. A temperature log was requested, and MAIN stated, There were no temperature logs. During a review of the facility's policy and procedure (P&P) titled, Safe Water Temperatures, undated, the P&P indicated, .maintain appropriate water temperatures in resident care areas . Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits monthly and as needed.

CONCERN (F)

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected most or all residents

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2. During a review of the facility's QAPI Minutes (a written record of a QAPI meeting that documents topics discussed, decisions made, and actions taken), dated January to December 2024, the minutes indicated there was no analysis of data regarding abuse allegations and no discussion of possible trends regarding abuse occurrence in the facility. During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), the ADMIN identified himself as the facility's abuse coordinator (designated staff member within a nursing home responsible for overseeing and coordinating the facility's efforts to prevent resident abuse). The ADMIN stated he reported abuse allegations to QAPI but did not keep a log to track trends regarding abuse. The ADMIN stated, It's not QAPI's job to track abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P indicated, Establish and implement a QAPI review and analysis of reports, allegations or findings of abuse, neglect, mistreatment, misappropriation of property. 3. During an interview on 1/14/25 at 10:14 a.m. with Resident 84, Resident 84 stated she sometimes felt like she should not report incidents or concerns to staff because she was afraid of staff retaliation. During an interview on 1/16/25 at 5:56 p.m. with the Administrator (ADMIN), the ADMIN identified himself as the facility's abuse coordinator (designated staff member within a nursing home responsible for overseeing and coordinating the facility's efforts to prevent resident abuse). The ADMIN stated retaliation only occurred against staff who reported abuse. The ADMIN stated retaliation against residents who reported abuse was not possible; it's not a thing. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P did not include prohibiting and preventing retaliation against residents, families, or visitors that reported abuse. The facility was unable to provide a policy or procedure regarding how the facility would ensure residents would not be subjected to acts of retaliation during and after an abuse investigation. Based on interview and record review, the facility's abuse program failed to protect the residents when: 1. Resident 54's transfer request after a resident-to-resident altercation was not completed. (Cross Reference F745) 2. Reports of abuse were not reviewed and analyzed by QAPI (QAPI, data-driven approach to improving quality in healthcare facilities) per the facility's policy ad procedure. 3. There was no policy and procedure developed to prohibit and prevent retaliation (act of revenge that causes harassment or harm) against residents, families, and visitors who report incidents of abuse, neglect, or other similar violations. These failures had the potential to compromise the safety of all residents, staff, and visitors. The facility census was 94. Findings: 1. During an interview on 1/13/25 at 9:03 a.m. with Resident 54, Resident 54 stated she was involved in a resident-to-resident altercation on 12/13/24 and has been trying to leave the facility. Resident 54 stated, I don't feel safe here. During an interview on 1/16/25 at 9:26 a.m. with Resident 54, Resident 54 stated she did not feel safe at the facility and still wanted to transfer to a different facility. Resident 54 stated she had not heard any update in a month. During an interview on 1/16/25 at 10:01 a.m. with the Social Services Director (SSD), the SSD stated she did not call any facilities to follow-up on transferring Resident 54 since 12/18/24. The SSD stated it was very important for residents to feel safe at the facility, and she should have seen her more frequently and followed up with transferring Resident 54 to a different facility. During an interview on 1/16/25 at 11:06 a.m. with the Director of Nursing (DON), the DON stated after Resident 54 stated she did not feel safe, the SSD should have followed up daily to address any psychosocial needs. During a review of Resident 54's Summary- Resident-to-Resident Incident, dated 12/13/24, Resident 54's Summary- Resident-to-Resident Incident indicated, When asked if [Resident 54] feels safe in the facility, [Resident 54] stated, 'No.' .When asked if [Resident 54] would like to be place in another facility . [Resident 54] stated, 'Yes.' During a review of Resident 54's Social Services Note, dated 12/17/24, the note indicated Resident 54 did not feel safe at the facility and discussed other facility options with the SSD. The note indicated the SSD faxed a referral. During a review of Resident 54's Social Services Note, dated 12/18/24, the note indicated, .[facility name 1] has been called to see if they have reviewed referral have called and have asked for them to call back awaiting response, [facility name 2] was called to see if they have reviewed referral they have not called back at this time. During a review of Resident 54's Social Services Note, dated 12/19/24, the note indicated, [facility name 1] have called have not been able to speak with admission. Will f/u (follow up) as needed. During a review of Resident 54's Psychiatric Visit Progress Report, dated 12/23/24, the Psychiatric Visit Progress Report indicated, Patient reports feeling depressed because of this place and how they're running this place. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, was reviewed. The P&P indicated, Protect residents from any further harm .

CONCERN (F)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to ensure five out of five licensed nurses (Registered Nurse 3, 4, 5, 6 and Licensed Vocational Nurse 2) were competent (having the necessary ability, knowledge, or skill to do something successfully) in medication administration. This failure resulted in a medication error rate of 24% and had the potential to result in significant adverse events (any undesirable or harmful effects that occur as a result of medical treatment including medications) to a medically compromised population. The facility census was 94. (Cross-reference F759) Findings: During multiple observations on 1/15/25 at various times with Registered Nurse (RN) 3, RN 4, RN 5, RN 6, and Licensed Vocational Nurse (LVN) 2, medications were administered to Resident 36, 39, 71, 81, 193, and 291. The medication error rate was 24%. During an interview on 1/15/25 at 12:55 p.m. with the Director of Nursing (DON), the DON stated nurses were evaluated for medication administration competency upon hire and if there were any errors with competency during medication administration audits (observations to help identify potential and actual medication errors at different stages). The DON further stated medication administration audits were completed by the Pharmacist (PHARM). During an interview on 1/16/25 at 3:26 p.m. with the PHARM, the PHARM stated he has not completed medication administration audits and that was not his responsibility. During a review of Duties and Responsibilities (job description), for RN 3, 4, 5, 6 and LVN 2, the Duties and Responsibilities indicated, Implement and maintain established nursing objectives and standards . Ensure that established departmental policies and procedures are followed . Prepare and administer medications as ordered by the physician . During a review of [facility name] Facility Assessment, dated 1/6/25, the Facility Assessment indicated, .Staff Training/Education & Competencies . Upon hire skills checks are completed through competency evaluations and are reviewed annually thereafter or as needed. Performance evaluations are performed annually to ensure staff are meeting the facility standards of performance and conduct . During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices . Medications are administered in accordance with written orders .

CONCERN (F)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent when five out of five licensed nurses were observed and made the following medication errors: 1. Potassium (medication used to treat low amount of potassium in the blood) was not administered in accordance with physician order to Resident 36. 2. Resident 81 was not instructed to stay sitting in upright position after being administered Potassium-Phosphate (supplement to increase potassium and phosphate in the blood,) despite manufacturer guidelines to not lie down for 10 minutes after to prevent stomach irritation and discomfort. 3. Resident 81 was administered twice the ordered dose of cholecalciferol (Vitamin D-medication). 4. A powdered medication, polyethylene glycol (laxative- medication that draws more water into bowels to facilitate a bowel movement), was not mixed with enough water per manufacturer's guidelines and administered to Resident 291. 5. Insulin (medication that lowers the level of glucose [sugar] in the blood) was administered after meals, despite the physician order stating before meals to Resident 71. 6. Incorrect dose of insulin was attempted to be administered to Resident 291. These failures resulted in six identified medications errors out of 25 opportunities for medication administration. The facility's overall medication error rate was 24%. Findings: 1. During a review of Resident 36's Face Sheet (demographics), the Face Sheet indicated Resident 36 was admitted on [DATE] with diagnoses including chronic kidney disease, stage 3 (moderate level of kidney damage where the kidneys are not filtering waste effectively). During an observation on 1/15/25 at 8:31 a.m. with Registered Nurse (RN) 4 in Resident 36's room, RN 4 administered one tablet of Potassium 10 mEq (milliequivalent- unit of measure) with approximately 2 oz (ounces- unit of measurement) of water. During a review of Resident 36's Physician's Order, dated 6/7/24, the Physician's Orders indicated, K (potassium) Tablet 10 MEQ. Give 1 tablet by mouth two time a day related to chronic kidney disease, stage 3 (moderate). Please give with 4 oz H20 [water] and food to help minimize GI [gastrointestinal, stomach] irritation. During an interview on 1/15/25 at 10:44 a.m. with RN 4, RN 4 stated she did not give 4 oz of water and, Oh, I should have given more water! During an interview on 1/16/25 at 11:17 a.m. with the Director of Nursing (DON), the DON stated nurses should always follow the direction on the order. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders of the attending physician . 2. During a review of Resident 81's Face Sheet (demographics), the Face Sheet indicated Resident 81 was admitted on [DATE] with diagnoses including hypokalemia (low levels of potassium in the blood). During an observation on 1/15/25 at 9:07 a.m. with Registered Nurse (RN) 6 in Resident 81's room, RN 6 administered one tablet of [Potassium-Phosphate] 250mg. The label printed on the medication pack stated, Do not lie down for at least 10 minutes after. RN 6 did not instruct Resident 81 to not lie down for 10 minutes. During an observation on 1/15/25 at 9:14 a.m. in Resident 81's room, Resident 81 was lying down, flat in bed. During a concurrent observation and interview on 1/15/25 at 10:31 a.m. with RN 6 in the hallway, RN 6 took out Resident 81's [Potassium-Phosphate] medication and read the warning, located on the label. RN 6 stated she forgot to educated Resident 81 on not lying down after taking the medication. During an interview on 1/16/25 at 11:19 a.m. with the Director of Nursing (DON), the DON stated the expectation was for nurses to follow the direction and educate the patient. During a review of Resident 81's Physician's Orders, dated 9/13/24, the Physician's Orders indicated, [Potassium-Phosphate] Oral Tablet . Give 1 tablet by mouth with meals for supplement. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders of the attending physician . 3. During a review of Resident 81's Face Sheet (demographics), the Face Sheet indicated Resident 81 was admitted on [DATE] with diagnoses including cervical disc degeneration (natural part of aging that occurs when the spinal discs in the neck wear down). During an observation on 1/15/25 at 9:07 a.m. with Registered Nurse (RN) 6 in Resident 81's room, RN 6 administered two tablets of cholecalciferol 125 mcg (microgram-unit of measure). During a review of Resident 81's Physician's Orders, dated 9/13/24, the Physician's Orders indicated, Cholecalciferol Oral Tablet 125 MCG. Give 1 tablet by mouth one time a day for supplement. During an interview on 1/15/25 at 10:31 a.m. with RN 6, RN 6 stated, I did give two; it should have been one. During an interview on 1/16/25 at 11:17 a.m. with the Director of Nursing (DON), the DON stated nurses should always follow the direction on the order. During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders of the attending physician . 4. During a review of Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including metabolic encephalopathy (brain disorder that occurs when an underlying condition impairs brain function). During an observation on 1/15/25 at 9:26 a.m. with Registered Nurse (RN) 5 in Resident 291's room, RN 5 prepared [Polyethylene Glycol] 17 grams with approximately 2.5 ounces of water and then administered to Resident 291. The directions on the bottle of [Polyethylene Glycol] stated, stir and dissolve in any 4 to 8 ounces of beverage. During an interview on 1/15/25 at 1:12 p.m. with RN 5, RN 5 stated she did not know how much water to mix with the medication. During an interview on 1/16/25 at 11:20 a.m. with the Director of Nursing (DON), the DON stated nurses should mix Polyethylene Glycol with 4-6 oz of water and follow the directions that are directly on the bottle. During a review of Resident 291's Physician's Order, dated 12/20/24, the Physician's Orders indicated, [Polyethylene Glycol] Oral Packet 17 gram. Give 17 grams by mouth two times a day for constipation. During a review of the ClearLax- polyethylene glycol, dated February 2024, the ClearLax polyethylene glycol indicated, . Directions . stir and dissolve in any 4 to 8 ounces of beverage . 5. During a review of Resident 71's Face Sheet (demographics), the Face Sheet indicated Resident 71 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars). During an observation on 1/15/25 at 12:04 p.m. in Resident 71's room, Resident 71 had eaten ½ of a grilled cheese and one bag of chips. During an observation on 1/15/25 at 12:14 p.m. in Resident 71's room, Registered Nurse (RN) 4, administered 1 unit (unit measurement) of insulin. During a concurrent interview and record review on 1/15/25 at 12:27 p.m. with RN 4, Resident 71's Medication Administration Record (MAR), dated 1/15/25 was reviewed. The MAR indicated insulin was to be administered before meals. RN 4 stated, Oh, I missed that. During an interview on 1/16/25 at 11:21 a.m. with the Director of Nursing (DON), the DON stated nurses should always follow the order. During a review of Resident 71's Physician's Orders, dated 12/14/24, the Physician's Orders indicated, insulin injected per sliding scale (increasing administration of the insulin dose based on blood sugar levels) . before meals . During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders . 6. During a review of Resident 291's Face Sheet (demographics), the Face Sheet indicated Resident 291 was admitted on [DATE] with diagnoses including diabetes mellitus type 2 (disease that causes high blood sugars). During a concurrent observation and interview on 1/15/25 at 4:15 p.m. with Registered Nurse (RN) 3 in Resident 291's room, RN 3 checked Resident 291's blood sugar with a glucometer (handheld device that measures the amount of sugar in the bloodstream) and stated the result was 205 milligram/deciliter (mg/dL, unit of measurement). RN 3 went to the medication cart and documented 305 mg/dL into Resident 291's Medication Administration Record (MAR) for the blood sugar result. RN 3 stated the sliding scale for blood sugar result of 305, was to administer 8 units of insulin (medication that manages blood sugar levels). RN 3 turned the dial to 8 units of insulin and confirmed the prefilled pen injector was turned to 8 units. RN 3 stated, Yes, I'm ready to give, and began to walk towards Resident 291. RN 3 was then stopped and was asked to show the history on the glucometer results. RN 3 recalled the history on the glucometer and stated the value was 205! Oh, my god! That would have been so bad. RN 3 reviewed Resident 291's MAR and confirmed the correct dose of insulin should have been 4 units. During a review of Resident 291's Physician's Order, dated 1/8/25, the Physician's Orders indicated, insulin injected per sliding scale (increasing administration of the insulin dose based on blood sugar levels) was for blood sugar value of 0-149= 0 units to be given, 150-200= 2 units, 201-250= 4 units, 251-300= 6 units, 301-350= 8 units, 351-400= 10 units, and 401-500= 12 units and call physician. During an interview on 1/15/25 at 4:54 p.m. with the Medical Director (MD), MD stated, It's always life threatening to give too much insulin. During an interview on 1/16/25 at 3:30 p.m. with the Pharmacist (PHARM), the PHARM stated if double the dose of insulin was administered, that would be quite a jump, and significant damage could be caused to Resident 291. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated October 2017, the P&P indicated, .Medications are administered in accordance with written orders .

CONCERN (F)

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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) committee failed to maintain documentation and demonstrate evidence that the QAPI program was sustained during transitions in leadership when there were no follow-ups for medication administration audits (observations to help identify potential and actual medication errors at different stages) conducted by Pharmacy (Cross-reference F658, F726, F759, F760). These findings resulted in a medication error rate of 24%, including one considered significant, and had the potential to result in severe adverse effects for all residents. The facility census was 94. Findings: During a review of the facility's QAPI Minutes (a written record of a QAPI meeting that documents topics discussed, decisions made, and actions taken), dated January to December 2024, the minutes indicated that for January and February of 2024, Medication Administration Audits by the Pharmacist (PHARM) were planned to be completed monthly and reported to QAPI. The minutes indicated the audits were not completed for February. During an interview on 1/15/25 at 12:47 p.m. with the Director of Nursing (DON), the DON stated PHARM was responsible for conducting monthly medication administration audits. During an interview on 1/16/25 at 3:26 p.m. with PHARM, PHARM denied being responsible for conducting medication administration audits. During an interview on 1/17/25 at 9:17 a.m. with the Administrator (ADMIN), the ADMIN stated his start of employment was June 2024. The ADMIN stated he had no knowledge of the medication administration audits to be completed by PHARM and declined to discuss any further issues identified and addressed by QAPI prior to his start of employment because those issues were before my time. The facility was unable to provide documentation that medication administration was audited by PHARM monthly during February to December 2024. During a review of the facility's policy and procedure (P&P) titled, QAPI Plan, dated 10/24/24, the P&P indicated, The facility QAPI program is ongoing, comprehensive and addresses all care and services provided by the facility.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI, data-driven approach to improving quality in healthcare facilities) program failed to identify, address, and evaluate the following systemic quality deficiencies (issues that fall below the standards of quality for a facility's care, which QAPI programs were designed to identify and fix): 1. Nursing Medication Administration Competency (Cross-reference F658, F726, F759, F760) 2. Infection Control (Cross-reference F880, F881) 3. Abuse Program (Cross-reference F606, F607, F943) 4. Incomplete Resident's Records (Cross-reference F842) 5. Social Services (Cross-reference F607, F685, F742, F745, F791) These failures resulted in a lack of oversight over these necessary care services and had the potential to negatively affect the safety and quality of care provided to all residents. The facility census was 94. Findings: During a review of the facility's QAPI Minutes (a written record of a QAPI meeting that documents topics discussed, decisions made, and actions taken), dated January to December 2024, the minutes indicated the following were not identified as quality deficiencies to be addressed: 1. Nursing Medication Administration Competency 2. Infection Control 3. Abuse Program 4. Incomplete Resident's Records 5. Social Services During an interview on 1/17/25 at 9:17 am. with the Administrator (ADMIN), the ADMIN confirmed, the issues identified during survey were not previously identified or addressed by QAPI. The Admin confirmed,there were no Performance Improvement Projects (PIP, focused effort to identify and address a specific problem within a facility) conducted for issues identified during survey. During a follow-up interview on 1/17/25 at 9:20 a.m. with the ADMIN, the ADMIN stated he was unaware of the existence of the QAA Log (Quality Assessment and Assurance Log, a record of data and current PIPs to be reviewed as part of QAPI). During a review of the facility's QAPI Agenda and Minutes, dated June 2024, the documents indicated no PIPs were discussed, planned, or evaluated. During a review of the facility's QAPI Agenda and Minutes, dated August 2024, the documents indicated a PIP for Baseline Care Plans was initiated/ongoing, but with no discussion or evaluation. The minutes indicated Infection Control had a broken process, but did not include a discussion of conducting a PIP. During a review of the facility's QAPI Agenda and Minutes, dated September 2024, the documents indicated the following PIPs were assigned/ongoing: Handwashing, COVID (disease that can cause coughs, fevers, and death) Vaccines, Call Lights, and Care Conferences, but did not include any evaluation or discussion regarding the PIPs. During a review of the facility's QAPI Agenda and Minutes, dated October 2024, the documents indicated the following PIPs were assigned/ongoing: Call Lights, Care Conferences, and Falls, but did not include any evaluation or discussion regarding the PIPs. During a review of the facility's policy and procedure (P&P) titled, QAPI Plan, dated 10/24/24, the P&P indicated, The QAPI program is designed to address all systems and practices in this facility that affect residents . Information is collected, evaluated and monitored by the QAPI committee . Facility will conduct performance improvement projects that are designed to take a systemic approach to revise and improve care or services in areas that we identify as needing attention . An important aspect of our PIPs is a plan to determine the effectiveness of our performance improvement activities and whether the improvement is sustained . the QAPI committee will review data and input on a monthly basis to look for potential topics for PIPs .The facility will use the QAA log to include listing of current projects and outcomes . Quality deficiencies that are identified through feedback and data will undergo appropriate corrective action . The QAPI program, overseen by the QAPI committee, is designed to identify and address quality deficiencies through the analysis of underlying cause and actions targeted at correcting systems at a comprehensive level.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection prevention and control measures were implemented when: 1a. Water testing was not done to identify the presence of Legionella bacteria (can cause severe pneumonia [inflammation and fluid in the lungs]) in the building water system (cold and hot water distributed through the water pipes). 1b. Policies and Procedures (P&P) were not revised annually and updated as needed. 1c. Toilet plungers (used to free waste outlets of obstruction) located on the floor next to toilets in restroom of rooms 124, 130, 132, and 146. 1d. Four unlabeled urinals were in the restroom of rooms [ROOM NUMBERS]. 1e. One House Keeping staff did not know the dwell time (the amount of time the disinfectant needed to sit on the surface) of the [name of manufacturer] disinfectant. 2. Resident 83's used urinal with no lid cover was observed on the edge of his bedside table for approximately one hour. 3. Certified Nurse Assistant (CNA) 1 was observed not wearing a gown while providing perianal hygiene care and brief change for Resident 24 who was on Enhanced Barrier Precautions (EBP, a set of infection control measures that use personal protective equipment (PPE) such as gloves and gown to reduce the spread of multidrug-resistant organisms (MDROs, bacteria resistant to antibiotics). 4a. Enhanced Barrier Precaution (EBP) was not followed for one resident (Resident 344) 4b. Contact Precaution was not followed for two residents (Resident 35 and Resident 21) 4c. Droplet Precaution sign was not posted for one resident (Resident 344) These failures had the potential to result in cross contamination (bacteria or other germs are unintentionally transferred from one person to another with harmful effects) and the spread of communicable diseases (illnesses that spread from one person to another) to Residents, staff, and visitors. Findings: 1a. During an interview on 1/14/25 at 3:45 p.m. with Maintenance (MAIN), MAIN stated he was unable to provide documentation for water testing to identify the presence of legionella bacteria for the following months of January 2024 through January 2025. MAIN also stated he had not done the monthly water testing of Legionella. During an interview on 1/15/25 at 9:53 a.m. with Administrator (ADMIN), ADMIN stated maintenance staff should have completed the water testing for Legionella bacteria monthly. During a review of the facility's Policy and Procedure (P&P) titled, Legionella Water Management Program, undated, the P&P indicated, Facility shall establish an infection control program that will prevent, detect, and control water-borne contaminants, including Legionella which is overseen by the water management team. The water management program will identify areas in the water system where legionella bacteria can grow and spread . 1b. During a concurrent interview and record review on 1/14/25 at 2:22 p.m. with Infection Preventionist (IP), the facility's binder of Infection Prevention and Control Policy and Procedure Manual was reviewed. The binder contained Policies and Procedures (P&P) (Infection Prevention and Control Program, Enhanced Barrier Precautions, Pneumococcal Vaccine, Influenza Vaccine, Personal Protective Equipment, Handwashing/Hand Hygiene, and Isolation Categories of Transmission-Based Precautions), dated 2001. The IP stated the P&P were supposed to be revised annually and updated as needed. During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 2001, the P&P indicated, . The infection prevention and control committee, medical director, director of nursing services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include updating or supplementing policies and procedures as needed . 1c. During an observation on 1/15/25 at 8:52 a.m. in the restroom of room [ROOM NUMBER], there was one toilet plunger on the floor next to the toilet. During an observation on 1/15/25 at 8:53 a.m. in the restroom of rooms [ROOM NUMBERS], there was one toilet plunger on the floor next to the toilet. During an observation on 1/15/25 at 9:14 a.m. in the restroom of room [ROOM NUMBER], there was one toilet plunger on the floor next to the toilet. During an interview on 1/15/25 at 9:15 a.m. with Housekeeping Manager (HKM), HKM stated the toilet plungers should have been in a clear bag and taken to the dirty utility room. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, dated 2001, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment . 1d. During a concurrent observation and interview on 1/15/25 at 9:37 a.m. with Certified Nurse Assistant (CNA) 7 in the restroom of rooms [ROOM NUMBERS], one unlabeled urinal was located on the shower floor and three unlabeled urinals were hanging from the handle grab bar. CNA 7 stated the urinals should have been labeled with Resident's room number, and placed clean and dry next to the Residents bedside table. During an interview on 1/15/25 at 10:24 a.m. with Infection Preventionist (IP), IP stated the urinals are supposed to be labeled with the Residents room number and initials. The urinals should have been placed clean and dry next to the Residents bedside table. During a review of the facility's Policy and Procedure (P&P) titled, Bedpan/Urinal, Offering/Removing, dated 2001, the P&P indicated, . Empty and clean it as necessary . Remove the urinal from the bedside stand. Be sure that it is clean and dry . During a review of the facility's P&P titled, Infection Prevention and Control Program, dated 2001, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment . 1e. During an interview on 1/13/25 at 9:47 a.m. with Housekeeping (HK) 1, HK 1 stated the [name of manufacturer] dwell time to disinfect floors, bedside tables, and toilets was one minute. During an interview on 1/16/25 at 10:05 a.m. with Housekeeping Manager (HKM), HKM stated the dwell time to disinfect the floors, furniture, toilets, showers, and sinks were three to five minutes. During a review of the facility's [name of manufacturer] bottle indicated . Effective against SARS [Severe Acute Respiratory Syndrome- severe cold symptoms]-related Coronavirus two in three minutes . To clean and disinfect hard (includes countertops, doorknobs, and bathroom surfaces), nonporous (a floor that does not absorb water or other liquids) finished floors, sinks, and tubs . Sanitizes soft surfaces as a spot treatment in 5 minutes. For use as a spot treatment on soft surfaces such as upholstery, fabric, and furniture . During a review of the [name of manufacturer] disinfectant: General Guidelines for use, dated 8/15/22, the disinfectant general guidelines indicated, . To disinfect all surfaces must remain wet for 3 minutes . Soft surface sanitizing in 5 minutes . During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program, dated 2001, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment . 2. During an observation on 1/13/25 at 9:00 a.m. in Resident 83's room, Resident 83's urinal with approximately 150 milliliters(ml- unit of measure) of urine without a lid was placed at the edge of the bedside table, next to a cup of water. During a concurrent observation and interview on 1/13/25 at 10:05 a.m. in Resident 83's room, Certified Nursing Assistant (CNA) 6 acknowledged Resident 83's urinal had approximately 150 ml of urine in it and stated the urinal should have been emptied, cleaned and dried, and placed in a bag within Resident 83's reach. CNA 6 stated the urinal should not have been placed on Resident 83's bedside table because there was a potential for the spread of infection. During a concurrent interview and record review on 1/16/25 at 10:18 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Bedpan/Urinal, Offering/Removing dated February 2018 was reviewed. The policy indicated, .urinal at his bedside, check it frequently. Empty and clean it as necessary . The DON stated the urinal should not be left open on the beside table for potential infection control issues. The DON stated the urinal should be hung at the bedside in a bag. During a review of the facility's P&P titled, Bedpan/Urinal, Offering/Removing, dated 2001, the P&P indicated .Empty and clean it as necessary . Remove the urinal from the bedside stand. Be sure that it is clean and dry . 3. During an observation on 1/13/25 at 9:36 a.m. in the hallway of the Special Care Unit, there was a sign posted in front of Resident 24's door that indicated, Enhanced Barrier Precautions (EBP) .Bed B . Providers and staff must .wear gloves and a gown for the following High-Contact Resident Care Activities: .Providing hygiene .Changing briefs . During an observation on 1/13/25 at 11:24 a.m. in Resident 24's room, Certifed Nurse Assistant (CNA) 1 was not wearing a gown while she provided perianal hygiene care and changed Resident 24's briefs. During an interview on 1/13/25 at 11:45 a.m. with Registered Nurse (RN) 1, RN 1 stated that staff needed to wear a gown during brief change for Resident 24 because he was on EBP for his wound on his back. During an interview on 1/13/25 at 11:48 a.m. with CNA 1, CNA 1 confirmed she did not wear a gown while providing perianal hygiene care and changing Resident 24's briefs. During an interview on 1/14/25 at 2:26 p.m. with Infection Preventionist (IP), IP stated Resident 24 was on EBP due to the wound on his sacrum. IP stated that staff should be wearing a gown and gloves when performing care like changing Resident 24's briefs. During a review of Resident 24's Skin/Wound Note, dated 12/23/25, the note indicated, [Resident 24] was noted with a pressure ulcer (wound caused by pressure on the skin) to sacral (lower back). During a review of Resident 24's Physician's Orders, dated 12/26/24, the order indicated, Resident 24 was on Enhanced Barrier Precautions .related to wounds .instruct staff to use PPE gown, glove with high care contact activities. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated August 2022, the P&P indicated, Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms . The P&P indicated, High contact resident care activities requiring the use of gown and gloves for EBP's include: . providing hygiene . changing briefs or assisting with toileting . The P&P indicated, EBP's are indicated . for residents with wounds .4a. During an observation on 1/15/25 at 10:46 a.m. in room [ROOM NUMBER]B, Enhanced Barrier Precaution (EBP) signage, that stated, staff must also: wear gloves and a gown for the following High-Contact Resident Care Activities . bathing/showering . providing hygiene . was posted outside of the door with a personal protective equipment (PPE) cart. The Occupational Therapist (OT) was observed providing oral care and washing Resident 344's face without a gown. During an interview on 1/15/25 at 10:53 a.m. with the OT, the OT stated EBP did not apply to OT staff, so she did not have to wear PPE. OT read the sign and then stated, oh it says hygiene, so I guess I need it. During an interview on 1/15/25 at 3:22 p.m. with Infection Preventionist (IP), IP stated Resident 344 was placed on EBP for foley catheter (medical device- tube that drains urine from the bladder into a collection bag). IP stated that all staff needed to follow the precaution sign posted and must wear the correct PPE. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated August 2022, the P&P indicated, .EBPs employ targeted gown and glove use during high contact resident care activities .examples of high-contact care activities requiring the use of gown and gloves for EBPs include: .bathing .providing hygiene .EBPS are indicated .for residents with .indwelling medical devices .Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . 4b. During a concurrent observation and interview on 1/15/25 at 11:40 a.m. with Registered Nurse (RN) 5 in room [ROOM NUMBER]. A contact precaution sign was posted outside the door with a personal protective equipment (PPE) cart. In room [ROOM NUMBER], there were three residents, Resident 63 was in bed A, Resident 35 was in bed B, and Resident 21 was in bed C. Resident 63 was positive for MRSA (Methicillin-resistant Staphylococcus aureus- bacterial infection that becomes resistant to many antibiotics). RN 5 walked into room [ROOM NUMBER] without a gown and checked Resident 35's and Resident 21's blood sugar. RN 5 stated I didn't have to wear a gown because Resident 35 and Resident 21 were not on contact isolation, it was only their roommate- Resident 63. During an interview on 1/15/25 at 3:20 p.m. with Infection Preventionist (IP), IP stated if one resident was on contact isolation and they shared a room with other residents, staff must wear gown and gloves regardless upon entering the room. During a review of Resident 63's Medication Administration Record (MAR), dated 1/15/24, the MAR indicated, CONTACT PRECAUTIONS every shift for r/t [related to] MRSA positive on the wound culture . During a review of the facility's policy and procedure (P&P) titled, Isolation- Categories of Transmission-Based Precautions (TBP), dated September 2022, the P&P indicated, .Staff and visitors wear a disposable gown upon entering the room . 4c. During an observation on 1/17/25 at 9:58 a.m. in room [ROOM NUMBER], Registered Nurse (RN) 5 entered Resident 344's room wearing a surgical mask. An Enhanced Barrier Precaution sign was posted outside the door with a personal protective equipment (PPE) cart. During a concurrent interview and record review on 1/17/25 at 10:07 a.m. with RN 5, Resident 344's Medication Administration Record (MAR), dated 1/17/25 was reviewed. The MAR indicated, on 1/15/25 Resident 344 had Droplet Precaution related to influenza and Enhanced Barrier Precaution related to foley catheter. RN 5 confirmed there was not a Droplet Precaution sign posted. During an interview on 1/17/25 at 10:25 a.m. with Infection Preventionist (IP), IP stated if there was an order, there should have been a sign posted on the door. During an interview on 1/17/25 at 10:21 a.m. with the Director of Nursing (DON), the DON stated the expectation was to post the correct sign in accordance with the order for isolation precautions. During a review of the facility's policy and procedure (P&P) titled, Isolation- Categories of Transmission-Based Precautions (TBP), dated September 2022, the P&P indicated, .When a resident is placed on transmission-based precautions appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for the type of precaution .

CONCERN (F)

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

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to provide procedures for reporting incidents of abuse and training for seven staff members (Social Services Director (SSD), Registered Nurse (RN) 2, Licensed Vocational Nurse (LVN) 3, Certified Nurse Assistants (CNA) 3, 4, 5, and 6). These findings resulted in staff ineffectively identifying the facility's procedure for reporting incidents of abuse and had the potential to compromise the safety of all residents, staff, and visitors. Findings: During an interview on 1/13/25 at 12:32 p.m. with Resident 23, Resident 23 stated he has heard staff members at night being verbally abusive to his roommate, and he reported it to staff. Resident 23 stated, nothing happened after he reported the incident. During an interview on 1/14/25 at 1:47 a.m . with LVN 3, LVN 3 stated that if there was an abuse incident, she would report it during the next shift to the Director of Nursing (DON) because she's night shift and she wouldn't want to wake the DON up. During an interview on 1/14/25 at 1:48 a.m. with CNA 5, CNA 5 stated that if there was an abuse incident, she would report it to the DON in the morning after her shift and that she wasn't sure if she had to fill out a specific report. During a concurrent interview and record review on 1/16/25 at 6:43 p.m. with the Director of Staff Development (DSD), LVN 3's Employee Files, [undated], was reviewed. The abuse training post-test indicated, LVN 3 selected the incorrect answer that mandated reporters must report known or suspected instances of physical abuse, abandonment, isolation, financial abuse, or neglect by telephone to the long-term care ombudsman or law enforcement within 24 hours, instead of selecting the correct answer to report immediately, or as soon as possible. The DSD stated the abuse training consisted of staff taking a pretest, watching an abuse training video, then re-evaluating their learning with a post test . During a concurrent interview and record review on 1/16/25 at 6:44 p.m. with the DSD, CNA 6's Employee Files, [undated], was reviewed. The abuse training post-test was missing from CNA 6's employee files. The DSD confirmed there was no abuse training post-test in CNA 6's employee files . During a concurrent interview and record review on 1/16/25 at 6:45 p.m. with the DSD, CNA 4's Employee Files, [undated], was reviewed. The abuse training post-test was missing from CNA 4's employee files. The DSD stated, If [the abuse training post-test] is not in the employee file, we assume they didn't do it. During a review of RN 2's Employee Files, dated 6/25/24, the abuse training post-test indicated, RN 2 selected the incorrect answer that according to California law, mandated reporters are required to report all instances of abuse in a long-term care facility to the facility administrator, instead of the correct answer which was to report to the long-term care ombudsman or local law enforcement agency . During a review of CNA 5 's Employee Files, dated 6/25/24, the abuse training post-test indicated, CNA 5 selected the incorrect answer that according to California law, mandated reporters are required to report all instances of abuse in a long-term care facility to the facility administrator, instead of the correct answer which was to report to the long-term care ombudsman or local law enforcement agency. During a review of CNA 3 's Employee Files, dated 6/25/24, the abuse training post-test indicated, CNA 3 selected the incorrect answer that according to California law, mandated reporters are required to report all instances of abuse in a long-term care facility to the facility administrator, instead of the correct answer which was to report to the long-term care ombudsman or local law enforcement agency. During a concurrent interview and record review on 1/16/25 at 6:49 p.m. with the DSD, the SSD's Employee Files, dated 10/25/24 was reviewed. The abuse training post-test indicated the SSD selected the incorrect answer that mandated reporters must report known or suspected instances of physical abuse, abandonment, isolation, financial abuse, or neglect by telephone to the long-term care ombudsman or law enforcement within 24 hours, instead of the correct answer to report immediately, or as soon as possible. The abuse training post-test also indicated that the post-test was incomplete. The DSD confirmed that SSD's abuse training post-test was not completed. During an interview on 1/16/25 at 6:52 p.m. with the DSD, the DSD stated, the facility did not have a tracking system for staff that are struggling with the information from the abuse trainings. The DSD stated wrong answers on the abuse training post-test were corrected verbally, but education was not re-evaluated afterwards . During an interview on 1/16/25 at 6:53 p.m. with the Administrator (ADMIN), the ADMIN stated the questions on the abuse post-test seemed confusing and may need to be fixed. The ADMIN stated staff should be required to rewatch the abuse training video and complete the post-test until they get all the answers correct. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, dated April 2021, the P&P indicated, Provide staff orientation and training orientation programs that include topics such as . reporting of abuse . Implement measures to address factors that may lead to abusive situations, for example: adequately prepare staff for caregiving responsibilities . Report any allegations within time frames required by federal requirements.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews, the facility failed to ensure a sexual abuse allegation between Unlicensed Staff B (ULS B) and Resident 1 was reported within the 2 hour abuse reporting time frame. Findings: A review of the facility ' s initial report indicated an abuse allegation was reported to the state on 12/9/24. A review of the Summary-Staff-to-Resident Allegation indicated that on 12/9/24, ULS D reported that Resident 1 told him she was having inappropriate texts and inappropriate interactions with ULS B. A review of the staffing assignment sheet indicated ULS D was assigned to work on 12/8/24 on afternoon shift and Resident 1 was under his care at that time. ULS D reported to the ADM on 12/9/25 the sexual abuse allegation between ULS B and Resident 1. A review of the written statement by ULS D, undated, confirmed he was working with Resident 1 on 12/8/24. During an interview on 12/23/24 at 12:30 p.m., LN A stated it was important that abuse allegations were reported timely to ensure interventions to keep residents safe were in place immediately. During a concurrent interview and initial facility report record review dated 12/9/24 on 12/23/24 at 1:10 p.m., the ADM confirmed the staff reported the incident to him. During a concurrent interview, written statement by ULS D, staffing assignment dated 12/8/24 and facility initial report dated 12/9/24 record review on 12/23/24 at 1:55 p.m., the Interim Director of Nursing (IDON) stated everyone was a mandated reporter. The IDON stated it was important to report abuse allegations timely to ensure residents safety. A review of facility ' s staffing assignment dated 12/8/24 indicated ULS D was working on 12/8/24. The IDON verified the abuse allegation was reported late based on the facility ' s abuse reporting policy time frame. The IDON stated the abuse policy was not followed when the abuse allegation was not reported within the 2-hour time frame. During a concurrent interview and abuse policy record review on 12/23/24 at 2:00 p.m., when asked how soon an abuse allegation was to be reported to the State, the Ombudsman and local PD, the ADM stated within 24 hours. The ADM was not familiar with the reporting time frame for abuse allegations. The ADM stated based on this policy, the abuse allegation was reported late. During a telephone interview on 1/6/24 at 11:39 a.m., ULS D confirmed Resident 1 reported to him the abuse allegation on 12/8/24 and he reported the alleged abuse allegation to the ADM a day later, 12/9/24. ULS D confirmed he reported the abuse allegation late. A review of the facility ' s policy and procedure, untitled, undated, policy indicated, all alleged violations of abuse neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation of resident property, the mandated reporter shall .make phone report or call 911 immediately no later than 2 hours to the local law enforcement and licensing agencies of observing, obtaining, knowledge of, or suspecting the abuse .

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow a physician ' s order in obtaining a Keppra (medication to treat seizures), blood level for one of two sampled Residents, (Resident 10), by not having the laboratory company come to the facility to obtain the sample and the nursing Department did not follow up on the missed opportunity for four months. This failure had the potential to result in Resident 10 experiencing subsequent seizures in October and November of 2024 causing pain, distress, and a higher level of care to ensure no further damage to Resident 10 ' s brain. Findings: During a review of Resident 10 ' s admission Record indicated Resident 10 was admitted to the facility on [DATE] with a history of Parkinson ' s (a chronic brain disorder that causes movement problems, mental health issues and other health concerns), epileptic seizures (a chronic brain disorder which causes seizures by an abnormal electrical activity in the brain), muscle weakness and dysphagia (difficulty swallowing or feeding). During a review of Resident 10 ' s, Order Summary Report for October 2024, dated 1/02/24, indicated Resident 10 ' s physician had ordered a Keppra level every 4 months on the fourth day of the month (last laboratory Keppra level was dated 4/4/24). A review of Resident 10 ' s, SBAR Communication and progress note, dated 10/18/24 indicated Resident 10 had a seizure lasting 1 minute and his physician was notified. A review of Resident 10 ' s, SBAR Communication and progress note, dated 11/23/24, indicated Resident 10 had a two-minute seizure and was transferred to a higher level of care. During an interview on 12/12/24 at 2:29 pm. with Licensed Staff A (who was filling in the for the Director of Nursing who was on an extended vacation), Licensed Staff A stated Resident 10 ' s laboratory results for Keppra levels were indicated to be resulted on 3/6/24 and 4/4/24. License Staff A produced test results for 3/6/24 and 4/4/24 from the laboratory company. Licensed Staff A and the laboratory company representative confirmed and stated there were no other Keppra laboratory test results other than the ones produced. Licensed Staff A also confirmed there was no documentation of Resident 10 refusing Keppra laboratory test. Licensed Staff A stated the result of Resident 10 not having the Keppra laboratory test might mean the dose of Keppra would not be effective and the reason for Resident 10 having increased seizures. A review of the facility ' s policy and procedure titled, Diagnostic Services, Revised 4/9/18, indicated, The facility provides radiology and other diagnostic service as ordered by a physician to meet the needs of the resident[RV6] .

Dec 2024 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record Review the Facility failed to allow residents, who were smokers at time of their admission, the right to self-determination when the facility made the decision to enforce the Smoking Policy without considering the rights of the residents to choose their schedules. Residents, who were smokers, were not allowed input about the changes in the Policy including the timing of smoking breaks. Residents were not given guidance for managing the restrictions nor alternatives to smoking. This change in Policy infringed on the rights of the Residents who smoked, and affected nine of the thirteen residents, who identified as smokers in the facility, among them Resident 3, Resident 11, Resident 2, Resident 7, and Resident 12. Findings: During an interview on 10/29/24 at 2:30 p.m., Resident 3 stated she did not want to quit smoking and this change in policy infringed on her rights as a Resident. Resident 3 stated it was not right to change the door code to the exit by station 2, preventing her from exiting. Resident 3 stated she would like to exit to get fresh air, not just to smoke. Resident 3 stated it's my freedom, I'm a resident and this is one rule I do not want. During a review of Resident 3's clinical record, the admission record documented Resident 3 was admitted [DATE]. Resident 3's Smoking-Safety Screen, dated 8/14/24 assessed Resident 3's ability to smoke safely. The assessment determined that Resident 3 was safe to smoke with supervision. During an interview on 10/29/24 at 2:55 p.m., Resident 11 stated that she remembered that a brief mention about the smoking policy was made at a Resident Council meeting (A meeting for Residents to discuss ideas or problems concerning the facility.) Resident 11 stated the director (Activities Coordinator who assists with the meetings) handed out copies of the policy but Resident 11 did not have a copy now. Resident 11 stated she did not like the policy because she would like to go out to smoke in the evening to have a quiet place while her roommates were being changed by the CNAs. During a review of Resident 11's clinical record, the admission record documented Resident 11 was admitted [DATE]. Resident 11's Smoking-Safety Screen, dated 8/14/24 assessed Resident 11's ability to smoke safely. The assessment determined that Resident 11 was safe to smoke with supervision. During an interview on 12/3/24 at 3:30 p.m., Resident 2 stated she uses a vape pen to meet her needs for nicotine. Resident 2 stated she does not need a lighter or match to use her pen. She stated she would like to use it on her schedule and not be limited to the smoking policy scheduled times. Resident 2 stated she resented being yelled at for using her vape pen other than at the smoking times. During a review of Resident 2's clinical record, the admission record documented Resident 2 was admitted [DATE]. Resident 11's Smoking-Safety Screen, dated 8/14/24 assessed Resident 2's ability to smoke safely. The assessment determined that Resident 2 was safe to smoke without supervision. During an interview on 12/3/24 at 3:30 p.m., Resident 7 stated he did not plan to quit smoking. He stated it is his right to continue smoking. Resident 7 stated we were allowed to smoke when we wanted and to have more than 2 cigarettes at a time, but we had to go to the outdoor smoking area. Resident 7 stated he gets accused of breaking the policy whether they see him outside with or without his cigarettes. During a review of Resident 7's clinical record, the admission record documented Resident 7 was admitted [DATE]. Resident 7's Smoking-Safety Screen, dated 8/14/24 assessed Resident 7's ability to smoke safely. The assessment determined that Resident 7 was safe to smoke without supervision. During an interview on 12/3/24 at 3:30 p.m., Resident 12 stated he was aware of the smoking policy. Resident 12 stated the schedule would be better for him if there was an evening smoke break after dinner. During a review of Resident 12's clinical record, the admission record documented Resident 12 was admitted [DATE]. Resident 12's Smoking-Safety Screen, dated 8/14/24 assessed Resident 12's ability to smoke safely. The assessment determined that Resident 12 was safe to smoke with supervision. During an interview on 10/29/24 at 3 p.m., Licensed Staff A stated we started enforcing the smoking policy recently, but the Residents do not like this because they did not have to follow the policy in the past. During an interview on 12/3/24 at 3:55 pm., Unlicensed Staff B stated the facility had not been enforcing the smoking policy in the past. Unlicensed Staff B stated they do not like and have been non-compliant with the enforcement of the smoking policy. She has been told by residents it is their right to smoke and their right to keep the cigarettes that they purchased. During a review of the Resident Council minutes dated 7/30/24, the following was documented to be part of the discussion. Resident Council were encouraged to follow smoking protocol. This was under the section Administration. Fourteen residents were listed as present on 7/30/24. Five of these residents were on the list of smokers from the facility dated 10/22/24. During an interview on 10/29/24 at 10:00 a.m., Administrator stated we had concern about the safety of the facility related to the residents who smoke. Administrator stated management attended the Resident Council meeting and informed the residents smoking will only be tolerated under supervision and at set times.

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility failed to follow transfer and discharge requirements when nine of thirteen residents, who at the time they were admitted to the facility, identified as smokers, were given a Notice of Transfer and Discharge for endangering the health of safety of individuals in the facility, all on 10/23/24. The facility did not have appropriate documentation to support that the residents were noncompliant with the smoking policy or that their smoking behavior was a safety risk for the other residents at the facility. The failure to identify and document in each of the nine residents records the behavior that caused the need for the facility to initiate a resident discharge could result in unfair and unsafe discharges. Findings: During a review of Resident 2's clinical record, the admission record documented Resident 2 was admitted [DATE]. Resident 2's Smoking-Safety Screen, dated 8/14/24 assessed Resident 2's ability to smoke safely. The assessment determined that Resident 2 was safe to smoke without supervision. Resident 2's Progress Notes had an entry by social services, dated 10/24/24 at 18:23 p.m., revealed the following Late Note for 10/23/24 (resident 2) was given a 30 day notice of discharge due to none compliance with the smoking policy, she had been given a policy and schedule time of smoking before she believes that because what she uses vaping it does not apply to her, she was educated that smoking is smoking. Documentation to show she was given the policy prior was not in Resident 2's electronic medical record. Documentation to show non-compliance was not provided by staff. During a review of Resident 3's clinical record, the admission record documented Resident 3 was admitted [DATE]. Resident 3's Smoking-Safety Screen, dated 8/14/24 assessed Resident 3's ability to smoke safely. The assessment determined that Resident 3 was safe to smoke with supervision. Resident 3's Progress Notes had an entry by social services, dated 10/24/24 at 18:41 p.m., revealed the following Late Note for 10/23/24 (resident 3) was given a 30-day notice of discharge due to none compliance with the smoking policy, she had been given a policy and schedule time of smoking before she refused to sign the notice. Documentation to show she was given the policy prior was not in Resident 3's electronic medical record. The following progress note was written after the 30-day discharge notice was given. Progress notes by Licensed Staff written 10/23/24 at 23:44 (11:42 p.m.,) noted pt were outside by station 2 exit door smoking. Told her smoking time is over it was past 8 pm pt ignored writer. During an interview on 10/29/24 at 2:30 p.m., Resident 3 felt it unfair that 10 of the smokers were given the Notice of discharge on the same day. During a review of Resident 4's clinical record, the admission record documented Resident 4 was admitted [DATE]. Resident 4's Smoking-Safety Screen, dated 10/3/24 assessed Resident 4's ability to smoke safely. The assessment determined that Resident 4 was safe to smoke without supervision. Resident 4's Progress Notes had an entry by social services, dated 10/24/24 at 17:56 p.m., documenting Resident 4 was given a 30-day discharge notice for noncompliance with the smoking policy. Documentation to show non-compliance was not provided by staff. During a review of Resident 5's clinical record, the admission record documented Resident 5 was admitted [DATE]. Resident 5's Smoking-Safety Screen, dated 8/14/24 assessed Resident 5's ability to smoke safely. The assessment determined that Resident 5 was safe to smoke with supervision. Resident 5's Progress Notes had an entry by social services, dated 10/24/24 at 18:45 p.m., revealing the following Late Note for 10/23/24 (resident 5) was given a 30-day notice of discharge due to none compliance with the smoking policy, he had been given a policy and schedule time of smoking before. Documentation to show he was given the policy prior was not in Resident 5's electronic medical record. Documentation to show non-compliance was not provided by staff. During a review of Resident 7's clinical record, the admission record documented Resident 7 was admitted [DATE]. Resident 7's Smoking-Safety Screen, dated 8/14/24 assessed Resident 7's ability to smoke safely. The assessment determined that Resident 7 was safe to smoke without supervision. Resident 7's Progress Notes had an entry by social services, dated 10/24/24 at 18:36 p.m., revealing the following Late Note for 10/23/24 (resident 7) was given a 30-day notice of discharge due to none compliance with the smoking policy, he had been given a policy and schedule time of smoking before he became angry and belligerent with this writer and refused to sign notice of transfer. Documentation to show he was given the policy prior was not in Resident 7's electronic medical record. Documentation to show non-compliance was not provided by staff. During a review of Resident 9's clinical record, the admission record documented Resident 9 was admitted [DATE]. Resident 9's Smoking-Safety Screen, dated 8/14/24 assessed Resident 9's ability to smoke safely. The assessment determined that Resident 9 was safe to smoke with supervision. Resident 9's Progress Notes had an entry by social services, dated 10/24/24 at 18:10 p.m., documenting Resident 9 was given a 30-day discharge notice for noncompliance with the smoking policy. This note indicated that Resident 9 had a past incident of noncompliance, (date not included.) No other Documentation to show non-compliance was provided by staff. During a review of Resident 11's clinical record, the admission record documented Resident 11 was admitted [DATE]. Resident 11's Smoking-Safety Screen, dated 8/14/24 assessed Resident 11's ability to smoke safely. The assessment determined that Resident 11 was safe to smoke with supervision. Resident 11's Progress Notes had an entry by social services, dated 10/24/24 at 1846 p.m., revealed the following Late Note for 10/23/24 (resident 11) was given a 30-day notice of discharge due to none compliance with the smoking policy, she had been given a policy and schedule time of smoking before. Documentation to show she was given the policy prior was not in Resident 11's electronic medical record. Documentation to show non-compliance was not provided by staff. During an interview on 10/29/24 at 2:55 p.m., Resident 11 stated that she remembered that a brief mention about the smoking policy was made at a Resident Council meeting. Resident 11 stated the director handed out copies of the policy but does not have a copy now. Resident 11 thought they started enforcement about 3 weeks ago. Resident 11 stated she does not like the policy because she would go out to smoke in the evening if her roommates were having troubles. Resident 11 stated she did not have anywhere she could go to if discharged . During a review of Resident 12's clinical record, the admission record documented Resident 12 was admitted [DATE]. Resident 12's Smoking-Safety Screen, dated 8/14/24 assessed Resident 12's ability to smoke safely. The assessment determined that Resident 12 was safe to smoke with supervision. A social service progress note dated 9/26/24 at 14:53 documented This writer meet with resident today and provide him with a copy of smoking policy and smoking schedule and offer her the a patch if she wants, discus that if she dose not follow schedule will be given a 30 day notice to discharge per admiration. Resident refused to sign; she is always safe and leaving in a few das any way. Documentation to show non-compliance was not provided by staff. Resident 12's Progress Notes had an entry by social services, dated 10/24/24 at 18:21 p.m., revealing the following Late Note for 10/23/24 (resident 12) was given a 30-day notice of discharge due to none compliance with the smoking policy, he had been given a policy and schedule time of smoking before. During a review of Resident 13's clinical record, the admission record documented Resident 13 was admitted /26/24. Resident 13's Smoking-Safety Screen, dated 8/14/24 assessed Resident 13's ability to smoke safely. The assessment determined that Resident 13 was safe to smoke with supervision. Resident 13's Progress Notes had an entry by social services, dated 10/24/24 at 18:07 p.m., revealing the following Late Note for 10/23/24 (resident 13) was given a 30-day notice of discharge due to none compliance with the smoking policy, she had been given a policy and schedule time of smoking before. He requested a nicotine patch will provide when available. Documentation to show he was given the policy prior was not in Resident 13's electronic medical record. Documentation to show non-compliance was not provided by staff. During an interview on 12/3/24 at 4:15 p.m., Social Services Director (SSD) stated she was directed to issue 30-day discharge or transfer notice to a list of residents because of non-compliance with the smoking policy. SSD confirmed the notice was given to each resident on the same day. SSD indicated staff had been monitoring the residents for compliance with the smoking policy for some time. During an interview on 12/3/24 at 4:05 p.m., Administrator stated the 30-day notice of transfer discharge was sent to the residence to encourage compliance with the smoking policy. Administrator indicated finding appropriate placement for these residents would be difficult to accomplish. During a review of the facilities policy and procedure titled, Transfer and Discharge Facility Initiated, dated 10/2022, indicated Once admitted to the facility, residents have the right to remain in the facility. Facility -initiated transfers and discharges, when necessary, must meet specific criteria . each resident will be permitted to remain in the facility and not be transferred or discharged unless . c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident and d. the health of individuals in the facility would otherwise be endangered . The policy also indicated that the grounds for transfer or discharge must be in the medical record.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement the interventions to reduce the risk of elopement (leaving the facility without knowledge of the staff) for one of one sampled resident (Resident 1), who left the facility, undetected, and was found on a busy street. A bystander stayed with him until the emergency responders arrived. This failure had the potential to result in serious injuries, including bruises, lacerations, head injury and broken bones. Findings: During a review of Resident 1's admission Record, printed 9/16/24, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. This record indicated Resident 1's most recent hospital stay was 4/26/24 to 7/24/24. Resident 1's principal diagnosis was Unspecified dementia, unspecified severity, with other behavioral disturbance (impaired memory and judgement). During a review of Resident 1's medical records, on 9/16/24, a SBAR (Situation, Background, Assessment, and Request) Communication Form and Progress Note, dated 4/24/24, documented the following: Situation, Resident 1 was, having episodes of wanting to leave, and he gets angry, upset and physically aggressive. Background documented his diagnosis of dementia, and he was very impulsive and hard to be re-directed (to change his focus). The request made was to transfer Resident 1 to an acute care hospital. During a review of Resident 1's medical records, on 9/16/24, Resident 1's admission Record indicated the date of readmission as 7/24/24. Resident 1's Wandering Risk Scale (to assess risk of elopement) was done on 7/24/24. Resident 1 was found to be a High Risk to Wander. Resident 1's score was 17, and the scale's scoring showed 11 and above was a High Risk to Wander. During a review of Resident 1's medical records, on 9/16/24, Resident 1's Care Plan documented the Problem: Resident has impaired cognitive function with a goal that resident will be able to communicate basic needs on a daily basis through the review date. This was initiated on 7/30/24. On 8/27/24, an On-Line Health Facility Complaint from the Ombudsman reported, Resident walked out of the facility and didn't know where he was. A mile away from North Bay, He was ringing door bells and North Bay didn't know that [Resident 1's name] was missing. Safe Team was called and returned [Resident 1's name] to the facility. North Bay has not reported this incident to the Ombudsman. The compliant indicated the event occurred on 8/19/24. During a review of Resident 1's medical records, one, Progress Note, documented the event. The Social Services staff documented to the Progress Notes on 8/19/24 at 6:41 p.m. Resident was not seen in facility staff went out looking for him shortly after the safe team brought resident back they drop him off they left without given [sic] any report to staff resident said he was looking for cigarettes. Wife is aware . During an Interview on 9/16/24 at 2:50 p.m., the Licensed Nurse (Registry Staff) who was assigned Resident 1 on 8/19/24, was called. The Licensed Nurse stated she did not remember one of her residents Eloping on the day she worked for the facility. The Licensed Nurse stated she did remember hearing that a resident had left and came back. She recalled a resident telling staff he did want to stay at the facility but does not remember which resident. During a review of Resident 1's medical records, a Wandering Risk scale was done 8/19/24. An order by the doctor to monitor and use the wander guard system (a bracelet for residents to wear which sets off the alarm at exit doors) was made 8/19/24. Resident 1's Care Plan was updated on 8/19/24, with the Problem: Resident is an elopement risk/wanderer, and the goal was, Resident will not leave facility unattended. Interventions included monitoring for wandering, provide structured activities and Wander Alert on Left Wrist. During a review of Resident 1's medical records, Resident 1's Medication Administration Record for 8/2024, had the following order, dated 8/19/24. Monitor wander guard placement every shift. The documentation for nursing to indicate this was done started 8/19/24, on the evening shift. During an interview on 9/13/24 at 4 p.m., the Administrator stated he was aware Resident 1 had eloped. The Administrator stated Resident 1 had been wearing a wander guard since the event. The Administrator stated the facility hired a receptionist to help monitor the entry and hired other staff. An in-service on Prevention of Elopement was conducted. During an interview on 9/16/24 at 4 p.m., the Administrator stated the facility was aware Resident 1 was an elopement risk and had expected nursing to write the care plan and implement measures to prevent elopement. The Administrator stated he investigated the event and learned the care plan and measures to reduce the risk for elopement had not been initiated. During a review of the facility's Elopement Prevention Policy, dated 8/2024, the policy indicated, It is our policy to identify residents at risk and intervene accordingly, and to establish a plan of care when risk factors are present .Upon admission, residents who are cognitively impaired and independently mobile .and/or have a history of wandering or elopement will have elopement risk evaluation completed. Residents found at risk are to have the care plan written to address this risk. Based on interviews and record reviews, the facility failed to implement the interventions to reduce the risk of elopement (leaving the facility without knowledge of the staff) for one of one sampled resident (Resident 1), who left the facility, undetected, and was found on a busy street. A bystander stayed with him until the emergency responders arrived. This failure had the potential to result in serious injuries, including bruises, lacerations, head injury and broken bones. Findings: During a review of Resident 1's admission Record, printed 9/16/24, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. This record indicated Resident 1's most recent hospital stay was 4/26/24 to 7/24/24. Resident 1's principal diagnosis was Unspecified dementia, unspecified severity, with other behavioral disturbance (impaired memory and judgement). During a review of Resident 1's medical records, on 9/16/24, a SBAR (Situation, Background, Assessment, and Request) Communication Form and Progress Note, dated 4/24/24, documented the following: Situation, Resident 1 was, having episodes of wanting to leave, and he gets angry, upset and physically aggressive. Background documented his diagnosis of dementia, and he was very impulsive and hard to be re-directed (to change his focus). The request made was to transfer Resident 1 to an acute care hospital. During a review of Resident 1's medical records, on 9/16/24, Resident 1's admission Record indicated the date of readmission as 7/24/24. Resident 1's Wandering Risk Scale (to assess risk of elopement) was done on 7/24/24. Resident 1 was found to be a High Risk to Wander. Resident 1's score was 17, and the scale's scoring showed 11 and above was a High Risk to Wander. During a review of Resident 1's medical records, on 9/16/24, Resident 1's Care Plan documented the Problem: Resident has impaired cognitive function with a goal that resident will be able to communicate basic needs on a daily basis through the review date. This was initiated on 7/30/24. On 8/27/24, an On-Line Health Facility Complaint from the Ombudsman reported, Resident walked out of the facility and didn't know where he was. A mile away from North Bay, He was ringing door bells and North Bay didn't know that [Resident 1's name] was missing. Safe Team was called and returned [Resident 1's name] to the facility. North Bay has not reported this incident to the Ombudsman. The compliant indicated the event occurred on 8/19/24. During a review of Resident 1's medical records, one, Progress Note, documented the event. The Social Services staff documented to the Progress Notes on 8/19/24 at 6:41 p.m. Resident was not seen in facility staff went out looking for him shortly after the safe team brought resident back they drop him off they left without given [sic] any report to staff resident said he was looking for cigarettes. Wife is aware . During an Interview on 9/16/24 at 2:50 p.m., the Licensed Nurse (Registry Staff) who was assigned Resident 1 on 8/19/24, was called. The Licensed Nurse stated she did not remember one of her residents Eloping on the day she worked for the facility. The Licensed Nurse stated she did remember hearing that a resident had left and came back. She recalled a resident telling staff he did want to stay at the facility but does not remember which resident. During a review of Resident 1's medical records, a Wandering Risk scale was done 8/19/24. An order by the doctor to monitor and use the wander guard system (a bracelet for residents to wear which sets off the alarm at exit doors) was made 8/19/24. Resident 1's Care Plan was updated on 8/19/24, with the Problem: Resident is an elopement risk/wanderer, and the goal was, Resident will not leave facility unattended. Interventions included monitoring for wandering, provide structured activities and Wander Alert on Left Wrist. During a review of Resident 1's medical records, Resident 1's Medication Administration Record for 8/2024, had the following order, dated 8/19/24. Monitor wander guard placement every shift. The documentation for nursing to indicate this was done started 8/19/24, on the evening shift. During an interview on 9/13/24 at 4 p.m., the Administrator stated he was aware Resident 1 had eloped. The Administrator stated Resident 1 had been wearing a wander guard since the event. The Administrator stated the facility hired a receptionist to help monitor the entry and hired other staff. An in-service on Prevention of Elopement was conducted. During an interview on 9/16/24 at 4 p.m., the Administrator stated the facility was aware Resident 1 was an elopement risk and had expected nursing to write the care plan and implement measures to prevent elopement. The Administrator stated he investigated the event and learned the care plan and measures to reduce the risk for elopement had not been initiated. During a review of the facility's Elopement Prevention Policy, dated 8/2024, the policy indicated, It is our policy to identify residents at risk and intervene accordingly, and to establish a plan of care when risk factors are present .Upon admission, residents who are cognitively impaired and independently mobile .and/or have a history of wandering or elopement will have elopement risk evaluation completed. Residents found at risk are to have the care plan written to address this risk.

May 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (decision maker) (wife) for one of two samepled residents (Resident 1) of the intention to transfer the resident to the hospital. Resident 1's Responsible Party stated she did not know her husband was at the hospital until he called her (with help from the hospital staff.) This failure to notify the Responsible Party in writing and in advance of the reason for transfer disregarded Resident/Responsible Party's right to be informed and to participate in the resident's care. Findings: During a review of Residents 1's medical record on 5/15/24, Resident 1's admission Record, dated 5/15/24, indicated Resident 1 was a veteran with medical coverage from the Veterans Administration (VA.) Resident 1's diagnosis included dementia with other behavioral disturbance, diabetes, hypertension, and unspecified mood disorder. During an interview on 5/15/24 at 3:00 p.m., Infection Preventionist (IP) stated that they had an unscheduled meeting on4/24/24 with the Social Worker from the VA and discussed the need to continue to have a one-on-one staff person with Resident 1. IP stated the facility found Resident 1 to be more aggressive with his wandering behavior and needed the sitter or to be sent to the VA Hospital. IP stated the Social Worker from the VA told the facility to do what they needed to do. During a review of Resident 1's progress notes, nurse progress notes from 4/25/24 at 19:33 (7:33 p.m.) documented at 1730 resident was transported to (hospital) along with his belongings and medications. Resident vital signs stable, denies pain, no sob, compliant with transfer. During a review of Residents 1's medical record on 5/15/24 Resident 1's Quarterly Social Service evaluation dated 4/18/24 documented Resident 1's behavior and need for a one-on-one staff to monitor him. This evaluation did not indicate that the facility could not meet his needs and possible transfer to another facility. During a review of Resident 1's progress notes, the social services progress notes for 4/24/24 at 5:44 p.m., indicated a voice mail message was left for Resident 1's responsible Party that the facility could not meet his needs. During a review of Resident 1's progress notes, nurse progress notes for 4/25/24 at 1:40 p.m., indicated a message was left to tell Resident 1's responsible Party he would be transferred to the hospital in the evening. During a telephone interview on 6/18/24 at 1:50 p.m., Resident 1's Responsible Party stated she had not been made aware in [NAME] or in writing that Resident 1 had been transferred to the VA Hospital until Saturday when the hospital facilitated a call between her and her spouse (Resident 1.) Resident 1's Responsible Party stated she did not get any calls from the facility and did not see any messages. She stated she still does not understand why the facility transferred him to the hospital.

Apr 2024 5 deficiencies 1 IJ (1 facility-wide)

CRITICAL (L) 📢 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

Food Safety (Tag F0812)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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Based on observation, interview, and record review, the facility failed to maintain a sanitary environment for food storage and preparation when the kitchen where the residents' food was stored and prepared was found to be infested with rats. This failure resulted in 90 out of 90 residents being served food that had been prepared in a kitchen contaminated with rat droppings and urine. On 4/3/24 at 11:06 a.m., due to the facility's failure to maintain sanitary conditions in the kitchen for food storage and preparation, Administrator and Director of Nursing (DON) were verbally notified of the Immediate Jeopardy. The Health Facilities Evaluator Nurse informed Administrator and DON of the surveyor's findings that rat droppings and gnawed food in the kitchen indicated a rat infestation and residents could not be served food from the kitchen. Lunchtime was in one hour and resident needed a meal to be served from an alternative source. Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident (State Operations Manual, Appendix Q). On 4/11/24 at 12:56 p.m., the facility presented a corrective plan of action, including but not limited to: 1) discarded all contaminated food, 2) food for residents to be prepared off site and delivered to the facility, 3) pest control service every three days and increased rat bait stations until no more activity, 4) hired additional pest control company for rat exclusion work. On 4/15/24 at 4:05 p.m., the removal of Immediate Jeopardy occurred in the presence of Administrator after interviews, observations, and record review confirmed the facility implemented the corrective plan of action. The facility kitchen remained closed for all food preparation and distribution at the time of the exit conference. Findings: During an observation and concurrent interview on 4/3/24 at 9:36 a.m. in the facility kitchen, kitchen staff were preparing food. When queried, [NAME] A stated the dietary manager was out of the country for the past month. Several dark brown droppings were under the ware washing area (area of the kitchen for rinsing and washing pots, pans, and dishes). When queried, Director of Nursing (DON) stated they were droppings. More droppings were under the two-compartment sink, the steam table (appliance used to keep food warm while it is being plated for residents' meals), under the ice machine, and in the dry storage area under shelves of food and on food. Dietary Aide B stated the droppings were rat poop. She stated she had been seeing the droppings in the kitchen for two months. In the dry storage area, multiple food items had been gnawed on, including bananas, a loaf of wheat bread, and a bag of spaghetti. DON verified the food items had been gnawed on and she saw the droppings on the food. DON stated that at a recent stand-up meeting someone had mentioned that they had had to throw away food from the kitchen. On returning to the kitchen from the dry storage area, Dietary Aide B was noted to be preparing sandwiches with wheat bread. During an interview on 4/3/24 at 9:58 a.m., Administrator stated the pest control company had been out to the facility numerous times for reports of rodents in the kitchen. Administrator stated the last time the pest control company was on site was last week. When asked the last time he had been in the kitchen to check for signs of rodents, Administrator stated last week. During a record review and concurrent interview on 4/3/24 at 10:05 a.m., Maintenance Director stated he had been getting complaints of rats in the kitchen for two weeks. When asked how he responded to the complaints, he stated he put poison baits in the kitchen under the dishwasher because they had a nest in the wall under there. He stated he opened the wall behind the dishwashing area and put poison in the nest. He also put steel wool and spray foam in the holes where they were coming in, but he had noticed this morning they were gnawing on the foam. Maintenance Director stated he did see the droppings under the ware washing area this morning. When asked if he told anyone, he said he told the dietary aide. When asked if he called the pest control company, Maintenance Director stated, No, not yet. Review of the pest control visit documentation revealed they had not been to the facility since 3/19/24. Maintenance Director stated he had received complaints from the kitchen staff that there were droppings or gnawed food every day since 3/19/24. The 3/19/24 pest control report indicated a rat was removed from the premises. During an observation on 4/3/24 at 10:20 a.m., Maintenance Director indicated the patched wall where he had found the rats' nest just outside the staff breakroom door. An area approximately 2 feet wide and 1.5 feet high just above the floor was patched over with spackle. On the other side of the wall was the ware washing area of the kitchen. During an interview on 4/3/24 at 11:20 a.m., Infection Preventionist (IP) stated the last time she was in the kitchen was to observe the maintenance staff perform the ice machine cleaning process. IP stated she was not doing a kitchen inspection at that time. IP stated she did rounds twice a month in the kitchen. She stated she had not gotten any complaints of rats from kitchen staff, but she heard they recently caught one. When asked about potential harm to residents with a rat infestation in the kitchen, IP stated rats carried disease, and verified residents could be exposed. IP was shown a photo this surveyor took of the rat droppings in the kitchen. IP verified the kitchen staff cleaned the kitchen every evening, so the droppings were from rats in the kitchen last night. During a phone interview on 4/3/24 at 11:30 a.m., the pest control company's customer service stated that during the last six months the facility had called in reports of rat activity in the kitchen on 11/27/23, 12/19/23, 2/20/24, 2/28/24, 2/29/24, 3/8/24, and 3/19/24. During an interview on 4/3/24 at 11:30 a.m., [NAME] C stated he had been noticing gnawed food in dry storage for two months. During an interview on 4/3/24 at 12:47 p.m., Pest Control Service Specialist was on site and stated that he was assigned this account at the beginning of March 2024. He stated he was last at the facility on 3/19/24 for an extra service request to remove a trapped rat. He stated he did not look in dry storage or under the dishwasher or sink during that visit. He stated he did look in dry storage during his visit on 3/8/24 and saw rat droppings at the time. When asked how he responded to finding rat droppings in dry storage, Pest Control Service Specialist stated he told the staff to clean them up. He stated that today (4/3/24) he found a hole and saw droppings under the dishwasher, he found holes on either side of the kitchen back door, he saw droppings in dry storage and gnawed food. Pest Control Service Specialist verified there had been rats in the facility kitchen. Pest Control Service Specialist stated he set additional traps in the kitchen and the facility would now be on escalation which means visits every three days. He stated to get off escalation the facility would have to have three visits with no catches and his manager must do a final walk-through. Pest Control Service Specialist stated he did not know if the facility had been on escalation before since he was new to the account, but the facility had not been on escalation since he was assigned at the beginning of March 2024. During an observation and concurrent interview on 4/3/24 at 1:10 p.m., County Health Inspector (CHI) D arrived at the facility and inspected the kitchen. CHI D verified the presence of rat droppings and gnawed food in the kitchen, including a bag of hamburger buns, a box of creamy wheat, a bag of corn meal, a bag of pancake mix, a bag of raisin bran cereal, and a box of salt. A tray of coffee mugs, boxes of food, and canned goods also had rat droppings on them. A white cardboard box on a shelf in dry storage had a yellowish dried liquid stain on the top that CHI D stated was likely rat urine. During an interview on 4/3/24 at 1:39 p.m., Registered Dietitian (RD) stated she did kitchen inspections twice a month. RD denied seeing any signs of rat activity or staff reporting rat activity to her. During an interview on 4/3/24 at 2:13 p.m., CHI D stated that due to the rat infestation, the facility kitchen could not be used to prepare or distribute food, and food for the residents needed to be obtained from an outside source until further notice. During a record review on 4/4/24 at 8 a.m., CHI D's emailed report of the facility's inspection titled, Permanent Food Facility Inspection Report, dated 4/3/24, indicated, Placard Status: Red – closed; suspension of permit to operate. The report further indicated major violations cited included rodents inside the facility, contaminated and adulterated food, food contact surfaces not cleaned and sanitized as required, and improper hot and cold holding temperatures for food. During an observation and concurrent interview on 4/6/24 at 5:14 p.m., County Health Inspector (CHI) J arrived at the facility and inspected the kitchen. CHI J verified water damaged wall under the ware washing station had been repaired with spray foam and wood and could be chewed through by rats. CHI J pointed out dried, grayish rat droppings on the floor behind the supports holding the ware washing station. CHI J stated the area behind the oven repaired with plaster could also be chewed through by rats. More dried, grayish rat droppings noted on the floor behind the cook line. CHI J verified the droppings looked old and had been there for some time. During an interview on 4/10/24 at 2:30 p.m., Dietary Manager stated he just got back from a month-long vacation. Dietary Manager denied any knowledge of the calls to the pest control company since November 2024. He stated that all he knew was the pest control guy came and put down the traps prior to his vacaton. When queried, Dietary Manager stated if the kitchen staff saw any signs of rodents while he was on vacation, they should have reported it to Administrator and cleaned it up. During an interview on 4/25/24 at 1:13 p.m., RD stated she did not know who had oversight of the kitchen while Dietary Manager was away for a month. During an interview on 4/30/24 at 10:50 a.m., Administrator stated that while Dietary Manager was away RD had oversight of the kitchen. Review of facility policy Food Receiving and Storage, revised 11/2022, indicated, Non-refrigerated foods . are stored in a designated 'dry storage' unit which is temperature and humidity controlled, free of insects and rodents and kept clean. Review of facility policy Food Preparation and Service, revised 11/2022, indicated, Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. Review of the Food and Drug Administration (FDA) Food Code, last revised 2022, Chapter 6: Physical Facilities indicated, 6-202.16 Exterior Walls and Roofs, Protective Barrier. Perimeter walls and roofs of a FOOD ESTABLISHMENT shall effectively protect the establishment from the weather and the entry of insects, rodents, and other animals. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; Pf and (D) Eliminating harborage conditions.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to adequately staff the Noc shift (10:30 p.m. to 6:30 a.m.) when the registry nurses scheduled to work Noc shift did not report to work three nights in a row. This failure resulted in three nurses working a triple shift (three consecutive 8-hour shifts) for those three days, potentially putting residents at risk of medication errors or delay in care when nurses caring for the residents are too fatigued to accurately follow physician orders or provide care. Findings: During a record review and concurrent interview on 4/3/24 at 3:22 p.m., facility staffing assignment sheet for 3/17/24 revealed Licensed Nurse E worked AM shift (6:30 a.m. to 3:30 p.m.), PM shift (3:30 p.m. to 11:30 p.m.), and Noc shift. Review of staffing assignment sheet for 3/18/24 revealed Licensed Nurse F worked AM shift, PM shift, and Noc shift. Director of Nursing (DON) verified Licensed Nurses E and F worked 24-hours straight on those two days. DON stated Licensed Nurse G also worked 24 hours on 3/19/24. DON stated the nurses all worked double shifts (16 hours) and then the Noc nurse did not show, so the nurses stayed to cover the Noc shift. DON stated she did not know about it until after it happened. She stated she came into work early on 3/18/24 to check in with the Noc shift staff and was surprised to see Licensed Nurse E was still there. DON stated the staff tried to reach her to let her know the registry nurse that was scheduled did not report to work, but she had her phone on sleep mode, so it did not ring. DON stated she worked with Staffing Coordinator and told her this could not happen again. DON stated then it happened again (3/18/24). DON stated the staff tried again to call her, but her phone did not ring. DON stated Staffing Coordinator called the registry on 3/19/24 and they promised the nurse scheduled that night would show, but then it happened a third time (3/19/24). When queried, DON stated working for 24 hours straight was not safe, especially for nurses, You get tired. During an interview on 4/17/24 at 11 a.m., Licensed Nurse E verified that on 3/17/24 he worked a 24-hour shift. He stated that he clocked into work at about 6:40 a.m. and clocked out at about 7:10 a.m. the next day on Monday. Licensed Nurse E stated he was scheduled to work a double shift due to short staffing, then unfortunately the nurse who was supposed to work Noc did not show. Licensed Nurse E stated he tried to contact the scheduler, and no one answered, and he tried to call other colleagues to see if they could come, but no one could come in. Licensed Nurse E stated, I couldn't leave my colleague with over 90 patients alone, so I decided to stay. When queried, Licensed Nurse E stated the nurses were not supposed to put themselves in that position where they were compromised and might make errors. He stated he was not allowed to work 24 hours straight because it was not safe to staff or patients. During an interview on 4/17/24 at 11:18 a.m., Licensed Nurse G verified he worked a 24-hour shift last month. He stated he did not want to leave his patients and leave the other nurse by herself. Licensed Nurse G stated a registry nurse was supposed to come but did not come. Licensed Nurse G stated he came in at 6 a.m. and clocked out at 7 a.m. the next day. He stated it was unexpected but felt he was able to do it to help out. Licensed Nurse G stated he was not allowed to work 24 hours straight. He stated it was not safe for one's health or for the patients. He stated nurses had to read the medication, give the right medication, you might make a mistake. Licensed Nurse G stated he did not talk to anyone (facility leadership) about working the triple shift. During an interview on 4/17/24 at 1:32 p.m., Staffing Coordinator stated she recalled that on 3/17/24 she went to bed at 8 p.m. to wake up early, so when the staff texted her at 10 p.m. (to tell her the registry nurse was not coming) she was asleep already. Staffing Coordinator stated that when she found out in the morning that the registry nurse did not report to work, she called the registry right away to tell them, This is unacceptable. Staffing Coordinator stated the registry always gave her a back-up (staff), but she could only access that information in the portal from the office. She had no access to the portal at home. When asked how she responded the second time the registry nurse did not report to work, Staffing Coordinator stated she called the registry and told them they needed to replace staff right away when they could not come in for their shift. When asked if anyone called to verify the nurse showed up for Noc shift that second night, Staffing Coordinator stated, No. Staffing Coordinator stated that when the registry nurse that was scheduled did not show on the third night, the nurse was a no call no show (did not report to work and did not call to explain why). Staffing Coordinator stated that when she found out, she told the registry she did not want that nurse back, she needed reliable nurses. When asked if staff were allowed to work 24 hours straight, Staffing Coordinator stated she was not sure. During an interview on 4/17/24 at 1:45 p.m., Staff H stated Licensed Nurse G worked a 24-hour shift on 3/19/24. Staff H verified this happened three nights in a row where the registry nurses scheduled to work did not show up for their shift. During an interview on 4/17/24 at 2:38 p.m., Licensed Nurse F stated she was a treatment nurse. Licensed Nurse F stated she recalled that on 3/18/24 she came in at 8 a.m., then one nurse called out (sick) so she ended up passing medications to residents instead of starting the wound treatments. She stated she did the treatments in the afternoon, but then they got a phone call around 11:30 p.m. that the registry nurse was not coming in for the Noc shift. Licensed Nurse F stated three of the nurses were working double shifts that day, so she stayed to cover the registry nurse that called out. When queried, Licensed Nurse F stated she did not want to drive home in the morning, so her son picked her up and she slept almost all day. She stated she was not allowed to work 24 hours straight, but she did not want to leave her coworker by herself, and she did not want to leave her patients without a nurse. When asked about the safety of working a 24-hour shift, Licensed Nurse F stated, I don't think it's safe because we're human. It was a hard choice. She stated it was hard to be awake during the night, and if you're not careful you can do med (medication) errors. Licensed Nurse F stated when she realized she had to stay and work through the night, she called the person who does the schedule, but she did not answer. She stated she also texted both DON and Administrator around midnight that she was going to stay but got no response to her texts. During an interview on 4/17/24 at 1:09 p.m., Medical Director stated she was not aware that three nurses had worked 24-hour shifts in March. When asked about the safety of nurses working 24-hour shifts, Medical Director stated it was not safe because nurses did med pass, and they had to take care of people. She stated that if the nurses were too sleepy to work, their response time would be slow. She stated it put the nurses at risk of falling asleep without knowing it. Medical Director stated people did not fall asleep while they were driving because they decided to take a nap, they fell asleep without knowing it. She stated that could happen when a nurse was sitting in a chair at a computer, which would result in a delay in care. When asked if a root cause analysis should be done, Medical Director stated, Yes, always do a root cause analysis. There has to be improvement. During an interview on 4/30/24 at 1:43 p.m., Administrator stated he had heard that a nurse had worked a 24-hour shift but was not aware it had happened three days in a row. When queried, Administrator stated the DON should have come in and worked the shift. Administrator stated a root cause analysis of the nurses working 24-hour shifts had not been done and did not know how a root cause analysis would be part of this occurrence. Review of Licensed Nurse E's time sheet for 3/17/24 indicated he clocked in at 6:37 a.m. and clocked out at 7:17 a.m. on 3/18/24, for a total shift of 24 hours and 40 minutes with 30-minute breaks at 6:25 p.m. and 3 a.m. Review of Licensed Nurse F's time sheet for 3/18/24 indicated she clocked in at 8:16 a.m. and clocked out at 8:30 a.m. on 3/19/24, for a total shift of 24 hours and 14 minutes with 30-minute breaks at 12 p.m., 7:39 p.m., and 2:57 a.m. Review of Licensed Nurse G's time sheet for 3/19/24 indicated he clocked in at 6:06 a.m. and clocked out at 7 a.m. on 3/20/24, for a total shift of 24 hours and 54 minutes with 30-minute breaks at 10:12 a.m. and 7 p.m. Review of facility staffing assignment sheet dated 3/19/24 indicated Licensed Nurse G was scheduled for AM shift and PM shift. The Noc shift assignment sheet had one of the Noc shift nurse's name crossed out with Licensed Nurse G's name written to the side. Review of facility policy Staffing, Sufficient and Competent Nursing, revised 8/2022, indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment.

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

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Based on observation interview and record review the facility failed to store garbage in a manner that made it inaccessible to pests. This failure potentially contributed to a rat infestation in the kitchen. Finding: During an observation on 4/3/24 at 9:34 a.m., a dumpster on the side of the facility, approximately 20 feet from the kitchen door, had the lid propped open with a long stick. The facility's dumpster area was surrounded by extensive overgrowth of English ivy. A photo of the dumpster was obtained. During a phone interview on 4/3/24 at 11:20 a.m., the pest control company's customer service stated that during the last six months the facility had called in reports of rat activity in the kitchen on 11/27/23, 12/19/23, 2/20/24, 2/28/24, 2/29/24, 3/8/24, and 3/19/24. During an interview on 4/3/24 at 11:30 a.m., [NAME] C stated he had been noticing gnawed food in dry storage for two months. During an interview on 4/3/24 at 12:47 p.m., Pest Control Service Specialist D was on site and stated that he was assigned this account at the beginning of March 2024. He stated he was last at the facility on 3/19/24 for an extra service request to remove a trapped rat. He stated he looked in dry storage during his visit on 3/8/24 and saw rat droppings at the time. He stated that today (4/3/24) he found a hole and saw droppings under the dishwasher, he found holes on either side of the kitchen back door, he saw droppings in dry storage and gnawed food. Pest Control Service Specialist D verified there had been rats in the facility kitchen. During an observation on 4/4/24 at 11:39 a.m., the dumpster on the side of the facility outside the kitchen door was propped open with a long stick and piled high with clear bags full of used Styrofoam food containers. During an observation and concurrent interview on 4/6/24 at 5:40 p.m. with Registered Dietitian, a staff member put a clear garbage bag of Styrofoam food containers in the dumpster and pushed the lid down, but the lid popped back up approximately 6 to 8 inches because the dumpster was so full of garbage. Ivy was still surrounding the dumpster area. Registered Dietitian verified the need to cut back the ivy to prevent rats. During an interview on 4/10/24 at 2:30 p.m., Dietary Manager was shown the photos of the facility's dumpster taken on 4/3/24 and 4/4/24. Dietary Manager verified the dumpster should not be propped open. When queried, Dietary Manager stated the reason the dumpster should not be open was to keep rodents out. Review of the Food and Drug Administration (FDA) Food Code, last revised 2022, Chapter 5: Water, Plumbing and Waste, subsection 5-5 Refuse, Returnables, and Recyclables revealed, 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 5-502.11 Frequency. REFUSE, recyclables, and returnables shall be removed from the PREMISES at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents.

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

Administration (Tag F0835)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility administrator failed to 1. Follow up on reports of rats in the facility kitchen to ensure the pest control company was controlling the rats, 2. Follow up on letters from the county health department requesting a plan to address code compliance issues in the kitchen (dating back to 8/2023), and 3. Ensure the staffing agency sent nurses to cover shifts as agreed upon. These failures resulted in the facility's kitchen closing for several weeks requiring food to be obtained from an outside source for the residents, and also resulted in nurses working 24-shifts to cover for registry nurses who did not report to work. Findings: 1. During an observation and concurrent interview on 4/3/24 at 9:36 a.m. in the facility kitchen, kitchen staff were preparing food. Several dark brown droppings were under the ware washing area (area of the kitchen for rinsing and washing pots, pans, and dishes). More droppings were under the two-compartment sink, the steam table (appliance used to keep food warm while it is being plated for residents' meals), under the ice machine, and in the dry storage area under shelves of food and on food. Dietary Aide B stated the droppings were rat poop. She stated she had been seeing the droppings in the kitchen for two months. In the dry storage area, multiple food items had been gnawed on, including bananas, a loaf of wheat bread, and a bag of spaghetti. During an interview on 4/3/24 at 9:58 a.m., Administrator stated he knew about the rat problem in the kitchen, and he had had pest control come out numerous times to address it. Administrator stated the last time pest control was at the facility was a week ago. When queried, Administrator stated that the last time he had checked the kitchen to see if the pest control company's efforts to control the rats were effective was one week ago. During a record review and concurrent interview on 4/3/24 at 10:05 a.m., Maintenance Director stated he had been getting complaints of rats in the kitchen for two weeks. Review of the pest control visit documentation revealed they had not been to the facility since 3/19/24 (15 days earlier). Maintenance Director stated he had received complaints from the kitchen staff that there were droppings or gnawed food every day since 3/19/24. The 3/19/24 pest control report indicated that during the visit a rat was removed from the facility. During a phone interview on 4/3/24 at 11:30 a.m., the pest control company's customer service stated that during the last six months the facility had called in reports of rat activity in the kitchen on 11/27/23, 12/19/23, 2/20/24, 2/28/24, 2/29/24, 3/8/24, and 3/19/24. During an interview on 4/30/24 at 10:50 a.m., Administrator stated he had ultimate oversight of the pest control program. Administrator stated he did not know about the five calls to the pest control company reporting rodent activity in February and March. Administrator stated he did not have a copy of the contract with the pest control company and had just requested one from the company. Review of facility job description, Administrator, signed by Administrator on 1/4/21, under section Essential Job Functions indicated, Ensure that the facility is maintaining all policies and procedures through regular inspections and walkthroughs; urgently develop action plans to correct any deficiencies. 2. During a record review on 4/4/24 at 8 a.m., County Health Inspector (CHI) D's emailed report of the facility's kitchen inspection titled, Permanent Food Facility Inspection Report, dated 4/3/24, indicated, Placard Status: Red – closed; suspension of permit to operate. The report further indicated major violations cited included rodents inside the facility, contaminated and adulterated food, food contact surfaces not cleaned and sanitized as required, and improper hot and cold holding temperatures for food. During a review of an email on 4/5/24 at 5:22 p.m., CHI D indicated the facility's kitchen permit would remain suspended until the facility worked with a licensed contractor to address code compliance issues detailed in an 8/9/23 county inspection report and a plan review correction letter sent on 12/4/23, and the county health department had completed an on-site visit to verify the work. During an observation and concurrent interview on 4/6/24 at 5:14 p.m., CHI J arrived at the facility and inspected the kitchen. CHI J verified water damage under the ware washing station had been repaired with spray foam and wood. CHI J stated the repair was not up to code because the foam and wood were not smooth, cleanable surfaces and could be chewed through by rats. CHI J stated the area behind the oven that had been repaired with plaster was also not up to code and could be chewed through by rats. CHI J pointed out the kitchen floor was so damaged that it was not cleanable. CHI J stated the facility had been notified last year that there were code compliance issues in the kitchen, but the county health department had not received a response from the facility. During an interview on 4/30/24 at 10:50 p.m., Administrator stated that after the change of ownership finally went through, the county health department came to inspect the facility kitchen in August 2023 because new owenership required a new permit (to operate the kitchen). Administrator stated the facility was given a conditional permit and the county wanted a bunch of stuff including architectural plans for a three-compartment sink. Administrator stated, They (the architectural plans) didn't get done. Review of facility job description, Administrator, signed by Administrator on 1/4/21, under section General Purpose indicated, Responsible for the day-to-day functions of the facility, ensuring compliance in accordance with local, state, federal regulations and guidelines. 3. During a record review and concurrent interview on 4/3/24 at 3:22 p.m. with Director of Nursing (DON), review of facility staffing assignment sheet for 3/17/24 revealed Licensed Nurse E worked AM shift (6:30 a.m. to 3:30 p.m.), PM shift (3:30 p.m. to 11:30 p.m.), and Noc shift (11:30 p.m. to 6:30 a.m.). Review of staffing assignment sheet for 3/18/24 revealed Licensed Nurse F worked AM shift, PM shift, and Noc shift. DON verified Licensed Nurse E and Licensed Nurse F worked 24-hours straight on those two days. DON stated Licensed Nurse G also worked 24-hours on 3/19/24. DON stated the three nurses all worked double shifts (16 hours) and then the Noc nurse did not show, so the nurses stayed to cover the shift. DON stated the staff tried to reach her on 3/17/24 to let her know the registry nurse that was scheduled did not report to work, but she had her phone on sleep mode, so it did not ring. DON stated she worked with Staffing Coordinator and told her this could not happen again. DON stated then it happened again the next night (3/18/24). DON stated the staff tried again to call her, but her phone did not ring. DON stated Staffing Coordinator called the registry and they promised the nurse scheduled that night would show, but then it happened a third time 3/19/24 (the registry Noc nurse did not show). When queried, DON stated working for 24 hours straight was not safe, especially for nurses, You get tired. During an interview on 4/17/24 at 1:09 p.m., Medical Director stated she was not aware that three nurses had worked 24-hour shifts in March. When asked about the safety of nurses working 24-hour shifts, Medical Director stated it was not safe because nurses did med (medication) pass, and they had to take care of people. She stated that if the nurses were too sleepy to work, their response time would be slow. She stated it put the nurses at risk of falling asleep without knowing it. Medical Director stated people did not fall asleep while they were driving because they decided to take a nap, they fell asleep without knowing it. She stated that could happen when a nurse was sitting in a chair at a computer, which would result in a delay in care. During an interview on 4/17/24 at 2:38 p.m., Licensed Nurse F stated she was a treatment nurse. Licensed Nurse F stated that on 3/18/24 she came in at 8 a.m., then they got a phone call around 11:30 p.m. that the registry nurse was not coming in for the Noc shift. Licensed Nurse F stated when she realized she had to stay and work through the night, she called the person who does the schedule, but she did not answer. Licensed Nurse F stated she also texted both DON and Administrator around midnight that she was going to stay but got no response to her texts. During an interview on 4/30/24 at 2:45 p.m., Administrator stated he he did not review the contract for the staffing registry and he was not involved in the facility's response to this staffing agency's failure to send staff to cover these three shifts. Administrator stated the DON and the staffing coordinator were self-sufficient. Review of facility job description, Administrator, signed by Administrator on 1/4/21, under section Essential Job Functions indicated, Assume the administrative authority, responsibility, and accountability of directing the activities, programs, and operations of the facility. Ensure that the facility is properly staffed.

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 F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when signs of a rat infestation in the kitchen were not adequately addressed. This resulted in rats contaminating the residents' food and the kitchen where food was prepared. Findings: During an observation and concurrent interview on 4/3/24 at 9:36 a.m. in the facility kitchen, kitchen staff were preparing food. When queried, [NAME] A stated the dietary manager was in [NAME] for the past month. Several dark brown droppings were under the ware washing area (area of the kitchen for rinsing and washing pots, pans, and dishes). When queried, Director of Nursing (DON) stated they were droppings. More droppings were under the two-compartment sink, the steam table (appliance used to keep food warm while it is being plated for residents' meals), under the ice machine, and in the dry storage area under shelves of food and on food. Dietary Aide B stated the droppings were rat poop. She stated she had been seeing the droppings in the kitchen for two months. In the dry storage area, multiple food items had been gnawed on, including bananas, a loaf of wheat bread, and a bag of spaghetti. DON verified the food items had been gnawed on and she saw the droppings on the food. DON stated that at a recent stand-up meeting someone had mentioned that they had had to throw away food from the kitchen. On returning to the kitchen from the dry storage area, Dietary Aide B was noted to be preparing sandwiches with wheat bread. During an interview on 4/3/24 at 9:58 a.m., Administrator stated the pest control company had been out to the facility numerous times for reports of rodents in the kitchen. Administrator stated the last time the pest control company was on site was last week. When asked the last time he had been in the kitchen to check for signs of rodents, Administrator stated last week. During a record review and concurrent interview on 4/3/24 at 10:05 a.m., Maintenance Director stated he had been getting complaints of rats in the kitchen for two weeks. When asked how he responded to the complaints, he stated he put poison baits in the kitchen under the dishwasher because they had a nest in the wall under there. He stated he opened the wall behind the dishwashing area and put poison in the nest. He also put steel wool and spray foam in the holes where they were coming in, but he had noticed this morning they were gnawing on the foam. Maintenance Director stated he did see the droppings under the dishwasher this morning. When asked if he told anyone, he said he told the dietary aide. When asked if he called the pest control company, Maintenance Director stated, No, not yet. Review of the pest control visit documentation revealed they had not been to the facility since 3/19/24. Maintenance Director stated he had received complaints from the kitchen staff that there were droppings or gnawed food every day since 3/19/24. The 3/19/24 pest control report indicated a rat was removed from the premises. During an observation on 4/3/24 at 10:20 a.m., Maintenance Director indicated the patched wall where he had found the rats' nest just outside the staff breakroom door. An area approximately 2 feet wide and 1.5 feet high just above the floor was patched over with spackle. On the other side of the wall was the ware washing area of the kitchen. During an interview on 4/3/24 at 11:20 a.m., Infection Preventionist (IP) stated the last time she was in the kitchen was to observe the maintenance staff perform the ice machine cleaning process. IP stated she was not doing a kitchen inspection at that time. IP stated she did rounds twice a month in the kitchen. She stated she had not gotten any complaints of rats from kitchen staff, but she heard they recently caught one. When asked about potential harm to residents with a rat infestation in the kitchen, IP stated rats carried disease, and verified residents could be exposed. IP was shown a photo this surveyor took of the rat droppings in the kitchen. IP verified the kitchen staff cleaned the kitchen every evening, so the droppings were from rats in the kitchen last night. During a phone interview on 4/3/24 at 11:30 a.m., the pest control company's customer service stated that during the last six months the facility had called in reports of rat activity in the kitchen on 11/27/23, 12/19/23, 2/20/24, 2/28/24, 2/29/24, 3/8/24, and 3/19/24. During an interview on 4/3/24 at 11:30 a.m., [NAME] C stated he had been noticing gnawed food in dry storage for two months. During an interview on 4/3/24 at 12:47 p.m., Pest Control Service Specialist was on site and stated that he was assigned this account at the beginning of March 2024. He stated he was last at the facility on 3/19/24 for an extra service request to remove a trapped rat. He stated he did not look in dry storage or under the dishwasher or sink during that visit. He stated he did look in dry storage during his visit on 3/8/24 and saw rat droppings at the time. When asked how he responded to finding rat droppings in dry storage, Pest Control Service Specialist stated he told the staff to clean them up. He stated that today (4/3/24) he found a hole and saw droppings under the dishwasher, he found holes on either side of the kitchen back door, he saw droppings in dry storage and gnawed food. Pest Control Service Specialist verified there had been rats in the facility kitchen. Pest Control Service Specialist stated he set additional traps in the kitchen and the facility would now be on escalation which means visits every three days. He stated to get off escalation the facility would have to have three visits with no catches and his manager must do a final walk-through. Pest Control Service Specialist stated he did not know if the facility had been on escalation before since he was new to the account, but the facility had not been on escalation since he was assigned at the beginning of March 2024. During an observation and concurrent interview on 4/3/24 at 1:10 p.m., County Health Inspector (CHI) D arrived at the facility and inspected the kitchen. CHI D verified the presence of rat droppings and gnawed food in the kitchen, including a bag of hamburger buns, a box of creamy wheat, a bag of corn meal, a bag of pancake mix, a bag of raisin bran cereal, and a box of salt. A tray of coffee mugs, boxes of food, and canned goods also had rat droppings on them. A white cardboard box on a shelf in dry storage had a yellowish dried liquid stain on the top that CHI D stated was likely rat urine. During an interview on 4/3/24 at 2:13 p.m., CHI D stated that due to the rat infestation, the facility kitchen could not be used to prepare or distribute food, and food for the residents needed to be obtained from an outside source until further notice. During a record review on 4/4/24 at 8 a.m., CHI D's emailed report of the facility's inspection titled, Permanent Food Facility Inspection Report, dated 4/3/24, indicated, Placard Status: Red – closed; suspension of permit to operate. The report further indicated major violations cited included rodents inside the facility, contaminated and adulterated food, and food contact surfaces not cleaned and sanitized as required. During an observation and concurrent interview on 4/6/24 at 5:14 p.m., County Health Inspector (CHI) J arrived at the facility and inspected the kitchen. CHI J verified water damage under the ware washing station had been repaired with spray foam and wood and could be chewed through by rats. CHI J pointed out dried, grayish rat droppings on the floor behind the supports holding the ware washing station. CHI J stated the area behind the oven repaired with plaster could also be chewed through by rats. More dried, grayish rat droppings noted on the floor behind the cook line. CHI J verified the droppings looked old and had been there for some time. During an interview on 4/10/24 at 2:30 p.m., Dietary Manager stated he just got back from a month-long vacation. Dietary Manager denied any knowledge of the calls to the pest control company since November. He stated that all he knew was the pest control guy came and put down the traps. When queried, Dietary Manager stated if the kitchen staff saw any signs of rodents while he was on vacation, they should have reported it to Administrator and cleaned it up. Review of facility policy Pest Control, last revised 5/2008, indicated, Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to take precautions to prevent the development of a pressure ulcer for 1 of 4 sampled residents (Resident 1). This failure in not taking precautions, resulted in a Deep Tissue Injury (DTI, an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body), to Residents 1 ' s sacrum (low back to upper buttock area). Findings: During a review of Resident 1 ' s records from her hospitalization over 6/13/23 to 6/14/23, she was triaged in the Emergency Department just before midnight on 6/13/23. Resident 1 was admitted to the hospital and transported to the nursing unit at 5:30 a.m. Pictures of Resident 1 ' s sacrum were taken on 6/13/23 at 5:33 a.m., because the nurses had identified a DTI. The picture of Resident 1 ' s sacrum showed two rounded areas of skin that were black in color with purple around one of the black areas, and the rest of her buttock was reddened. During a review of Resident 1 ' s Hospitalist Discharge summary from the hospital, dated 6/14/23, documentation included; Deep tissue Injury (DTI) present on admission. Under the Physical the physician indicated that Resident 1's skin assessment reflected: see wound care pictures, patient has DTI to sacrum. During a review of Resident 1 ' s admission Record to the nursing home facility, the record indicated Resident 1 had the following diagnoses; Encephalopathy, (a form of brain injury,) chronic kidney disease, seizure disorder, and dementia (causing deficits to memory and thinking). During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool required by Medicare), dated 4/6/23, Resident 1 ' s BIMS (brief interview for mental status to evaluate memory), score was 6 out of 15 which indicated moderate memory problems. Resident 1 ' s MDS section M for skin assessment, indicated she was at risk for pressure ulcer formation, but did not have any pressure ulcers or other skin problems. During a review of Resident 1 ' s Braden Scale for Predicting Pressure Sore Risk, dated 3/31/23, indicated Resident 1 ' s score was 16 which was at risk to develop a pressure sore, (a high risk is a score between 15 and 18, with the lowest risk for developing pressure sores being 24). During a review of Resident 1 ' s Nursing Care Plan, developed on 6/14/23, (after readmitted to the facility with a Deep Tissue Injury), the care plan had the problem identified as, Resident has actual impairment to skin integrity . has potential for pressure ulcer development. There was no evidence of an At Risk for Skin integrity impairment prior to Resident 1's hospital transfer. During a review of Resident 1 ' s Point Click Care, Task Data sheets had not shown documentation that Certified Nursing Assistants (CNAs), followed pressure relieving tasks such as turning and repositioning Resident 1 every 2 hours or as needed, to prevent her from developing a pressure sore. During a review of Resident 1 ' s Weekly Summary (Nursing documentation), dated 4/29/23, nursing documented that Resident 1 could do activities of daily living (getting out of bed, dressed, eating and bathing), with limited to extensive help by the staff. Resident 1 was not always able to control her urination, but mostly able to control her bowel movements. Nutritionally, her average intake of meals was 25 to 100%. Resident 1 did not have signs of dehydration. Resident 1 was noted to have intact skin without pressure sores or a DTI, and was not on any pressure relieving devices for the bed or her chair, (special mattress or overlay on a mattress or a padded cushion for her wheelchair seat). During a review of Resident 1 ' s, Weekly Summary, dated 5/26/23, the nursing documentation was the same information as the Weekly Summary dated 4/29/23. During a review of Resident 1 ' s, Weekly Summary, dated 6/9/23, nursing documented that Resident 1 needed extensive help to do her activities of daily living. Resident 1 was not always able to control her urination, but mostly able to control her bowel movements. Nutritionally, her average intake of meals was 25 to 75%. It was documented Resident 1 had no signs of dehydration. Nursing documented Resident 1 ' s skin was intact without pressure sores or DTIs. Resident 1 still did not have a pressure relieving devices in place for pressure sore prevention. During an interview on 6/22/23 at 1:20 p.m., Infection Preventionist (IP) denied that Resident 1 had any pressure sores or DTIs. IP reviewed the facilitie's binder which contained the log for tracking of any resident skin issues that were documented by the CNAs. IP stated that for 6/11/23 and 6/12/23, there was no documentation in the log that reflected that Resident 1 had skin problems. During an interview on 6/22/23 at 1:50 p.m., Licensed Nurse (LN), stated that Resident 1 did not have any skin issues. LN stated Resident 1 was getting up to the bathroom and up in a wheelchair with assistance, every day. LN stated Resident 1 returned from the hospital with two DTIs that were considered to be caused by unrelieved pressure. During an interview with Primary Care Physician (PCP), over the phone on 8/8/23 at 12:40 p.m., PCP stated that after reviewing the hospital's photo of Resident 1's DTI, this could not have developed in the 6 hours between the time Resident 1 left the nursing facility and the hosptial took the picture. PCP confirmed that Resident 1 was at risk for pressure sores due to her dementia and ability to move herself in bed. During a review of the facility's policy and procedure titled, Prevention of Pressure Injuries, dated 4/2020, the policy indicated; Skin Assessment: Inspect the skin on a daily basis when performing or assisting with personal care or ADLs [Activities of Daily Living]. The procedure ends with, Monitoring; 1.Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.

Aug 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to exercise reasonable care for the protection of residents ' property from loss for two of two residents (Resident 1 and 2) when the facility did not consistently mark the clothes and property of Residents 1 and 2. This failure placed the personal property of Residents 1 and 2 at risk for loss and misplacement. Findings: During an interview on 8/8/23, at 11:25 a.m., Resident 1 stated three pants and three sweaters have gone missing since his admission to the facility in May 2023. Resident 1 stated he often receives clothes from other residents and sees his clothes being worn by other residents. During an interview on 8/8/23, at 11:35 a.m., Resident 2 stated he has had clothes missing since arriving at the facility. During an interview on 8/8/23, at 2:20 p.m., the Social Services Director (SSD) stated she was responsible for the facility ' s theft and loss and program for resident property. The SSD stated a key interventions undertaken by the facility to prevent theft and loss of resident property were labeling resident property with the resident ' s name. During an observation of Residents 1 and 2 room on 8/8/23, at 2:45 p.m., with the SSD, a sample of the residents ' property was checked for marking. For Resident 1, five items were checked in his closet: two pants and three long sleeve t-shirts. The pants and two of three long sleeve t-shirts were marked with his name. One long sleeve t-shirt had no identification. For Resident 2, eight items were checked in his closet: three shirts, two pants, two canes and one jacket. The shirts and the pants were identified with Resident 2 ' s name. The two canes and the jacket had no identification. During a concurrent interview, Resident 2 confirmed the canes and the jacket belonged to him. During an interview on 8/8/23, at 3:15 p.m., the Laundry Department Supervisor (LDS) stated most loss or misplacement of resident clothes occur when they are not marked with their names. If unmarked resident clothes are sent to the laundry, then laundry staff does not know who to return the clothes to after washing them. During a concurrent observation, the LDS showed a large bin containing what the LDS estimated to be over 50 pieces of unmarked clothes. The LDS stated these were resident clothes sent to the laundry that were not marked with the resident ' s name therefore could not be returned to their owners. A review of the facility ' s policy and procedure titled Notice of Theft and Loss Control Policy, updated October 2017, indicated: This Center makes reasonable makes reasonable efforts to safeguard resident property and valuables in accordance with state and federal guidelines . Resident personal items .are marked for identification purposes . clothing is marked with a permanent laundry marking pen.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop and implement a care to address the offensive behavior of one of one resident (Resident 3). This failure placed other residents at risk of having their quality of life at the facility disrupted by Resident 3 ' s offensive behavior. Findings: During an interview on 8/8/23, at 11:25 a.m., Residents 1 and 2, who are roommates, stated their former roommate defecated and urinated on the floor of the room a few weeks ago. Resident 1 and 2 stated the whole floor was covered with feces and urine, remained so until staff came to clean the room. In the meantime, Residents 1 and 2 stated they felt trapped in their beds because it was impossible to leave their beds without stepping onto feces and urine. Residents 1 and 2 also reported with they felt disgusted by the offensive sights and smells of Resident 3 ' s bowel and bladder incontinence in the room. A review of the facility census for June and July 2023 indicated Resident 3 shared the same room with Residents 1 and 2 until 6/29/23, after which he was transferred to another room. During an interview on 8/8/23, at 11:42 a.m., the Assistant Director of Nursing (ADON) confirmed Resident 3 shared a room with Resident 1 and 2 but on 6/29/23 was transferred to another room at the request of his roommates. The ADON stated because of complications from a stroke Resident 3 was incontinent of bowel and bladder and unable to walk but had a history of crawling out of bed and dragging himself through the floor. The ADON stated if he was soiled when crawling out of bed, he would contaminate the floor with his urine and feces. During an interview on 8/8/23, at 3:50 p.m., Certified Nursing Assistant A (CNA A) stated he was familiar with Resident 3. CNA A stated Resident 3 had history of dragging himself through the floor, including when soiled with urine and feces. A review of Resident 3 ' s care plans (documents indicating the care and services to be provided to residents) indicated no care or interventions to address Resident 3 ' s behavior of crawling out of bed and dragging himself through the floor while incontinent. During an interview on 8/9/23, at 2:35 p.m., the facility ' s Infection and Preventionist (IP) stated Resident 3 had history of dragging himself through the floor of his room while incontinent dating back to his admission to the facility in 2021. The IP was asked if the facility had developed and implemented a care plan for Resident 3 to address this behavior. The IP reviewed Resident 3 ' s care plans and stated no such care plan had been created. A review of the facility police and procedure titled Care Plans, Comprehensive Person-Centered, revised December 2016, indicated: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide speech therapy (treatment for speech, language, and swallowing disorders) in the frequency ordered of three times a week for two of two residents (Residents 1 and 4). This failure had the potential to impair Residents 1 and 4 swallowing and verbal communication abilities. Findings: During an interview on 7/14/23, at 2:20 p.m., Resident 1 stated he was not receiving speech therapy in the frequency ordered. A review of Resident 1 ' s physician ' s order indicated order dated 5/8/23 for speech therapy three times a week for four weeks. During an interview on 8/8/23, at 4:45 p.m., the Speech Language Therapist (SLT) stated she was treating Resident 1. The SLT stated Resident 1 was receiving speech therapy for aphasia (difficulty with sound production and language processing). The SLT stated Resident 1 had an order for speech therapy three times a week and had been receiving therapy continuously since his admission in May. The SLT stated thrice a week treatment was the standard for speech therapy. The SLT stated treatment fewer than three a week might result in a less effective treatment. The SLT stated Resident 1 ' s received had his speech therapy evaluation received his first treatment on 5/3/23. Thereafter, the SLT stated Resident 1 received speech therapy as follows: Treatments in May 2023, on 5/3/23, 5/8/23, 5/11/23, 5/13/23, 5/14/23, 5/20/23, 5/21/23, 5/27/23 and 5/29/23 (nine treatments over a four-week period); Treatments in June 2023, on 6/2/23, 6/5/23, 6/9/23, 6/10/23, 6/11/23, 6/16/23, 6/17/23, 6/18/23, 6/23/23 and 6/24/23 (10 treatments over a four-week period); Treatments in June 2023, on 7/1/23, 7/2/23, 7/3/23, 7/9/23, 7/11/23, 7/12/23, 7/15/23, 7/16/23, 7/20/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23 and 7/31/23 (13 treatments over a four-week period); Treatments during the first week of August 2023, on 8/4/23 and 8/7/23 (two treatments over a one-week period). During the same interview on 8/8/23, at 4:45 p.m., the SLP stated Resident 4 was also receiving speech therapy, for aphasia and dysarthria (weakness in the muscles responsible for speech). The SLP stated Resident 4 also had an order for speech therapy three times a week. The SLP stated Resident 4 had his evaluation and first treatment on 7/29/23. Thereafter, the SLT stated Resident 4 had received speech therapy as follows: Treatments in July 2023, on 7/29/23, 7/30/23 and 7/31/23 (three treatments over a one-week period); Treatments in August 2023, one treatment on 8/7/23 (one treatment over a one-week period). The SLT was asked If there was a reason or explanation for Residents 1 and 4 not consistently receiving speech therapy three times per week. The SLT stated she did not know. A review of facility policy and procedure titled Speech Therapy, revised May 2013, indicated Speech therapists treat stroke survivors and other brain injury survivors who experience impaired ability to swallow or have difficulty expressing thought or understanding language.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1) when Resident 1 had a fall. This failure resulted in Resident 1 sustaining a contusion (a bruise) on his rib and forehead and a fracture (a broken bone) of his eighth rib. Findings: A review of Resident 1's face sheet (demographics) indicated he was initially admitted mid-2020. His diagnoses included Anemia (a low blood count that can make you tired and short of breath), Major Depression, and repeated falls. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool used to guide care) dated 2/11/23, indicated Resident 1 had severely impaired cognition. The MDS also indicated Resident 1 needed extensive assistance of 1 staff during toileting. During an interview on 2/13/23 at 10:13 a.m., Licensed Staff B stated, common causes of falls included toileting without assistance, behaviors, agitation. Licensed Staff B stated short staffing contributes to increased fall incidents as residents had to wait for a long time before staff answer their call lights/needs. Licensed Staff B stated, falls should be care planned and interventions should be specific in addressing the fall risk. During an interview on 2/13/23 at 10:34 a.m., Licensed Staff C stated, the facility policy was to frequently monitor residents who were at risk for falls. During an interview on 2/13/23 at 11 a.m., the Director of Staff Development (DSD) stated each fall incident was care planned and had specific interventions to address the fall risk. DSD stated common causes of falls included residents doing things unassisted and generalized weakness. During a concurrent interview and record review with the Director of Nursing (DON), on 2/13//23 at 11:32 a.m., of the Xray results and the Fall risk scale, the DON verified Resident 1 fell on 2/4/23 which resulted in a contusion of the forehead and a fractured rib. The DON verified Resident 1 ' s Morse Fall Scale score was 65 on 1/21/23, which indicated Resident 1 was at high risk for falls. During a telephone interview on 2/14/23 at 12:39 p.m., Unlicensed Staff F stated they were short staffed at that time Resident 1 fell and this could possibly contribute to his fall on 2/4/24. During a telephone interview on 2/14/23 at 1:47 p.m., the DON stated short staffing put residents at risk for falls and accidents. A review of the daily staffing sheet for 2/4/23 indicated the CNA staffing need was not met when there were only 26 CNAs available to care for residents in a 24-hour period. A review of a staffing sheet for the morning shift on 2/4/23 indicated the CNA caring for Resident 1 at the time of his fall had 10 residents under her care. During a review of facility's policy and procedure (P&P) titled Fall Policy, revised 6/15/22, the P&P indicated the staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling .if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . if the resident continuous to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. During a review of the Facility Assessment, updated 1/2/23, the staffing assessment indicated the facility needed 11 licensed nurses and 28 CNAs to care for residents competently during both day to day operations and emergencies.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on interviews and record review, the facility failed to ensure there were sufficient and competent nursing staff available to care for residents during both day-to-day operations and emergencies. This failure resulted in 1.) the facility not meeting the nursing staffing needs based on the facility assessment for 13 out of 21 days from January 2023 and 10 out of 13 days for February 2023 and, 2.) had the potential for a fall for one of two sampled residents (Resident 1), which resulted in bruising and a fractured rib Findings: 1. During an interview on 2/13/23 at 10:00 a.m., Unlicensed Staff A stated, the facility frequently did not have enough Certified Nursing Assistant (CNA ' s) to provide timely and quality care for the residents at the facility. Unlicensed Staff A stated, they were short staffed today. Unlicensed Staff A stated, she had 9 residents this morning. Unlicensed Staff A stated, it was hard to provide quality care when the facility was short staffed. Unlicensed Staff A stated, staff just do the best they could when the facility was short staffed. Unlicensed Staff A stated, morning shifts tends to get busy and to provide quality care, CNAs should provide care for 7 or 8 residents only. Unlicensed Staff A stated the facility only cares about meeting the hours, so they do not get in trouble. During an interview on 2/13/23 at 10:43 a.m., Unlicensed Staff D stated the facility did not have enough staff to cover shifts. Unlicensed Staff D stated having 10 residents to care for today. Unlicensed Staff D stated she felt frustrated as short staffing could put residents at risk for not receiving the right care. Unlicensed Staff D stated, short staffing could lead to increased falls and accidents. During an interview on 2/13/23 at 11:00 a.m., the Director of Staff Development (DSD) stated, short staffing could contribute to increased accidents and fall incidents. The DSD stated, if the facility was short staffed, call lights could not be answered timely, and could result to residents feeling stressed. During a concurrent interview and Facility Assessment record review via telephone on 2/14/23 at 9:13 a.m., the Director of Nursing (DON) verified based on their facility assessment, dated 1/2/23, it indicated the facility needed 11 nurses and 28 CNAs in a 24-hour period to care for their residents during both day-to-day operations and emergencies. During a concurrent interview and daily direct care staffing record review via telephone on 2/14/23 at 10:30 a.m., the DON verified, based on the facility assessment, there were days where staffing needs were not met for 1/2023 and 2/2023. The DON verified that for 1/2023, the CNA staffing need was not met for 12 out of 21 days on these dates: 1/17/23 ( 26 CNA's on duty), 1/18/23 (27 CNA's on duty), 1/19/23 (27 CNA's on duty), 1/20/23 (27 CNA's on duty), 1/23/23 (27 CNA's on duty), 1/24/23 (27 CNA's on duty), 1/25/23 (26 CNA's on duty), 1/26/23 (26 CNA's on duty), 1/27/23 (27 CNA's on duty), 1/29/23 (27 CNA's on duty), 1/30/23 (27 CNA's on duty) and 1/31/23 (26 CNA's on duty). The DON verified that for 2/2023, the CNA staffing need was not met for 10 out of 13 days on these dates: 2/1/23 (26 CNA's on duty), 2/2/23 (27 CNA's on duty), 2/3/23 (26 CNA ' s only), 2/4/23 (26 CNA's on duty) , 2/5/23 (27 CNA's on duty), 2/6/23 (27 CNA's on duty), 2/7/23 (26 CNA's on duty), 2/10/23 (26 CNA's on duty), 2/11/23 (27 CNA's on duty), 2/13/23 (27 CNA's on duty). During a telephone interview on 2/14/23 at 1:47 p.m., the DON stated short staffing could lead to decreased quality of care and residents needs not being met in a timely manner. The DON stated, short staffing could put residents at risk for falls/accidents, medication errors and skin issues. During a review of the Facility Assessment, updated 1/2/23, the staffing assessment indicated the facility needed 11 licensed nurses and 28 CNAs to care for residents competently during both day-to-day operations and emergencies. 2. A review of Resident 1's face sheet (demographics) indicated he was initially admitted mid-2020. His diagnoses included Anemia (a low blood count that can make you tired and short of breath), Major Depression, and repeated falls. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool used to guide care) dated 2/11/23, indicated Resident 1 had severely impaired cognition. The MDS also indicated Resident 1 needed extensive assistance of 1 staff during toileting. During an interview on 2/13/23 at 10:13 a.m., Licensed Staff B stated, common causes of falls included toileting without assistance, behaviors, agitation. Licensed Staff B stated short staffing contributes to increased fall incidents as residents had to wait for a long time before staff answer their call lights/needs. Licensed Staff B stated, falls should be care planned and interventions should be specific in addressing the fall risk. During an interview on 2/13/23 at 10:34 a.m., Licensed Staff C stated, the facility policy was to frequently monitor residents who were at risk for falls. During a concurrent interview and record review with the Director of Nursing (DON), on 2/13//23 at 11:32 a.m., of the Xray results and the Fall risk scale, the DON verified Resident 1 fell on 2/4/23 which resulted in a contusion of the forehead and a fractured rib. The DON verified Resident 1 ' s Morse Fall Scale score was 65 on 1/21/23, which indicated Resident 1 was at high risk for falls. During a telephone interview on 2/14/23 at 12:39 p.m., Unlicensed Staff F stated they were short staffed at that time Resident 1 fell and this could possibly contribute to his fall on 2/4/24. During a telephone interview on 2/14/23 at 1:47 p.m., the DON stated short staffing put residents at risk for falls and accidents. A review of the daily staffing sheet for 2/4/23 indicated the CNA staffing need was not met when there were only 26 CNAs available to care for residents in a 24-hour period. A review of a staffing sheet for the morning shift on 2/4/23 indicated the CNA caring for Resident 1 at the time of his fall had 10 residents under her care. During a review of facility's policy and procedure (P&P) titled Fall Policy, revised 6/15/22, the P&P indicated the staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling .if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . if the resident continuous to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. During a review of the Facility Assessment, updated 1/2/23, the staffing assessment indicated the facility needed 11 licensed nurses and 28 CNAs to care for residents competently during both day-to-day operations and emergencies.

Jan 2023 21 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from accidents by implementing interventions to reduce hazard(s) and risk(s) monitoring for effectiveness and modifying interventions when necessary for two out of two sampled residents (Resident 169 and 59). This failure resulted in: 1) Resident 169 sustaining a Comminuted (bone broken into 2 more pieces), mildly displaced fracture involving the left parasymphyseal pubic bone (a unique joint consisting of a fibrocartilaginous (a dense, whitish tissue with a distinct fibrous texture) disc sandwiched between the articular surfaces of the pubic bones or bones that make up the pelvis) and Non displaced fracture of the anterior cortex of the left sacral ala ( bone called the sacrum, a large triangular bone at the bottom of the spine, breaks.(broken pelvis and spine) 2) Resident 59 sustained Right Femur Fracture (a break in the thigh bone) with surgical repair. Findings: 1)A review of Resident 169's facesheet ( demographics) indicated she was [AGE] years old, initially admitted on [DATE]. Her diagnoses includes Anemia (a low blood count that can make you tired and short of breath), Depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities) and Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). During a concurrent observation in Resident's 169's room at 108A and interview on 1/11/23 at 9:09 a.m., Resident 169 was in her wheelchair, asleep. Unlicensed Staff M stated, Resident 169 was under her care today. Unlicensed Staff M stated, Resident 169 was a fall risk. Unlicensed Staff M stated, staff knew a resident was a fall risk if she had a bracelet and a signage that stated she was a fall risk. Unlicensed Staff M visually and verbally verified Resident 169 does not have either one of those. Unlicensed Staff M stated the facility policy was also for Resident 169 who was a fall risk to wear an orange bracelet indicating she was a fall risk. Unlicensed Staff M stated Resident 169 should be wearing an orange bracelet because she was a fall risk. Unlicensed Staff M stated since Resident 169 was not wearing it, the facility policy was not followed. She stated it was important to have this bracelet so other staff could identify residents that were a fall risk. Unlicensed Staff M stated if a resident was not wearing this orange bracelet, staff would not know they were a fall risk and residents could fall and hurt themselves. During a concurrent observation in Resident's 169's room at 108A and interview on 1/11/23 at 9:20 a.m., Resident 169 1 staff per 1 resident sitter (they can only observe one patient at any given time) stated her service was provided by the Veterans Administration (VA, an outside medical provider) to ensure Resident 169's safety and decrease her risk for falling. During a fall care plan and Minimum Data Set Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) record review on 1/11/23 at 12:09 p m., the fall care plan indicated Resident 169 should have a signage in the bathroom and at her bedside table stating, call for help, do not fall. A review of Resident 169's MDS, dated [DATE], indicated the Brief Interview for Mental Status (a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) assessment score of 9 indicating a moderately impaired cognition. During a concurrent observation in Resident's 169's room at 108A and interview on 1/11/23 at 12:19 p.m., Unlicensed Staff D visually and verbally verified Resident 169 had no signage in the bathroom and bedside table to remind Resident 169 to call for help and not fall. Unlicensed Staff D verified Resident 169 used to have that signage in her previous room. Unlicensed Staff D stated if the signage was not transferred to Resident 169's current room, the fall care plan was not followed and was a safety risk for the resident because it could result in a fall and resident could end up hurting themselves. During a concurrent observation and interview on 1/13/23 at 9:47 a.m., the Director of Nursing (DON) stated the facility's fall protocol included assessing for fall risk upon admission, fall care plan initiation upon admission and rehabilitation services to evaluate for durable medical equipment (DME, a medical equipment and supplies ordered by a healthcare provider for a patient's routine, long-term use) to be used, functional assessment/limitation. The DON stated she had initiated a fall reduction program, however, the program was not successful because of the lack for follow through. The DON stated when Resident 169 had multiple falls, the DON reached out to VA to notify them the facility was unable to care for Resident 169 due to her behaviors and impulsivity. The DON stated VA responded by providing the facility with 24 hour one on one staff to monitor for Resident 169's safety. The DON verified there was no signage on Resident 169's bedside table or the bathroom despite the fact it was care planned. The DON stated the facility should be following care plans. The DON stated the care plan was designed to guide staff on how to care for residents safely. The DON stated Resident 169's fall care plan was not updated but instead a new one was created every time she falls. When asked what happened to the old fall care plan, the DON stated, it's just in the system. The DON verified the facility does not update the care plan and the facility does not resolve a care plan even when it was not effective. DON stated the care plans not updated nor resolved would indicate the care plan was still in effect. The DON stated the call do not fall signage care plan was active, meaning it was still in effect when she moved to her current room. The DON verified the facility did not follow the fall care plan when the signage was missing from Resident 169's room. The DON stated if the care plan was not followed, the facility was not in compliance. The DON stated it was important to follow the care plan for safety. The DON stated if the care plan was not followed, this could put Resident 169 at risk for falls and accidents. During a concurrent interview, care plan and bowel/bladder log review on 1/13/23 at 11:30 a.m., the DON verified Resident 169 was on bowel and bladder program (B/B, goal was to help patients manage incidence of incontinence or accidents effectively with a combination of exercises, techniques, and lifestyle changes) since 4/2022, however the log had days when there was incomplete entry and there was no entry noted after 4/2022. The DON verified, the April log, was also the only log for Resident 169's B/B monitoring. The DON verified this meant their fall care plan was not followed. The DON stated Resident 169's fall on 8/25/22 might have been prevented if Resident 169 continued to be on the B/B program per fall care plan. Resident 169 should have been placed on prompted voiding program (a behavioural therapy used to improve bladder control for people with or without dementia (impaired thinking, remembering or reasoning that can affect a person's ability to function safely) using verbal prompts and positive reinforcement per her care plan on 9/9/22. The prompted voiding program was necessary due to the fact Resident 169 would go to the bathroom frequently unassisted. She stated this was also in place to help prevent future falls. The DON stated that since this care plan was not carried out, it could be a safety risk. During a concurrent interview, Xray ( Xray imaging creates pictures of the inside of your body) and Computerized Tomography scan (CT, a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) and care plan record review on 1/17/23 at 10:10 a.m., the DON verified Resident 169 fall on 8/25/22 resulted in fracture, however it was missed by the X ray initially. The DON stated after the fall on 8/25/22, Resident 169 continued to complain of pain. The DON suspected it was hairline fracture (a small crack or bruise within a bone) which was why it was probably missed when Resident 169 was initially Xrayed. The DON verified Resident 169 fell again on 8/27/22 and was sent out on 8/27/22 due to persistent pain. The DON stated the hospital did an Xray of the right hip again but was negative for fracture. However, since Resident 169 continued to be in pain, a CT scan of the right hip was done which showed right hip fracture. Resident 169 was admitted to the hospital from [DATE] to 9/9/22. Resident 169 care plan on 9/9/22 indicated she would be placed on prompted voiding program. The DON stated the prompted voiding program was necessary due to the fact that Resident 169 would often go to the bathroom unassisted. She stated the prompted toileting program should be in place to help prevent future falls. She stated that since this care plan was not followed, it could be a safety risk. DON verified one on one staff provided by the VA (due to falls and behaviors) was initiated on 9/9/22 at 11:00 p.m., after Resident 169 had already fallen. The DON verified Resident 169 was readmitted at around 8:00 p.m. on 9/9/22 and fell at 10:15 p.m., and the one on one staff, provided by the VA, was not yet available at that time. The DON was not sure what was the staffing ratio for her on the days that she fell on 8/25/22, 8/27/22 and 9/9/22. Review of the fall care plan with the DON, who verified staffing wise it would appear staffing ratio for Resident 169 would be 1 staff per 2 to 3 residents per care plan. DON stated due to Resident 169's frequent falls, the Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) decided to lessen number of residents per staff that cared for her. The DON stated that based on the care plan, they were not following the staffing ratio for Resident 169. She stated the main purpose of staffing ratio of 1 staff per 2 to 3 resident was because of safety concerns due to Resident 169's falls and behaviors as well. The DON stated not following the staffing ratio for Resident 169 could increase her risk for falls. DON stated the fall could have been prevented if the facility was following the staffing ratio as per care planned. The DON verified, the staffing ratio was not followed on these dates 8/25/22: morning shift 1 staff to 6 residents, afternoon shift 1 staff to 6 residents and night shift 1 staff to 18 residents; 8/27/22 morning shift 1 staff to 8 residents, afternoon shift 1 staff to 7 residents, night shift 1 staff to 15 residents; 9/9/22: afternoon shift 1 staff to 9 residents and night shift 1 staff to 15 residents. During a concurrent interview and daily staffing record review on 1/17/23 at 11:07 a.m., the Staffing Coordinator verified that based on the facility record, the staffing ratio was not followed on these dates 8/25/22: morning shift 1 staff to 6 residents, afternoon shift 1 staff to 6 residents and night shift 1 staff to 18 residents; 8/27/22 morning shift 1 staff to 8 residents, afternoon shift 1 staff to 7 residents, night shift 1 staff to 15 residents; 9/9/22: afternoon shift 1 staff to 9 residents and night shift 1 staff to 15 residents. During a record review for Resident 59, the Face sheet (A one-page summary of important information about a resident) indicated Resident 59 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems), Schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others) and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for resident 59, the Care Plan for ADL (Activities of Daily Living) Self Care Deficit initiated on 7/09/2022 indicated, [Resident 59] ambulating independently without any assistive device. During a record review for Resident 59, the document titled Morse Fall Scale dated 7/08/2022 indicated Resident 59 had a total score of 70 points (A patient who scores under 25 points is considered to be at low risk of falling, a patient who scores between 25-45 points is considered to be at moderate risk of falling, and a patient who scores higher than 45 points is considered to be at high risk of falling). The document indicated Resident 59 had an impaired gait (manner of walking). The document indicated, [Resident 59] overestimates or forgets limit of her ability to walk. During a record review for Resident 59, the document titled Clinical Functional Abilities Evaluation dated 7/10/2022 indicated Resident 59's ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed was dependent on staff. She required maximum assistance with walking. During a record review for Resident 59, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 7/15/2022 indicated Resident 59 had a BIMS score of zero out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). Resident 59 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assistance with all transfer needs, toilet use and limited (resident highly involve in activity; staff provide guided maneuvering of limbs or other non-weightbearing assistance) one-person physical assistance with walking in room and walking in corridor. First Fall (8/30/2022) During a record review for Resident 59, the document titled Progress Note dated 8/30/2022 at 3:54 p.m. indicated Resident 59 had complained of right hip pain. The progress note indicated Resident 59's left leg appeared longer that the right leg and was unable to stand up and walk as she could previously. The progress note indicated Resident 59 was asked if she had fallen and Resident 59 stated she fell yesterday. The progress note indicated, There were no reported falls. The progress note indicated Resident 59 was sent to the hospital for further evaluation. During a record review for Resident 59, the fall care plan initiated on 8/30/2022 interventions to include: provide hip padding when she returns for further protection; PT/OT (Physical Thrapy/ Occupational Therapy) eval and treat as appropriate; Will move patient close to the nurses' station when a bed becomes available; and IDT to request medication review and lab test as appropriate. During a record review for Resident 59, the document titled Progress Note dated 9/01/2022 at 7:35 p.m. indicated the Interdisciplinary Team (IDT - group of health care professionals who work together toward the goals of the resident) met to discuss about the fall incident involving Resident 59. The Progress Note indicated, NOC (night) shift Nurse stated that around 1-2am, she saw her walking and she assisted her back to her bed. PM shift stated that she was also walking independently like her usual. The Progress note indicated Resident 59 had Displaced Thigh Femoral Neck Fracture (displaced fracture occurs when the bone fragments on each side of the break are not aligned) and will undergo surgery. During a record review for Resident 59, the document titled Progress Note dated 9/04/2022 at 10:19 p.m. indicated Resident 59 came back from hospital with right femur fracture (a break in the thigh bone). During a record review for Resident 59, the document titled Progress Note dated 9/05/2022 at 12:03 p.m. indicated Resident 59 was re-admitted with surgical incision to her right hip. During a record review for Resident 59,the document titled Physical Therapy Evaluation and Plan of Treatment dated 9/7/2022 indicate Resident 59 required minimal assist (when the assisting person(s) or device(s) are required to perform approximately 25 percent of the work of a mobility task while resident perform 75 percent of the work) with transfer and ambulation. During a record review for Resident 59, the document titled Progress Note dated 9/07/2022 at 9:28 p.m. indicated Resident 59 had multiple attempts of ambulating without assist/walker. During a record review for Resident 59, the document titled Physical Therapy Discharge Summary dated 9/29/2022 indicated Resident 59 required supervision with transfer and ambulation. Second Fall (11/05/2022) During a record review for Resident 59, the document titled Weekly Summary dated 10/31/2022 at 1:51 p.m. indicated Resident 59 required extensive assist with transfers, ambulation, and toilet use. The document indicated Resident 59 was continent with both bowel and bladder function. During a record review for Resident 59, the document titled Progress Note dated 11/06/2022 at 5:33 a.m. indicated, [Resident 59] came back from (hospital) related to fall, at 0030 AM . staff supervision at the point of service, . Res. independent to bed mobility and transfer. During a record review for Resident 59, the document titled Progress Note dated 11/06/2022 at 1:36 p.m. indicated Resident 59 had, unsteady gait to right lower extremity observed when patient took few steps during transferring from bed to wheelchair. The progress note indicated, ROM (range of motion) is decreased on her RLE (right lower extremity) after fall. During a record review for Resident 59, the document titled Progress Note dated 11/07/2022 at 5:11 a.m. indicated Resident 59 was given oxycodone (used to relieve pain severe enough to require opioid (powerful pain-reducing medications) treatment and when other pain medicines did not work well enough or cannot be tolerated) 5 mg (milligram) when she was observed grimacing and guarding her right hip. During a record review for Resident 59, the document titled Progress Note dated 11/07/2022 at 7:30 p.m. indicated, IDT discussed this morning regarding resident's recent unwitnessed fall on 11/05/22.at approximately 1745, staff heard a noise from the resident's room which is adjacent to the nurses' station. [Resident 59] was noted to be sitting on the floor with her back against the closet door. She was noted to be holding her pants. The progress note indicated Resident 59 was sent to the hospital for evaluation. During a record review for Resident 59, the document titled Progress Note dated 11/07/2022 at 8:42 p.m. indicated Resident 59 was given oxycodone 5 mg due to facial grimacing when propelling her wheelchair. During a record review for Resident 59, the fall care plan initiated on 11/07/2022 indicated intervention to offer [Resident 59] wheelchair and encourage to sit down in between walks. Third Fall (12/11/2022) During a record review for Resident 59, the document titled Weekly Summary dated 12/05/2022 at 2:59 a.m. indicated Resident 59 required extensive assist with transfers, ambulation, and toilet use. The document indicated Resident 59 was continent with both bowel and bladder function. During a record review for Resident 59, the document titled Progress Note dated 12/12/2022 at 12:42 p.m. indicated [Resident 59] is under monitoring for s/p unwitnessed fall day 1. No changes in LOC (level of consciousness) but decreased ROM to BLE (bilateral lower extremity) from her baseline noted as she c/o (complaint of) pain during transferring from bed to wheelchair and wheelchair to bed. During a record review for Resident 59, the document titled Progress Note dated 12/13/2022 at 6:00 a.m. indicated, [Resident 59] had tendency to ambulate with limitation. During a record review for Resident 59, the document titled Progress Note dated 12/13/2022 at 6:17 p.m. indicated, IDT discussed this morning regarding resident unwitnessed fall when she was found lying on her left side.[Resident 59] seems to be back in her normal baseline, ambulating without any assistive device. During a record review for Resident 59 with the DON on 1/13/2023 at 3:22 p.m. the DON verified the fall care plan for Resident 59 did not have new interventions after the 12/05/2022 fall. Fourth Fall (12/16/2022) During a record review for Resident 59, the document titled Progress Note dated 12/17/2022 at 1:29 p.m. indicated, [Resident 59] remains under S/P (status post - just an event, that a resident has experienced previously) unwitnessed fall day 1 STAT (immediately) bilateral hip x-ray (a type of radiation that can go through many solid substances such as bones and organs in the body to be photographed) pending still at this time Facial grimacing noted when personal care provided. Given Oxycodone 2.5 mg. During a record review for Resident 59, the document titled Progress Note dated 12/19/2022 at 3:33 p.m. indicated, On 12/16/22 [Resident 59] was noted after falling on the floor in the middle of her room, no witnesses Review of the Fall Care Plan initiated on 12/16/2022 indicated intervention, Will frequently reorient patient for use of wheelchair when out of bed. During an observation on 1/10/23 at 11:24 a.m. in Resident 59's room, Resident 59 was in her bed, awake; however, she did not respond when spoken to. During an interview with the DON on 1/13/2023 at 3:31 p.m. when asked how supervision was provided to Resident 59 to prevent her from falling, the DON stated Resident 59 gets easily agitated when staff try to stand beside her. The DON stated Resident 59 was moved close to the nurse's station to provide line of sight supervision. During an observation at the nurse's station on 1/13/2023 at 4:23 p.m. Resident 59 was observed transferring from her bed to her wheelchair without assistance. Two licensed nurses were at the nurses' station; however, none of the licensed nurses observed Resident 59 transferring. During an interview with Unlicensed Staff D on 1/17/2023 at 11:20 a.m. when asked how much assistance was provided to Resident 59, Unlicensed Staff D stated, Resident 59 required limited assistance when getting up. Unlicensed Staff D stated, Resident 59 had trouble walking, could be independent but sometimes needs assistance. Unlicensed Staff D she would constantly check Resident 59 in her room. When Unlicensed Staff D was asked about the risks for Resident 59 when she had repeated falls, she stated, resident could have fracture. During a review of facility's policy and procedure (P&P) titled Fall Policy, revised 6/15/22, the P&P indicated the staff will identify interventions related to residents specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling .if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . if the resident continuous to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a comprehensive assessment for one of 19 sampled residents (Resident 24) when a Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was not completed within 14 days of Resident 24's admission to hospice services. This failure resulted in an inaccurate representation of Resident 24's current clinical status and had the potential to cause inadequate care based on a delinquent comprehensive assessment and care planning. Findings: During a record review for Resident 24, the Face sheet (A one-page summary of important information about a resident) indicated Resident 24 was admitted on [DATE] with diagnoses including Malignant Neoplasm of Right Ovary (cancer of the ovary [a female reproductive organ in which ova or eggs are produced, present in humans and other vertebrates as a pair]; Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems), Heart Failure (A chronic condition in which the heart doesn't pump blood as well as it should) and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 24, the Physician's Order indicated Resident 24 was admitted to Hospice Services on 8/29/2022 for diagnosis of Neoplasm of Right Ovary. During an electronic record review for Resident 24, the MDS tracking indicated a Significant Change assessment for Resident 24 dated 9/9/2022. Assessment status indicated In progress. During a record review and concurrent interview with the MDSC (MDS Coordinator) on 1/18/23 at 10:16 a.m., the MDSC verified Resident 24 had a Significant Change in Status Assessment (SCSA) with ARD (Assessment Reference Date - last day of the observation period that the assessment covers for the resident) 9/9/2022. MDSC stated the assessment was created to reflect Resident 24's admission to Hospice Services. When asked about the target date of completion of the assessment, the MDSC stated she should close the assessment within 14 days from the ARD. The MDSC verified the status of the assessment indicated, In progress. During a record review and concurrent interview with the MDSC on 1/18/23 at 10:29 a.m., when asked what in progress mean for the MDS. The MDSC stated, assessment was not completed. Review of the Facility policy and procedure titled Resident Assessments revised in November 2019 indicated, The Resident Assessment Coordinator is responsible for ensuring that the interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to OBRA (Omnibus Budget Reconciliation Act - a schedule of assessments that will be performed for a nursing facility resident at admission, quarterly, and annually, whenever the resident experiences a significant change in status, and whenever the facility identifies a significant error in a prior assessment) required assessments. The policy indicated, A Significant Change in Status Assessment (SCSA) is completed within 14 days of the interdisciplinary team determining that the resident meets the guidelines for major improvement or decline; A SCSA is required when a resident enrolls in a hospice program.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to meet professional standards during medication pass observation for 2 of 19 sampled residents (Resident 28 and Resident 43) when: 1. Licensed Nurse administered Sodium Chloride tablet (also known as salt) to Resident 28 when there was no physician's order for the medication. 2. Licensed Nurse administered Prosight with vitamins and minerals to Resident 28 that was expired. 3. Licensed Nurse did not provide instruction to Resident 28 on how to properly administer the Albuterol oral inhaler (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness). 4. Licensed Nurse did not notify the physician when Resident 43's blood sugar was 416 Findings: Resident 28 During a medication observation on [DATE] at 8:47 a.m., Licensed Staff F prepared ten oral medications for Resident 28 which included Sodium Chloride tablet 1000 mg (also known as salt) and Prosight with vitamins and minerals. The medication bottle for Prosight with vitamins and minerals indicated an expiration date of 8/2022. During a record review and concurrent interview with Licensed Staff F on [DATE] at 3:01 p.m., Licensed Staff F verified Resident 28 did not have an order for Sodium Chloride tablet. Licensed Staff F also verified the medicine bottle for Prosight with vitamins and minerals indicated an expiration date of 8/2022. Licensed Staff F stated she did not check for the expiration of the medication. During an observation on [DATE] at 8:55 a.m. in Resident 28's room, Licensed Staff F handed the Albuterol oral to Resident 28 and instructed Resident 28 to rinse her mouth after albuterol administration; however, Resident 28 was not instructed how the medication should be administered. Resident 28 self-administered the Albuterol 2 puffs and immediately removed the mouthpiece and rinsed her mouth. During an interview and concurrent record review with Licensed Staff F on [DATE] at 3:07 p.m. when asked what instructions should be given to Resident 28 prior to albuterol administration, Licensed Staff F stated she would always instruct Resident 28 to shake the medication and watch resident during administration. Licensed Staff F was asked about the risks for Resident 28 if she did not receive the recommended dose of Albuterol according to doctor's order, she stated, it would be a problem for the resident. Resident 43 During a record review for Resident 43, the Medication Administration Record (MAR) indicated an order for Insulin Lispro [NAME] KwikPen (disposable prefilled pen containing multiple doses of insulin) Solution Pen-injector 100 UNIT/ML. Inject as per sliding scale: if . 351 - 400 = 10 >401 give 12 units then call MD. The MAR indicated Resident 43's blood sugar on [DATE] at 11:30 was 416. Resident 43 received 12 units of Insulin lispro according to the sliding scale. There was no record that physician was notified. During an interview with the Infection Preventionist Nurse (IPN) on [DATE] at 10:06 a.m. when asked about their process when resident's blood sugar was above the sliding scale order, the IPN stated they would follow the sliding scale order for the resident. The IPN verified there was no documentation that MD was notified of resident's blood sugar of 416 on [DATE]. During an interview with Licensed Staff A on [DATE] at 4:25 p.m. when asked about their process when resident's blood sugar was out of the sliding scale order, Licensed Staff A stated they would follow sliding the scale instructions and notify the doctor. During an interview with Licensed Staff I on [DATE] 4:29 p.m. when asked about their process when resident's blood sugar was high, Licensed Staff I stated they would give insulin per sliding scale order, notify the doctor if above 400 and document in resident's record. Review of the Facility policy and procedure titled Administering Medications revised in [DATE] indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of the Facility policy and procedure titled Administering Oral Medications revised in [DATE] indicated, Check the label on the medication and confirm the medication name and dose with the MAR. Check the expiration date on the medication.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and records review, the facility failed to ensure that nutritional care and services were provided to one of two sampled residents (Resident 170). Resident 170 had a weight loss of eight pounds which yielded to 9.89 percent weight loss in a month from 12/05/2022 to 01/08/2023. This deficient practice had the potential to result in Resident 170's further unplanned weight loss. Findings: During an observation on 1/09/23 at 10:40 a.m. in Resident 170's room, Resident 170 was sitting in her wheelchair looking at the window. When Resident 170 was asked if she had any concern about her care, Resident 170 stated she was concerned about being thin and wanted to keep up with her weight. During a record review for Resident 170, the Face sheet (A one-page summary of important information about a resident) indicated Resident 170 was admitted on [DATE] with diagnoses including Left Femur Fracture (a break in the thigh bone), Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems); Protein Calorie Malnutrition (when a person is not consuming enough protein and calories), Anxiety (intense, excessive, and persistent worry and fear about everyday situations) and Hypertension (High Blood Pressure). During a record review for Resident 170, the document titled Weights and Vitals Summary indicated Resident 170 weighed 91 lbs. (pounds) on 12/05/2022. On 12/18/2022, Resident 170 weighed 84 pounds which is a 7.69 % weight loss. During a record review for Resident 170, the document titled Nutrition Evaluation Form dated 12/18/2022, the Registered Dietician (RD - an expert in the field of food and nutrition) indicated Resident 170 was high risk of malnutrition related to low body weight, BMI (Body mass index - is a measure of body fat based on height and weight), and poor oral intakes. The RD indicated Resident 170 met 50 percent of her estimated nutritional needs. The RD indicated, [Resident 170] would benefit from supplements to help meet nutritional needs. Alternates, supplements, snacks, fluids all offered and encouraged PRN (as needed) as tolerated at this time. Nutritional intervention indicated, House supplement (weight gain supplement) 120 ml TID (three times a day). During a record review for Resident 170, the Physician's Order indicated an order dated 12/22/2022 for House Supplement two times a day for Weight Management. During a record review for Resident 170, the document titled EMPRES-Nutrition Hydration Skin Committee Review Form dated 12/23/2022 indicated Resident 174 triggered for significant weight loss (loss of more than 5 percent of usual body weight over 6 to 12 months) of 7.7% in two weeks since admission. The document indicated Resident 170's food intake was between 30 to 100% for breakfast, lunch, and dinner. The IDT (Interdisciplinary Team - group of health care professionals who work together toward the goals of the resident) recommended a fortified diet. During a record review for Resident 170, the Physician's Order indicated an order dated 12/31/2022 for Fortified (a food that has extra nutrients added to it or has nutrients added that are not normally there) NAS (no added salt) diet. During a record review for Resident 170 with the DON (Director of Nursing) on 1/17/2023 at 11:47 a.m., the DON verified the Nutrition Evaluation Form dated 12/18/2022 indicated an RD recommendation for house supplement 120 ml TID. During a record review for Resident 170 and concurrent interview with the DON on 1/17/2023 at 11:51 a.m., the DON verified the doctor's order dated 12/23/22 indicated an order for House Supplement two times a day for weight management. The DON was asked reason for the delay to initiate the RD recommendation for house supplement, she stated RD would normally email her recommendations; however, she did not receive the RD report for the 12/18/2022 visit. The DON stated she took the initiative to start Resident 170 on house supplement due to Resident 170's history of malnutrition and weight loss. The DON verified RD's recommendation was not followed. During a record review for Resident 170 and concurrent interview with the DON on 1/17/2023 at 11:58 a.m., the DON verified the Nutrition Hydration Skin Committee Review Form dated 12/23/2022 indicated an IDT recommendation for fortified diet. During a record review for Resident 170 and concurrent interview with the DON on 1/17/2023 at 12:01 p.m., the DON verified the doctor's order dated 12/31/2022 indicated an order for Fortified NAS diet. The DON was asked reason for delay of implementing the IDT recommendation for fortified diet, the DON stated the report she received from the RD for the 12/23/2022 visit did not indicate RD recommended fortified diet. The DON was asked about the risks for Resident 170 if she continued to lose weight, the DON stated Resident 170 could have further decline and potential for pressure ulcer. Review of the Facility policy titled Weight Assessment and Intervention revised in September 2008 indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.

CONCERN (D)

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

Deficiency F0699 (Tag F0699)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure residents received Trauma Informed Care (TIC, an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health) which accounted for resident's experiences and preferences for two out of two sampled residents (Resident 220 and 171). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to the past torture experience). Findings: Resident 220 was [AGE] years old, initially admitted to the facility on [DATE]. His diagnoses include Post Traumatic Stress Disorder (PTSD, a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), Diabetes Mellitus (DM, a condition that happens when the body can't use glucose (a type of sugar) normally) and Chronic Kidney Disease Stage 4 (Stage 4 CKD meant that your kidneys are moderately or severely damaged and are not working as well as they should to filter waste from your blood. Waste products may build up in your blood and cause other health problems). His Minimum Data Sheet assessment (MDS, a part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. It provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems) dated 12/30/22, the Brief Interview of Mental Status (BIMS, a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score was 15, indicating intact cognition. During an interview on 1/ 9/23 at 11:15 a.m., Resident 220 stated he had PTSD and was immunocompromised. Resident 220 stated staff appeared to not know how to care for his psychiatric needs. During an interview on 1/12/23 at 1:20 p.m., Unlicensed Staff C stated she does not know what TIC was. During an interview on 1/12/23 at 3:09 p.m., Unlicensed Staff D stated she does not know what TIC was. Unlicensed Staff D stated the facility had not in serviced them about trauma informed care. During an interview on 1/12/23 at 3:45 p.m., Unlicensed Staff K stated the facility had not given them an in service about TIC. Unlicensed Staff K stated she was not aware of what trauma informed care was. During a concurrent interview and care plan record review on 1/13/23 at 3:50 p.m., the Director of Nursing (DON) verified the facility have not introduced the staff about TIC yet. The DON also verified Resident 220 had no care plan to address his PTSD. The DON stated it was important for staff to understand and know about TIC and to develop and follow the PTSD care plan to ensure staff knew how to properly care for these residents. The DON stated, if there was no PTSD care plan and the facility did not teach the staff about TIC, then staff would not be aware on how to care for residents with trauma. The DON stated this could result in residents not being cared for adequately or appropriately. The DON stated these residents could be traumatized again. During an interview on 1/13/23 at 3:55 p.m., the Director of Staff Development (DSD) verified Resident 220 did not have a PTSD care plan. The DSD verified the facility had not given an in service to staff on TIC. The DSD stated it was important to ensure PTSD was care planned so that staff knows what are possible triggers or behaviors that could result in resident's re-experiencing of the initial trauma event. The DSD stated it was important for staff to know about TIC to ensure residents with PTSD are cared for appropriately. She stated staff not knowing about TIC could result in residents re- traumatization. During an interview on 1/17/23 at 9:38 a.m., Licensed Staff F verified she did not receive TIC in service. During an interview on 1/17/23 at 9:40 a.m., Unlicensed Staff M stated the facility had not given them an in service about TIC. Unlicensed Staff M verified she does not know about TIC. During a concurrent interview and care plan record on 1/17/23 at 9:56 a.m., the Assistant Director of Nursing (ADON) verified she had not received any in service on TIC. The ADON stated it was important to learn about TIC to better care for residents with PTSD or residents who had experienced loss. The ADON stated if staff were not aware of TIC, they could be providing insufficient mental and emotional care to the resident that could result to re traumatization. The ADON verified Resident 220 had a diagnosis of PTSD but had no PTSD care plan. Stated that it was important to have a PTSD care plan for staff to better care for Resident 220. She stated the care plan should include behaviors that would trigger behaviors and how staff are going to deal with it effectively thereby preventing re traumatization. During an interview on 1/17/23 at 10:06 a.m., the DON verified Resident 220 had no PTSD care plan. The DON stated this could lead to inadequate care and re traumatization During a record review for Resident 171, the Face sheet indicated Resident 171 was admitted on [DATE] with diagnoses including Left Femur Fracture (a break in a thigh bone) with surgical repair; Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life); and Post Traumatic Stress Disorder. During a record review for Resident 171, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 12/26/22 indicated Resident 171 had a BIMS score of 15 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). The MDS indicated Resident 171 was bothered of the following problems over the last 2 weeks: little interest or pleasure in doing things half or more of the days; feeling down, depressed, or hopeless nearly every day; trouble falling or staying asleep or sleeping too much nearly every day; feeling tired or having little energy nearly every day; and feeling bad about himself for several days. During a review of the Care Area Assessments (CAAs - part of the MDS process and provides the foundation upon which a resident's individual care plan is formulated) of the MDS dated [DATE] indicated the following triggered Areas (require further investigation to determine if the triggered area require interventions and care planning) Psychosocial Well-Being, Mood State and Behavioral Symptoms. During a record review for Resident 171, the Care Plan (no title) revised on 1/06/2023 indicated Resident 171 was independent for meeting his emotional, intellectual, and social needs. The Care Plan interventions indicated, [Resident 171] will benefit from daily in room visits with offers: coffee, hydration, a la carte activities, music/movies at bedside, phone/video calls, sensory, aromatherapy. The Care Plan did not address Resident 171's mood and behavior symptoms. During an observation and concurrent interview with Resident 171 on 1/10/23 at 2:42 p.m., Resident 171 was in his room lying in bed. When asked Resident 171 if he had concern with his dialysis, he stated, no. Resident 171 stated he's been going for dialysis before he was admitted to the facility. Resident 171 stated he was told that if he missed dialysis for a week, he would be gone. When Resident 171 asked if he had other concerns, resident was observed holding his emotions, a bit teary and stated, this place don't do anything, I was even considering on going AMA (against medical advice - when a patient leaves a hospital against the advice of their doctor) and would just take my life with my own hands. During an interview with the Director of Nursing (DON) on 1/10/2023 at 3:23 p.m. the DON stated she had spoken to Resident 171 about his claim of hurting himself. The DON stated Resident 171 stated he was not serious about his claim of hurting himself. The DON stated she offered Resident 171 to see the psychologist on 1/11/2023; however, Resident 171 declined stating he has dialysis scheduled and requested if he could have it on 1/12/2023. The DON was asked if a psychological evaluation was done and who deemed Resident 171 to be safe, the DON stated she did not think Resident 171 had the capability to harm himself. The DON stated she was not qualified to do a psychological evaluation; however, she would ask the Medical Director who was in the building to perform psychological evaluation for Resident 171. During an interview with the Social Service Director (SSD) on 1/18/2023 at 9:19 a.m. when asked how the facility manages Resident 171's psychosocial needs, the SSD stated she tried to meet with Resident 171 however, Resident 171 was not receptive. SSD verified there was no care plan developed for Resident 171 to address his PTSD and psychosocial needs. During an interview with the Activity Director on 1/18/23 at 9:32 a.m. the Activity Director verified the facility did not have an activity program for PTSD residents. During a review of facility's policy and procedure (P&P) titled Trauma Informed Care, revised 3/2019, the P&P indicated all staff are provided in service training about trauma, it's impact on health, and PTSD in the context of the healthcare setting .caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers. Review of the Facility policy and procedure titled Behavioral Assessment, Intervention and Monitoring revised in March 2019 indicated, The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents.

CONCERN (D)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure the Director of Nursing (DON) only worked as a charge nurse if the facility census was 60 and below. This resulted in the DON working as a charge nurse on the floor seven times between 10/2022 and 12/2022 on different shifts and there was no DON coverage at those times. Findings: During an interview on 1/17/23 at 12:52 p.m., the Staffing Coordinator verified the DON also works as a charge nurse to cover a shift if they were not able to find a nurse to work on the floor. The staffing coordinator verified the DON worked on these dates: 10/5, Wednesday morning shift, 10/16 Sunday afternoon shift, 10/19 Wednesday morning shift, 10/22 Saturday afternoon shift, 10/25 Tuesday night shift, 11/3Thursday morning shift and 12/24 Saturday afternoon and night shift. The staffing coordinator verified the census was above 60 during these days. During an interview on 1/17/23 at 12:55 p.m., the DON stated she does work as a charge nurse at times. She stated it could either be on the morning, afternoon or the night shift on weekdays or weekends depending on the facility needs. She stated she probably worked as a charge nurse around 7 times between 10/2022 and 12/2022 on these dates: 10/5 Wednesday morning shift with a census of 94, 10/16 Sunday afternoon shift with a census of 92, 10/19 Wednesday morning shift with a census of 90, 10/22 Saturday afternoon shift with a census of 87, 10/25 Tuesday night shift with a census of 89, 11/3 Wednesday morning shift with a census of 91and 12/24 Saturday afternoon and night shift with a census of 90. She stated the facility census was never at 60 or below since she started working at the facility as a DON. She stated that the facility had definitely more than 60 residents when she worked as a charge nurse. She stated if she worked as charge nurse in the morning or afternoon shift, it meant there was no DON coverage during those times. She stated the facility was really busy and that was one of the reasons she was having a hard time keeping up with her other duties. Per federal regulation, the DON may only serve as a charge nurse when the facility's average daily census is 60 or fewer residents.

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure the prescribing physician obtained informed consent for one of five sampled residents selected for unnecessary medication review (Resident 24) prior to the administration of a psychotropic medication (medications which affects mood or behavior). This failure did not provide Resident 24's Responsible Party the right to be fully informed regarding care and treatment in order to make health care decisions for the Resident 24. Findings: During a record review for Resident 24, the Face sheet indicated Resident 24 was admitted on [DATE] with diagnoses including Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with Behavioral Disturbance and Psychosis (severe mental disorder). The Face sheet indicated Family Member Q was the responsible party for Resident 24. During a record review for Resident 24, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 6/12/2022 indicated Resident 24 had a BIMS score of 3 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). During an electronic record review for Resident 24, the Current Order Medication History for Resident 24 indicated Resident 24 was started on Risperidone (a drug used to treat certain mental disorders) solution 1 mg/ml (milligram/milliliter) on 6/21/2019 and was discontinued on 6/28/19. During a record review for Resident 24, the document titled CA Psychoactive Drugs Disclosure and Consent indicated Family Member Q signed the consent form on 6/21/2019 for the use of Risperdal (also known as Risperidone) 1 mg/ml two times a day. The signature line for the physician obtaining consent was left blank. During an electronic record review for Resident 24, the Current Order Medication History for Resident 24 indicated Resident 24 was started on Abilify 2 mg (a drug used to treat certain mental/mood disorders) on 7/28/2019 and was discontinued on 8/22/2019. During a record review for Resident 24, the document titled Psychoactive Drugs Disclosure and Consent indicated the Social Service Director (SSD) obtained verbal consent from Family Member Q on 7/28/2019. During an electronic record review for Resident 24, the Current Order Medication History for Resident 24 indicated Resident 24 was started on Abilify 2 mg (a drug used to treat certain mental/mood disorders) on 12/11/2019. During a record review for Resident 24, the document titled Psychoactive Drugs Disclosure and Consent indicated Family Member Q signed the consent form on 12/11/2019 for the use of Abilify 2 mg once a day. The signature line for the physician obtaining consent was left blank. During a record review for Resident 24 and concurrent interview with the SSD on 1/13/2023 at 11:55 a.m. the SSD verified the consent form for Risperidone on 6/21/2019 had no signature from the prescribing physician. When asked about their process prior to administering psychotropic medications to residents, SSD stated the prescribing physician would give an order and the nurses were responsible for obtaining consent from the resident or call the resident's representative to obtain verbal consent. SSD stated they could not start the medication until verbal consent obtained. During a record review for Resident 24 and concurrent interview with the SSD on 1/13/2023 at 2:54 p.m., SSD verified she obtained verbal consent from Family Member Q for the use of Abilify. When SSD was asked if she discussed the risks versus benefits of psychotropic use with Family Member Q, SSD stated, no, because I am not a nurse. SSD stated she informed Family Member Q of the new ordered antipsychotic, the dose, and the frequency. SSD stated Family Member Q did not ask about the medication side effects. During an interview with the DON (Director of Nursing) on 1/13/2023 at 3:29 p.m., when asked who was responsible for obtaining consent for psychotropic medications, the DON stated nurses were responsible for obtaining consent and discuss risks versus benefits with either the resident or their responsible party. During an interview with Family Member Q on 1/18/2023 at 10:50 a.m. Family Member Q stated the facility had called him to obtain consent for antipsychotic use; however, he verified the facility did not discuss the following: - The reason for the treatment and the nature and seriousness of the resident's illness; and - The nature of the proposed treatment including frequency and duration; and - The probable degree and duration (temporary or permanent) of improvement or remission, expected with or without such treatment; and - The nature, degree, duration, and probability of the side effects and significant risks (e.g., FDA boxed warning), commonly known by the health professions; and - The reasonable alternative treatments and risks, and why the health professional is recommending this particular treatment. Review of the California Code, Health, and Safety Code - HSC § 1418.9 indicated, a) If the attending physician and surgeon of a resident in a skilled nursing facility prescribes, orders, or increases an order for an antipsychotic medication for the resident, the physician and surgeon shall do both of the following: (1) Obtain the informed consent of the resident for purposes of prescribing, ordering, or increasing an order for the medication. (2) Seek the consent of the resident to notify the resident's interested family member, as designated in the medical record. If the resident consents to the notice, the physician and surgeon shall make reasonable attempts, either personally or through a designee, to notify the interested family member, as designated in the medical record, within 48 hours of the prescription, order, or increase of an order.

CONCERN (E)

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

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to ensure residents' MDS assessments (Minimum Data Set - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences assessments) were transmitted within 14 days after completion for 7 of 19 sampled residents (Resident 14, 25, 28, 37, 52, 56, and 169) and 5 randomly selected residents (Resident 2, 30, 35, 179 and 180). This failure resulted in lack of resident specific information to CMS (Centers for Medicare & Medicaid Services) for payment and quality measure monitoring. Findings: During an electronic record review for Resident 169, the MDS Tracking indicated Resident 169's quarterly MDS assessment dated [DATE] was completed on 11/23/2022 with a submit by date of 12/07/2022. The assessment status indicated, Export Ready. During an electronic record review for Resident 28, the MDS Tracking indicated Resident 28's quarterly MDS assessment dated [DATE] was completed on 8/18/2022 with a submit by date of 9/01/2022. The assessment status indicated, Export Ready. During an electronic record review for Resident 2, the MDS Tracking indicated Resident 2's Annual MDS assessment dated [DATE] was completed on 11/10/2022 with a submit by date of 11/24/2022. The assessment status indicated, Export Ready. During an electronic record review for Resident 25, the MDS Tracking indicated Resident 25's quarterly MDS assessment dated [DATE] was completed on 8/03/2022 with a submit by date of 8/17/2022. The assessment status indicated, Export Ready. During an electronic record review for Resident 37, the MDS Tracking indicated Resident 37's quarterly MDS assessment dated [DATE] was completed on 10/08/2022 with a submit by date of 10/22/2022. The assessment status indicated, Export Ready. During an electronic record review for Resident 14, the MDS Tracking indicated Resident 14's Annual MDS assessment dated [DATE] was completed on 8/02/2022 with a submit by date of 8/16/2022. The assessment status indicated, Export Ready. During an electronic record review for Resident 169 and concurrent interview with the MDSC (MDS Coordinator) on 1/18/23 at 10:21 a.m., the MDSC verified assessment status for Resident 169's quarterly MDS dated [DATE] indicated, Export Ready. When asked what Export Ready mean, the MDSC stated all sections of the MDS, and all care plans were completed and ready for transmission. MDSC stated all assessment should be transmitted within 14 days from the completion date. MDSC concurred Resident 169's quarterly MDS was late for transmission. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 effective October 2019 indicated, Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. The RAI indicated, Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was accurately completed for 6 of 19 sampled residents (Resident 17, 4, 39, 19, 9, and 118) and 6 randomly selected residents (Resident 2, 173, 24, 20, 174, and 175) when they did not receive the recommended Pneumococcal vaccine; however, Section O0300 of their MDS indicated their Pneumococcal vaccination was up to date. This failure resulted in residents not getting the recommended Pneumococcal vaccine and putting them at risk for increased respiratory infections. (Reference F883). Review of the Pneumococcal Vaccine Timing for Adults indicated, CDC recommends 1 dose of PPSV23 at age [AGE] years or older. Administer a single dose of PPSV23 at least 1 year after PCV13 was received. Their pneumococcal vaccinations are complete. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf Findings: Resident 2 During an electronic record review for Resident 2, the Immunization Tracking Log indicated Resident 2 received PPSV23 (pneumococcal polysaccharide vaccine - protects against 23 types of pneumococcal bacteria) on 1/23/2017 During a record review for Resident 2, Section O0300 of the MDS dated [DATE] indicated Resident 2's Pneumococcal vaccination was up to date. Resident 173 During an electronic record review for Resident 173, the Immunization Tracking Log indicated Resident 173 received PPSV23 on 9/09/2013. During a record review for Resident 173, Section O0300 of the MDS dated [DATE] indicated Resident 173's Pneumococcal vaccination was up to date. Resident 24 During an electronic record review for Resident 24, the Immunization Tracking Log indicated Resident 24 received PPSV23 on 9/03/2019. During a record review for Resident 24, Section O0300 of the MDS dated [DATE] indicated Resident 24's Pneumococcal vaccination was up to date. Resident 17 During an electronic record review for Resident 17, the Immunization Tracking Log indicated Resident 17 received PPSV23 on 7/08/2013 During a record review for Resident 17, Section O0300 of the MDS dated [DATE] indicated Resident 17's Pneumococcal vaccination was up to date. Resident 4 During an electronic record review for Resident 4, the Immunization Tracking Log indicated Resident 4 received PPSV23 on 10/24/2019. During a record review for Resident 4, Section O0300 of the MDS dated [DATE] indicated Resident 4's Pneumococcal vaccination was up to date. Resident 20 During an electronic record review for Resident 20, the Immunization Tracking Log indicated Resident 20 received PPSV23 on 1/01/2019. During a record review for Resident 20, Section O0300 of the MDS dated [DATE] indicated Resident 20's Pneumococcal vaccination was up to date. Resident 174 During an electronic record review for Resident 174, the Immunization Tracking Log indicated Resident 174 received PPSV23 on 4/15/2012. During a record review for Resident 174, Section O0300 of the MDS dated [DATE] indicated Resident 174's Pneumococcal vaccination was up to date. Resident 39 During an electronic record review for Resident 39, the Immunization Tracking Log indicated Resident 39 received PPSV23 on 1/01/2012. During a record review for Resident 39, Section O0300 of the MDS dated [DATE] indicated Resident 39's Pneumococcal vaccination was up to date. Resident 19 During an electronic record review for Resident 19, the Immunization Tracking Log indicated Resident 19 received PPSV23 on 6/12/2012. During a record review for Resident 19, Section O0300 of the MDS dated [DATE] indicated Resident 19's Pneumococcal vaccination was up to date. Resident 9 During an electronic record review for Resident 9, the Immunization Tracking Log indicated Resident 9 received PPSV23 on 9/08/2015. During a record review for Resident 9, Section O0300 of the MDS dated [DATE] indicated Resident 9's Pneumococcal vaccination was up to date. Resident 175 During an electronic record review for Resident 175, the Immunization Tracking Log indicated Resident 175 received PPSV23 on 1/01/2012. During a record review for Resident 175, Section O0300 of the MDS dated [DATE] indicated Resident 175's Pneumococcal vaccination was up to date. Resident 118 During a record review for Resident 118, Section O0300 of the MDS dated [DATE] indicated Resident 118's Pneumococcal vaccination was up to date. During a record review with the Infection Preventionist Nurse (IPN) on 1/12/2023 at 2:54 p.m., the IPN verified the MDS for Resident 2 dated 11/20/2022 indicated Resident 2's pneumococcal vaccine was up to date. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 effective October 2019 under Section O0300: Pneumococcal Vaccine indicated, Up to date in item O0300A means in accordance with current Advisory Committee on Immunization Practices (ACIP) recommendations.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on observation, investigation and record review, the facility failed to ensure 1) there were sufficient and competent nursing staff available to care for residents during both day to day operations and emergencies. 2) the licensed nurses had upon hire and annually, completed the nursing competency check to ensure they were competent to provide safe nursing care to the residents. 3) the call light (a means of communication for patients to their care providers that are outside of the patient's room) was within reach for eight out of eight sampled residents (Residents 9, 17, 34, 41, 49, 120, 218 and 220). This failure resulted in 1. the facility not meeting the nursing staffing needs based on the facility assessment for 30 out of 30 days for November 2022, 31 out of 31 days for the December 2022 and 10 out of 10 days for December 2023. 2. missing and incomplete nursing competency check for five out of five sampled licensed nurses (Licensed Staff E, F, G, H and ADON). 3. late provision of care due to long wait time for staff to answer call lights and residents fearing for their safety, feeling annoyed and frustrated nobody wants to help them. Findings: 1. During an interview on 1/9/23 at 11:23 a.m., Resident 41 stated he does not feel like there was enough staff to help the residents at the facility. During an interview on 1/9/23 at 10:26 a.m., Resident 218 stated he felt there were not enough staff to help with his needs. Resident 218 stated the staff takes a long time before they come to help him. He stated it was frustrating and annoying. During an interview on 1/9/23 at 11:04 a.m., Resident 49 stated the facility should put more staff on the floor to help residents promptly. During an interview on 1/9/23 at 11:15 a.m., Resident 220 stated the facility had no staff. Resident 220 stated staff takes forever to answer call light, and sometimes does not even answer at all. During an interview on 1/9/23 at 11:32 a.m., Resident 120 stated facility did not have enough staff to care for the residents at the facility. During an interview on 1/9/23 at 4:15 p.m., Resident 9 felt there was not enough staff to care for the residents at the facility. Resident 1 stated one time, she had to wait for over an hour for staff to help her. Resident 9 stated she ended up soiling herself. Resident 9 stated she felt humiliated and frustrated. During an interview with a resident's sitter at the facility on 1/9/23 at 4:33 p.m., she stated there were not enough staff to care for the residents at the facility. During an interview on 1/11/23 at 3:04 p.m., Resident 34 stated there were not enough staff to care for the residents at the facility. Resident 34 stated it was the reason why staff took a long time to answer call lights. During an interview on 1/11/23 at 3:15 p.m., Licensed Staff B stated there certainly was a staffing issue at the facility. Licensed Staff B stated that a lot of long term staff had left the company and these staff had no replacement yet. Licensed Staff B stated staff were exhausted. Licensed staff B stated the staffing issue was discussed with the Administrator and his response was at the end of the day, we are a business. Licensed Staff B stated not having enough staff to care for resident's could result in resident's unmet needs and safety concerns. During an interview on 1/12/23 at 1:20 p.m., Unlicensed Staff C stated the facility was frequently short staffed. Unlicensed Staff C stated this was discussed with the Administrator and his response was this is business. Unlicensed Staff C stated that this week, staffing was good only because the facility was on a survey. Unlicensed Staff C stated the facility was frequently short staffed. Unlicensed Staff C stated 1 Certified Nursing Assistant (CNA) usually had about 11 to 12 residents to care for on the morning shift. Unlicensed Staff C stated, if the facility was short staffed, resident care suffers. Unlicensed Staff C stated short staffing could lead to resident's unmet needs, late provision of care, accidents and falls. During an interview on 1/12/23 at 3:09 p.m., Unlicensed Staff D stated the facility does not have enough staff. Unlicensed Staff D stated that last month, she had to care for 14 residents in the morning shift. Unlicensed Staff D stated the facility was only concerned in reaching the patient per day (PPD, the total number of nursing hours in a unit in a 24-hour period) goals. Unlicensed Staff D stated the staff talked to the management about the issue with short staffing, however, the management's response was we reached our PPD goals. Unlicensed Staff D stated the risk of not having enough staff to care for residents were late provision of care and falls. Unlicensed Staff D stated this was frustrating because the quality of care was lacking due to short staffing. During an interview on 1/13/23 at 8:50 a.m., Licensed Staff E stated the facility does not have enough staff to care for the residents at the facility. Licensed staff E stated the facility expected her to care for all the residents on her wing and hang all 5 intravenous medication ( IV, a way of giving a drug or other substance through a needle or tube inserted into a vein) in the building. Licensed Staff E stated, the management expects her to do all these and finish medication pass (the process through which medication is administered to patients) on time. Licensed Staff E stated this was difficult because her station was also very busy. Licensed Staff E stated having a lot of residents to care for and rushing to finish medication pass on time could result to medication errors which was a huge safety risk for the residents. Licensed Staff E stated the facility was also short staffed on CNA's. Licensed Staff E stated not having enough CNA to care for residents could be frustrating to the residents. Licensed Staff E stated this could lead to late provision of care, lack of attention to resident's needs, falls and accidents. During a concurrent interview and daily nursing staffing record review on 1/13/23 at 11:01 a.m., the Director of Nursing (DON) verified the facility assessment had to be followed for staffing guidance. The DON verified that on a daily basis, facility would need 15 nurses and 29 Certified Nursing assistant (CNA's) in a 24 hour period per the facility assessment. The DON verified the staffing needs were not met for 11/2022, 12/2022 and 1/2023. The DON verified that for 11/2022, the Licensed Nurse staffing was not met for 29 out of 30 days on these days: 11/2 (10 nurses on duty), 11/3 (11 nurses on duty), 11/4 (11 nurses on duty), 11/5 (12 nurses on duty), 11/6 (10 nurses on duty), 11/7 (11 nurses on duty), 11/8 (13 nurses on duty), 11/9 (12 nurses on duty), 11/10 (11 nurses on duty), 11/12 ( 12 nurses on duty),11/13 (11 nurses on duty), 11/14 (12 nurses on duty), 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/29 and 11/30. The DON verified the CNA staffing was not met for 13 out of 30 days on these dates: 11/6 ( 28 CNA's on duty), 11/8 (28 CNA's on duty), 11/10 (27 CNA's on duty), 11/12 (27 CNA's on duty), 11/14 (28 CNA's on duty), 11/15 (28 CNA's on duty, 11/16 (28 CNA's on duty) 11/18 (25 CNA's on duty, 11/19 (27 CNA's on duty), 11/24 (28 CNA's on duty), 11/25 (28 CNA's on duty), 11/29 (28 CNA's on duty) and 11/30 (28 CNA's on duty). The DON verified that for 12/2022, the licensed nurse staffing was not met for 28 out of 31 days on these dates: 12/1 (11 nurses on duty), 12/2 12 nurses on duty), 12/3 (12 nurses on duty), 12/4 (12 nurses on duty), 12/5 (11 nurses on duty), 12/6 (12 nurses on duty), 12/7 (11 nurses on duty), 12/8 (11 nurses on duty), 12/9 (12 nurses on duty), 12/10 (12 nurses on duty), 12/11 (12 nurses on duty), 12/12 (10 nurses on duty), 12/13 (14 nurses on duty), 12/14 (12 nurses on duty), 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/28, 12/29 and 12/30. The DON verified the CNA staffing needs were not met for 22 out of 31 days on these dates: 12/1 (28 CNA's on duty), 12/2 (28 CNA's on duty), 12/4 (27 CNA's on duty) , 12/6 (26 CNA's on duty), 12/7 (26 CNA's on duty), 12/8 (28 CNA's on duty), 12/9 (26 CNA's on duty), 12/10 (28 CNA's on duty), 12/12 (24 CNA's on duty), 12/13 (24 CNA's on duty), 12/14 ( 27 CNA's on duty), 12/15, 12/16, 12/17, 12/19, 12/20, 12/21, 12/23, 12/25, 12/26, 12/27 and 12/31. The DON verified that for 1/2023, the licensed nurse staffing was not met for 10 out of 10 days on these dates: 1/1 (12 nurses on duty), 1/2 (12 nurses on duty), 1/3 (12 nurses on duty), 1/4 (11 nurses on duty), 1/5 (13 nurses on duty), 1/6 ((12 nurses on duty), 1/7 (13 nurses on duty), 1/8 (12 nurses on duty), 1/9 (14 nurses on duty) and 1/10 (14 nurses on duty). The DON verified the CNA staffing needs were not met on 3 out of 10 days on these dates: 1/3 (28 CNA's on duty), 1/5 (27 CNA's on duty), and 1/7 (28 CNA's on duty). The DON stated not having enough staff to care for residents could lead to safety issues, late provision of care, medication errors, falls and accidents. During a concurrent interview and daily staffing record review on 1/13/23 at 11:12 a.m., the Staffing Coordinator verified the facility did not meet the staffing need for 11/2022, 12/2022 and 1/2023, for both nurses and CNA's on multiple days. The Staffing Coordinator verified that for 11/2022, the Licensed Nurse staffing was not met for 30 out of 30 days on these days: 11/1. 11/2, 11/3, 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/10, 11/12,11/13, 11/14, 11/15, 11/16, 11/17, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, 11/29 and 11/30. The Staffing coordinator verified the CNA staffing was not met for 13 out of 30 days on these dates: 11/6, 11/8, 11/10, 11/12, 11/14, 11/15, 11/16 11/18, 11/19, 11/24, 11/25, 11/29 and 11/30. The Staffing Coordinator verified that for 12/2022, the licensed nurse staffing was not met for 28 out of 31 days on these dates: 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, 12/9, 12/10, 12/11, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/28, 12/29 and 12/30. The Staffing coordinator verified the CNA staffing needs were not met for 22 out of 31 days on these dates: 12/1, 12/2, 12/4, 12/6, 12/7, 12/8, 12/9, 12/10, 12/12, 12/13, 12/14, 12/15, 12/16, 12/17, 12/19, 12/20, 12/21, 12/23, 12/25, 12/26, 12/27 and 12/31. The Staffing Coordinator verified that for 1/2023, the licensed nurse staffing was not met for 10 out of 10 days on these dates: 1/1, 1/2, 1/3, 1/4, 1/5, 1/6, 1/7, 1/8, 1/9 and 1/10. The Staffing Coordinator verified the CNA staffing needs were not met on 3 out of 10 days on these dates: 1/3, 1/5 and 1/7. The Staffing coordinator stated not having enough staff to care for residents was a safety risk. Staffing Coordinator stated this could lead to resident feeling frustrated, angry and not adequately care for. During a review of the Facility Assessment, updated 1/2/23, the staffing assessment indicated the facility needed 15 licensed nurses and 29 CNA's to care for residents competently during both day to day operations and emergencies. 2. During an interview on 1/13/23 at 3:39 p.m., the Director of Staff Development (DSD) verified competency evaluations are completed at upon hire, annually and as needed. She verified nurses are evaluated for med pass competency prior to allowing a staff nurse to pass medication with no oversight. She stated the DON oversees this task. The DSD verified the annual nursing competency for Licensed Staff F and Licensed Staff was initiated but not completed. The DSD stated it was important for the nurses to be assessed for nursing competency, especially with med pass to ensure nurses are safe in passing medications to the residents and that they were safe to provide nursing care to the residents. During an interview on 1/13/23 at 3:50 p.m., the DON verified only Licensed Staff F and Licensed Staff E were checked off by the pharmacist on medication pass competency. DON verified the pharmacist would check the nurses off medication pass competency before allowing them to pass medications with no oversight. The DON verified Assistant Director of Nursing (ADON), Licensed Staff G and Licensed Staff H were employed prior to her working at the facility and as such was not able to produce records of their annual nursing competency checklist. She stated if these staff even had annual competency completed prior to her coming on board, she does not have one on file for them. The DON verified she had not performed the annual nursing competency checks for Licensed staff G, Licensed Staff H and the ADON. The DON stated it was important to have the competency completed prior to releasing the nurses on floor to ensure they were able to provide safe care to the residents. The DON stated not doing so could result to unsafe medication pass and unsafe nursing practice. The DON verified that nurse competency evaluation was not done for the ADON, Licensed Staff G and Licensed Staff H. The DON also verified the competency check for Licensed Staff E, G, F and H were not completed. During a review of facility's Policy and Procedure (P&P) titled, Competency of Nursing Staff, revised May 2019, the P&P indicated the facility and resident specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment .the facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. 3. During a concurrent observation and interview on 1/9/23 at 11:23 a.m., it was observed Resident 41's call light was not within reach. Resident 41 stated even if he pressed his call light, he still had to wait for a long time before staff comes to help him. Resident 41 stated sometimes, he had to wait for about 20 to 30 mins before staff came to help him. Resident 41 stated waiting for a long time before staff comes to help was frustrating. Resident 41 stated he felt like nobody wants to help him. During a concurrent observation and interview on 1/9/23 10:30 a.m., Licensed Staff B verified Resident 41's call light was all the way to his roommate side and not within reach. Licensed Staff B stated call light should be at resident's bedside and should be easy to reach at all times. Licensed Staff B stated that call light should be answered as soon as possible. Licensed Staff B stated a wait time of 5 minutes was not acceptable. Licensed Staff B stated it was a safety risk not to have call light within reach. Licensed Staff B stated resident could do things unassisted and could end up falling or having accidents. During an interview on 1/9/23 at 10:26 a.m., Resident 218 stated staff takes a long time before they come to help him. Resident 218 stated that sometimes he had to wait for more than 20 minutes before staff answered his call light. Resident 218 stated that it was frustrating and annoying. During an interview on 1/9/23 at 11:04 a.m., Resident 49 stated staff takes a while to answer call lights. Resident 49 stated she was concerned with her safety. Resident 49 stated she does not knew what could happen to her if staff does not come right away and there was a medical emergency. During an interview on 1/9/23 at 11:15 a.m., Resident 220 stated staff takes forever to answer a call light, and that sometimes, staff does not even answer at all. Resident 220 stated his call light was never in reach and had to resort to yelling at staff if he needed help. During a concurrent observation and interview on 1/9/23 at 11:28 a.m., Resident 223's call light was not within reach. Resident 223 stated he had issues with his call light not being within reach at all times. Resident 223 stated staff takes forever to answer call lights. Resident 223 stated he was worried some medical emergency would occur and nobody would come to help him timely. During a concurrent observation and interview on 1/09/23 at 11:30 p.m., Licensed Staff I verified Resident 223's call light was not within his reach. Licensed Staff I stated call light should always be within resident's reach per facility policy. Licensed Staff I stated if the call light was not within a resident's reach, then the facility policy was not followed. Licensed Staff I stated this was a safety risk. Licensed Staff I stated residents may do things unassisted that could result to falls and accidents. Licensed Staff I stated Resident 223 was a high risk for fall. During a concurrent observation and interview on 1/9/23 at 11:32 p.m., Resident 120 was on his wheelchair but his call light was not within his reach as it was curled to the wall on his bedside. Resident 120 had complaint about staff taking forever to answer his call light. When asked to elaborate, resident stated about 20 to 30 minutes wait time. Resident 120 stated it was frustrating at times to wait for staff to answer call lights. During a concurrent interview and observation on 1/0/23 at 4:15 p.m., Resident 9 had the call button attached to the garbage can. Licensed Staff I verified call light was attached to the garbage can. Licensed Staff I stated it should be within resident reach at all times. During an interview with a frequent visitor to the facility on 1/09/23 at 4:33 p.m., she stated call light wait times was frequently between 15 to 30 minutes. During a concurrent observation and interview on 1/10/23 at 9:33 a.m., Resident 17 call light was not in reach as it was on the floor behind the head of his bed. Licensed Staff B stated the facility policy was to ensure call lights are within reach at all times. Licensed Staff B stated if the call light was not within a resident reach, the policy was not followed. Licensed Staff B stated this was a safety risk for the residents as they could end up doing things themselves without assistance. Licensed Staff B stated this could result to falls, accidents and unmet needs. During an observation on 1/11/23 at 9:28 a.m., Resident 218 call light was on at 9:28 a.m. Licensed Staff B answered the call light at 9:40 a.m., Total wait time was 12 minutes. During an observation on 1/11/23 at 3:04 p.m., Resident 34 stated the facility does not respond to call light right away. Resident 34 stated there was one incident when he even thought of calling an ambulance himself. Resident 34 stated it was scary to think what could happen to him if there was a medical emergency. Resident 34 stated it was frustrating to wait for a long time for staff to answer call light. During an interview on 1/13/23 at 10:17 a.m., the DON verified call lights should be within residents reach at all times per facility policy. DON stated if the call light was not within resident's reach, then the facility was noncompliant. DON stated it was important to have the call light within reach so residents could communicate their needs to staff. DON stated if the call light was not within resident's reach, it was a safety risk that could result to late provision of care, accidents, falls. During an interview on 1/17/23 at 12:03 p.m., the Director of Staff Development (DSD) stated call lights should be within residents reach at all times. DSD stated it was important so that resident could ask for help if needed. DSD stated if call light was not within resident's reach, they could be at risk for staff not providing for their needs. DSD stated it was everyone's responsibility to answer call lights. Stated that a 12 minutes wait time to answer a call light was too long and was unacceptable. DSD stated staff should answer call light within 3 minutes. She stated not answering call light immediately, meaning under 3 minutes, could result to accidents and falls. During an interview on 1/17/23 at 2:55 p.m., the DON verified call lights should be within resident's reach at all times. The DON stated if the call light was not within a resident's reach, they were at risk for not getting their needs met. The DON stated answering call light was everyone's responsibility and call light should be answered within 5 minutes at the latest. The DON stated a 12 minutes wait time for a call light to be attended to was a long time. The DON stated if call lights were not answered timely within 5 minutes, then the resident could be at risk for accidents and falls. During an interview on 1/17/23 at 3:03 p.m., Unlicensed Staff J stated a call light should be within resident reach at all times. Unlicensed Staff J stated it was important so that residents could call staff for assistance. Unlicensed Staff J stated if the call light was not within a resident's reach, residents could not communicate their needs and they would be at risk for unmet needs. Licensed Staff J stated it was everyone's responsibility to answer call light, and call lights should be answered timely, within 5 minutes. Licensed Staff J stated if a call light was not answered timely, residents could be at risk for falls. The facility had no policy and procedure in place for call lights.

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to ensure that medication drug regimen for one of five sampled residents (Resident 24), who received psychotropic medication was reviewed for irregularities at least once a month according to facility policy. This failure had the potential to result in side effects that could go undetected by licensed staff and delay for the physician to act upon irregularities. Findings: During a record review for Resident 24, the Face sheet indicated Resident 24 was admitted on [DATE] with diagnoses including Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with Behavioral Disturbance and Psychosis (severe mental disorder). The Face sheet indicated Family Member Q was the responsible party for Resident 24. During an electronic record review for Resident 24, the Current Order Medication History for Resident 24 indicated Resident 24 was started on Abilify 2 mg (a drug used to treat certain mental/mood disorders) on 12/11/2019 During a record review for Resident 24, the Medication Administration Record (MAR) for January 2023 indicated Resident 24 was receiving Abilify tablet 2 mg (milligram) for the diagnosis of Psychosis manifested by being fearful that some is up to get her/ poison her. During a record review for Resident 24, the Behavior Care Plan revised on 12/18/2021 indicated Resident 24 had a behavior problem with paranoia when Resident 24 believed that nurses are poisoning her medications and delusions of somebody had killed her son or husband. During a record review of the Consultant Pharmacist's Medication Regimen Review with the ADON (Assistant Director of Nursing) on 1/17/2023 at 1:19 p.m., the ADON verified there was no pharmacy review on file for Resident 24 for January 2022, February 2022, March 2022, April 2022, May 2022, July 2022, August 2022, September 2022, and December 2022. During an interview and concurrent record review with the DON on 1/17/23 at 2:48 p.m. when asked about frequency of Pharmacy visit, the DON stated Pharmacist would come in every month to do medication record review. The DON verified Medication Regimen Review activity between 1/1/2022 and 1/18/2023 did not indicate Resident 24's medication record was reviewed. Review of the Facility policy titled Pharmacy Services - Role of the Consultant Pharmacist revised in April 2019 indicated, The Consultant Pharmacist will provide specific activities related to medication regimen review including: a. A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines and b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and records review, the facility failed to ensure medication error rate was below 5% when three of four Licensed Nurses (Licensed Staff E, F and G) were observed for medication pass and did not follow the manufacturer's recommendations and doctor's order regarding administration of medication for three residents (Residents 176, 28, and 177) which resulted in seven medication administration errors out of 31 administration opportunities (21% error rate). This failure had the potential to compromise the absorption of the medication and the risk of compromising the resident's health and well-being for not getting the right medication and required dose of medication according to the doctor's order. Findings: Resident 176 During a record review for Resident 176, the Face sheet (A one-page summary of important information about a resident) indicated Resident 176 was admitted on [DATE] with diagnoses including Diabetes Mellitus (disease that result in too much sugar in the blood). During a medication observation on 1/11/2023 at 8:30 a.m., Licensed Staff G prepared ten oral medications for Resident 176 which include Metformin (a drug used to treat Diabetes Mellitus) 1000 mg (milligram). During an observation on 1/11/2023 at 8:34 a.m. in Resident 176's room, Resident 176 was still in bed. Licensed Staff G handed Resident 176 his medicines and asked him if he had eaten his breakfast. Resident 176 stated not yet. Resident 176 took all his medicine with a glass of water. During a record review and concurrent interview with Licensed Staff G on 1/11/2023 at 10:44 a.m., Licensed Staff G verified Resident 176's Medication Administration Record (MAR) indicated, Metformin HCl Tablet 1000 MG Give 1000 mg by mouth two times a day related to Diabetes Mellitus, give with meals. Licensed Staff G stated Resident 176 already had his breakfast. When Licensed Staff G was asked reason why Metformin should be given with meals, Licensed Staff G stated, Per pharmacy recommendation. During an interview with Licensed Staff F on 1/11/2023 at 9:54 a.m. when asked about breakfast schedule, Licensed Staff F stated breakfast was served between 7:00 - 7:30 a.m. Resident 177 During a record review for Resident 177, the Face sheet indicated Resident 177 was admitted on [DATE] with diagnoses including Diabetes Mellitus, Chronic Obstructive Lung Disease and Parkinson's Disease (disorder of the central nervous system that affects movement). During a medication observation on 1/11/2023 at 11:19 a.m.in Resident 177's room, after checking Resident 177's blood sugar, Licensed Staff E stated Resident 177's blood sugar level was 266 and prepared 6 units of Insulin Lispro according to insulin sliding scale (the progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges) order. Licensed Staff E injected the insulin to Resident 177's right upper arm and pulled out the needle from the skin immediately with no wait time. During an interview and concurrent record review with Licensed Staff E on 1/12/2023 at 11:55 a.m. when asked how long should the needle be kept in the skin when using Lispro kwikpen (a disposable pre-filled pen containing 3 ml (300 units, 100 units/ml) of insulin lispro), Licensed Staff E stated, about 10 seconds. Review of the package insert for lispro with Licensed Staff E indicated, The needle should remain in the skin for at least 5 seconds to ensure complete delivery of the insulin dose. Licensed Staff E stated she was not sure if she kept the needle in Resident 177's skin per manufacturer's recommendation. Resident 28 During a record review for Resident 28, the Face sheet indicated Resident 28 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems), Unspecified Visual Loss, Bipolar Disorder (disorder associated with episodes of mood swings) and Hypertension (High Blood Pressure). During a medication observation on 1/11/2023 at 8:47 a.m., Licensed Staff F prepared ten oral medications for Resident 28 which included Sodium Chloride 1000 mg (also known as salt); Citalopram 20 mg (used to treat Depression [a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life]); Fluoxetine 20 mg (used to treat Depression); Simethicone 80 mg (used to relieve the painful symptoms of too much gas); Vitamin D units (essential for bone strength); Olanzapine 2.5 mg (used to treat bipolar disorder); Lactobacillus (type of probiotic [good bacteria]); Metoprolol 50 mg (used to treat high blood pressure); Gabapentin 100 mg (used to prevent and control seizures); and Prosight with vitamins and minerals (eye supplement). The medication bottle for Prosight w/ vitamins and minerals indicated an expiration date of 8/2022. During an observation on 1/11/2023 at 8:53 a.m. in Resident 28's room, Licensed Staff F handed Resident 28's medicines in a medicine cup. Resident 28 took all her medicines with a glass of water. During an observation on 1/11/2023 at 8:55 a.m. in Resident 28's room, Licensed Staff F handed the Albuterol oral inhaler (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) to Resident 28 and instructed Resident 28 to rinse her mouth after albuterol administration; however, Resident 28 was not instructed how the medication should be administered. Resident 28 self-administered the Albuterol 2 puffs and immediately removed the mouthpiece and rinsed her mouth. During a record review and concurrent interview with Licensed Staff F on 1/11/2023 at 3:01 p.m., Licensed Staff F verified Resident 28's MAR indicated an order for Calcium Tablet 600 mg. Give 1 tablet by mouth one time a day and Multivitamin Adult Tablet (Multiple Vitamins-Minerals). Give 1 tablet by mouth one time a day. Licensed Staff F verified Resident 28 did not have an order for Sodium Chloride tablet. Licensed Staff F also verified the medicine bottle for Prosight w/ vitamins and minerals indicated an expiration date of 8/2022. Licensed Staff F stated she did not check the expiration of the medication. During an interview and concurrent record review with Licensed Staff F on 1/11/2023 at 3:07 p.m. when asked what instructions should be given to Resident 28 prior to albuterol administration, Licensed Staff F stated she would always instruct Resident 28 to shake the meds and watch resident during administration. Licensed Staff F was asked about the risks for Resident 28 if she did not receive the recommended dose of Albuterol according to doctor's order, she stated, it would be a problem for the resident. Review of the package insert (includes details and directions that health care providers need to prescribe a drug properly, including approved uses for the drug, contraindications, potential adverse reactions, available formulations, and dosage, and how to administer the drug) for Albuterol with Licensed Staff F indicated, The patient will breathe out through the mouth and push as much air from the lungs as the patient can. Put the mouthpiece in the mouth and have patient close their lips around it. Push the top of the canister all the way down while the patient breathes in deeply and slowly through the mouth. Right after the spray comes out, release the canister. After the patient has breathed in all the way, take the inhaler out of the mouth. The patient should hold breath as long as they can, up to 10 seconds, then breathe normally. Review of the Facility policy and procedure titled Administering Medications through a Metered Dose Inhaler revised in October 2010 indicated, - Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply. - Place the mouthpiece in the mouth and instruct resident to close his or her lips to form a seal around the mouthpiece. - Firmly depress the mouthpiece against the medication canister to administer medication. - Instruct the resident to inhale deeply and hold for several seconds. - Remove the mouthpiece from the mouth and instruct the resident to exhale slowly through pursed lips. Review of the Facility policy and procedure titled Administering Oral Medications revised in November 2018 indicated, Check the label on the medication and confirm the medication name and dose with the MAR. Check the expiration date on the medication.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records review the facility failed to: 1. Maintain medication room temperature according to manufacturer's guidelines when the facility's emergency kit (E-kit - contain a small quantity of medications that can be dispensed when pharmacy services are not available) containing antibiotics (a medicine that inhibits the growth of or destroys microorganisms) was stored above 77°F (77 degrees Fahrenheit). This failure had the potential risk of bacterial growth and sub-potent antibiotics which could lead to more serious illnesses and antibiotic resistance. 2. Remove an expired bottle of Prosight (eye supplement) with vitamins and minerals from the medication cart; expired acetaminophen (fever reducer) suppository and expired bottle of Stomahesive protective powder (intends to absorb moisture and protect skin from damage) from the shelf of the facility's central supply room. This failure resulted in a medication error and a potential risk for less effective medication. Findings: 1. During an observation in the facility's medication room and concurrent record review with the DSD (Director of Staff Development) on [DATE] at 3:01 p.m., the medication room had emergency kits for narcotics (a drug that relieves pain), oral medications and intramuscular medications (administered into a muscle) containing antibiotics including but not limited to, Cefazoline, Ceftriaxone, and Vancomycin. Review of the document titled Medication Refrigerator and Room Temperature Log with the DSD indicated, Record Med room temperature once daily - Temperature should be between 15 degrees C (Celcius) (59 degrees F) and 30 degrees C (86 degrees F). The DSD verified the medication room thermometer read 78°F. During a review of the document titled Medication Refrigerator and Room Temperature Log from [DATE] to [DATE] indicated a recorded medication temperature for the following dates: 78°F on [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE]; [DATE] and [DATE]. 80°F on [DATE]; [DATE]; [DATE]; and [DATE] During a telephone interview and concurrent record review with the Pharmacist on [DATE] 2:52 p.m., when asked about the recommended room temperature storage for antibiotics, the Pharmacists stated room temperature should be maintained between 59°F to 86°F. Review of the drug summary for Ceftriaxone and Cefazoline with the Pharmacist indicated, Store unreconstituted (unmixed) product at 68 to 77 degrees F. When Pharmacist was asked about the potency of the medication when stored at a temperature higher than the manufacturer's recommendation, Pharmacist stated he would get back to this writer for an answer. During an interview with the DON (Director of Nursing) on [DATE] at 9:48 a.m. when asked about the facility's policy for medication storage, the DON stated facility followed the manufacturer's recommendation for medication storage. The DON concurred risk of compromising potency of the medications when stored on high temperature environment above the manufacturer's recommendation. Review of the Facility policy titled Storage of Medication revised in [DATE] indicated, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 2. During a medication observation on [DATE] at 8:47 a.m., Licensed Staff F prepared ten oral medications for Resident 28 which include Prosight with vitamins and minerals (eye supplement). The medication bottle for Prosight with vitamins and minerals indicated an expiration date of 8/2022. During an interview with Licensed Staff F on [DATE] at 11:00 a.m. Licensed Staff F verified the bottle for Prosight with vitamins and minerals was expired on [DATE]. During an observation and concurrent interview with the DON on [DATE] at 9:01 a.m. in the central supply room, there were three boxes of expired acetaminophen suppository and one bottle of Stomahesive protective powder. The DON verified the acetaminophen suppository expired in 07/2022 and the Stomahesive protective powder expired in 04/2022. DON stated she expected the nurses to check the expiration dates of the over-the-counter medications and to avoid accidental administration of expired medicines. Review of the Facility policy and procedure titled Administering Medications revised in [DATE] indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Review of Facility policy and procedure titled Medication Storage in the Facility, effective date in [DATE] indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

CONCERN (E)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected multiple residents

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Based on interview, and facility document review, the facility's Quality Assurance and Performance Improvement Program (QAPI, a data driven and proactive approach to quality improvement. It combines two approaches - Quality Assurance (QA) and Performance Improvement (PI). QA is a process used to ensure services are meeting quality standards and assuring care reaches a certain level.) failed to identify quality deficiencies as evidenced by: 1) Residents smoking assessments were not being completed timely, the residents were smoking in a non-designated smoking area, by the side of the building a few feet away from the exit door and this area did not contain a fire extinguisher (Cross Reference F689); 2) The facility did not provide Trauma Informed Care in services so staff could provide appropriate and compassionate care specific to individuals who had experienced trauma (Cross reference F699) 3) The facility's Registered Dietician (RD) provided inadequate oversight in the kitchen/dietary department which resulted in dietary staff not knowing how to sanitize items adequately. 4) The facility had no dining program since January 2022 and there were no social activities since January 2022. 5) The facility had not completed the Nursing Competency tests and the Facility's medication error rate was 21.21% 6) The facility had Minimum data Set Assessment (MDS, a health status screening and assessment tool used for all residents of long-term care nursing facilities) issues such as missing quarterly and comprehensive assessments late submissions and late assessment. 7) The facility was missing policies and procedures for ice machine cleaning and sanitizing. The failure to identify quality deficiencies potentially prevented the QAPI committee from addressing issues and developing corrective plans of actions to mitigate those areas of concern. Findings: 1) During a smoking safety screen record review on 1/10/22 at 10:30 a.m., the following residents had late smoking safety screen assessment: Resident 53's last assessment was on 8/4/21, Resident 28's last assessment was 8/10/22, Resident 224 last smoking assessment was on 8/9/22, Resident 225's last assessment was on 8/9/22, Resident 50's last assessment was on 4/7/22 and resident 226's last assessment was on 8/10/22 During an observation on 1/10/23 at 11:30 a.m., Resident 53 was observed to be smoking in a non-designated smoking area, on the side of the facility building a few feet away from the exit door. This area had no fire extinguisher or fireproof blanket noted nearby. During an interview on 1/11/23 at 10:15 a.m., the Assistant Director of Nursing (ADON) verified the side of the building a few feet away from the exit door was the unofficial smoking spot alternative. ADON verified this spot had no fire extinguisher nearby. ADON stated the alternative smoking spot should have a fire extinguisher in place in case of emergency. The ADON verified smoking safety screen assessment was done upon admission and quarterly. ADON stated if this assessment was not done, the facility was not in compliance. The ADON verified this was a safety risk, as resident could end up with burn or inhalation injury. 2) During an interview on 1/12/23 at 1:20 p.m., Unlicensed Staff C stated she does not know what trauma informed care was. During an interview on 1/12/23 at 3:09 p.m., Unlicensed Staff D stated she does not know what trauma informed care was. Unlicensed Staff D stated the facility had not in serviced them about trauma informed care. During an interview on 1/12/23 at 3:45 p.m., Unlicensed Staff K stated the facility has not given them an in service about trauma informed care. Unlicensed Staff K stated she was not aware of what trauma informed care was. 3) During an interview on 1/18/23 at 2:28 p.m., the Administrator verified there were no personnel files on the Registered Dietician (RD). The Administrator verified the facility had no copy of the RD's abuse training or background check. The Administrator verified the QAPI did not address the issue with RD's little to no oversight in the kitchen and the dietary department. The Administrator stated the RD had to spend about 16 hours in the facility weekly, however the RD did not spend this much time assessing residents in person at the facility. The Administrator stated the Interdisciplinary Team (IDT) was aware of resident's complaints of food quality, the Administrator stated the facility dealt with the dietary complaints one on one however there was no tracking of complaints nor resolution in place. The Administrator did not think RD's lack of oversight impacted the quality of food. 4) During an interview on 1/18/23 at 2:28 p.m., the Infection Preventionist (IP) stated the Dining program was discussed during the QAPI meeting. IP stated the roll out was supposed to start with Activity first and then the dining room. IP's reasoning was, after activities, the residents were already in the dining room, in time for meals. IP stated the All Facilities Letter (AFL, a letter from the Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C. The information contained in the AFL may include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility.) containing the guidelines for dining room and activity re opening was missed and was not discussed in QAPI. 5) During an interview on 1/18/23 at 2:28 p.m., the DON verified the medication error rates was not discussed in QAPI. The DON stated she was not aware nurses needed more training on passing medications safely. The DON verified the pharmacist was in charge of completing med pass observation. The DON verified she had mentioned to the Administrator, in passing, the issue about the nurses missing training and competency test. The DON verified there was no QAPI Plan about this issue discussed at this time. 6) During an interview on 1/18/23 at 2:28 p.m., the administrator stated he was not aware of the issue about MDS transmission. He stated this issue was not discussed in QAPI. 7) During an interview on 1/18/23 at 2:28 p.m., the Administrator stated they had not discussed the missing policies and procedures regarding ice machine cleaning. Review of facility's policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program, revised 3/2020, the P&P indicated, the responsibilities of the QAPI committee are to collect and analyze performance indicator data and other information .Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services .Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1) Transmission based precautions (additional measures focused on the particular mode of transmission and are always in addition to standard precautions) were not followed for one resident (Resident 168) when Resident 168's wound was positive for MRSA (Methicillin resistant Staphylococcus aureus - infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infection) and his wound drain was intermittently opened and the drainage was not contained. This failure caused potential spread of MRSA in the environment. 2) Four residents (Resident 182, 169, 23 and 3) were not offered hand hygiene before meals. This failure had the potential risk for residents of getting sick from common germs including Escherichia coli (E. coli) which can cause stomach aches and vomiting. 3) Licensed Staff F did not perform hand hygiene according to the facility policy during medication pass. This failure had the potential spread of disease-causing microorganisms and/or transmission of diseases to the residents. 4) Hand sanitizer utilized by licensed staff did not contain alcohol, per CDC (Center for Disease Control and Prevention) guidelines; and 5) The ice machine was not maintained per manufacture's guidelines. This failure caused potential spread of water-borne diseases such as Legionella (microbe that causes Legionnaires' disease, is a severe form of pneumonia - lung inflammation) when the ice machine was not sanitized per manufacturer's guidelines. Findings: 1) During an observation on 1/09/23 at 9:39 a.m. in Resident 168's room, Resident 168 had left upper arm PICC (Peripherally inserted central catheter - a thin, flexible tube that is inserted into a vein in the upper arm and guided into a large vein used to give medications or liquid nutrition) line in place. Resident 168 stated he gets two kinds of intravenous antibiotics (antibiotics [medicines that are used to treat or prevent bacterial infections] delivered into a vein by injection or through a catheter) five times a day for MRSA to his right foot wound. When Resident 168 was asked about the tubing that was tucked in his socks on his right foot, Resident 168 stated it was his wound vac (Vacuum-assisted closure of a wound - a type of therapy to help wounds heal) Resident 168 was thankful that this writer mentioned about the tubing, or he would have forgotten that his wound vac was disconnected. Resident 168 stated he would usually disconnect the wound vac when he does his exercises with therapy even when he was already told he should not disconnect it. During a record review for Resident 168, the Face sheet (A one-page summary of important information about a resident) indicated Resident 168 was admitted on [DATE] with diagnoses including Osteomyelitis (an infection in a bone); MRSA, and Diabetes Mellitus (disease that result in too much sugar in the blood). During a record review for Resident 168, the Medication Administration Record (MAR) for January 2023 indicated a physician's order for Vancomycin HCl Solution (antibiotic) 1 gram intravenously two times a day and Cefepime HCl Solution (antibiotic) 2 grams intravenously for diagnosis of Methicillin Resistant Staphylococcus Aureus Infection. During an observation on 1/10/2023 at 2:19 p.m. in Resident 168's room with the Medical Director, DON (Director of Nursing) and IPN (Infection Preventionist Nurse), Resident 168 was sitting on his bed with his wound vac on. The wound vac tubing had reddish drainage. When the Medical Director asked Resident 168 if he had been disconnecting his wound vac, Resident 168 verified that he was disconnecting his wound vac when he goes to therapy or when the machine was low on battery. The Medical Director told Resident 168 that the wound vac tubing needs to be capped when disconnected from the machine. During an observation and concurrent interview with the IPN on 1/10/2023 at 2:28 p.m. outside of Resident 168's room, the IPN verified there was no transmission-based precaution posted outside of Resident 168's room. The IPN stated she did not think there was a need to put a precaution signage since Resident 168's wound was contained through the wound vac. until it was brought to her attention that Resident 168 had been disconnecting his wound vac. The IPN concurred there would be a risk of indirect transmission from the CNA providing care to Resident 168 and to other residents. During a record review for Resident 168 on 1/10/2023 at 2:38 p.m. the physician's order for Resident 168 did not indicate what type of precaution staff should observe. During an interview with the IPN on 1/17/2023 at 10:00 a.m. the IPN verified there was no care plan developed for Resident 168 indicating precautions related to MRSA and Resident 168 disconnecting the wound vac prior to 1/10/2023. Review of the Facility policy titled Policies and Practices - Infection Control revised in October 2018 indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 2) During an observation on 1/09/2023 at 11:55 a.m., Resident 182 was sitting on her wheelchair at the hallway outside of her room. CNA (Certified Nurse Assistant) served Resident 182 her meal tray. Resident 182 was not offered hand hygiene. During an observation on 1/09/2023 at 11:56 a.m., CNA served Resident 169 her meal tray. Resident 182 was not offered hand hygiene. During an observation on 1/09/2023 at 11:57 a.m. CNA served Resident 23 her meal tray. Resident 23 was not offered hand hygiene. During an observation on 1/09/2023 at 11:58 a.m. CNA served Resident 3 her meal tray. Resident 3 was not offered hand hygiene. During an interview on 1/17/23 at 10:14 a.m. with the IPN when asked what method of hand hygiene was used for the residents before meals, the IPN stated they would usually use handwipes. The IPN stated the CNAs would hand it to the residents when serving their meal trays; however, the IPN stated they do not have an available hand wipe at the moment. The IPN stated she would not recommend alcohol-based hand rubs for the resident since some of the residents uses their bare hands to eat. During an interview on 1/18/2023 at 10:57 a.m. with Unlicensed Staff O when asked when would she offer hand hygiene to the residents, Unlicensed Staff O stated she would offer hand hygiene every two hours and after patient care. Unlicensed Staff O stated she would use soap and wash cloth. During an interview on 1/18/2023 at 11:01 a.m., Unlicensed Staff P when asked when would she offer hand hygiene to the residents, Unlicensed Staff P stated at start of the shift, after toilet use, before meals and every time food is offered. Unlicensed Staff P stated hand wipes were used for residents; however, Unlicensed Staff P stated wipes are not available at the moment. Review of the facility policy titled Handwashing/ Hand Hygiene revised in August 2019 indicated This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . Before and after eating or handling food; Before and after assisting a resident with meals . 3) During a medication observation on 1/09/2023 at 11:37 a.m. Licensed Staff H was observed passing medication in room [ROOM NUMBER]. Licensed Staff H used Purell wipes when leaving the room. During a medication observation on 1/11/2023 at 8:46 a.m., Licensed Staff F was observed using Purell handwipes that was on top of the medication cart to sanitize her palms and back of hands for approximately 3 seconds prior to preparing the medications for Resident 28. During an interview with Licensed Staff F on 1/11/2023 at 9:05 a.m., Licensed Staff F was asked about methods used for hand hygiene, Licensed Staff F stated she would either use the Purell hand wipes or hand sanitizer by the wall located at the hallways. Review of the facility policy titled Handwashing/ Hand Hygiene revised in August 2019 indicated This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before and after direct contact with residents; Before preparing or handling medications . 4) During an observation at the back nurse's station on 1/11/23 at 3:50 p.m., the medication cart had a container of Purell hand wipes. The container indicated the active ingredient in the wipes was Benzalkonium Chloride 0.13% and the product was, Non-Alcohol Formula. A photograph was taken of the container. During an observations and concurrent interviews on 1/11/23 at 4:00 p.m., multiple licensed nurses were interviewed about the products they used to hand sanitize: Purell wipes (non-alcohol based) versus hand gel (alcohol-based; located on wall-mounted dispensers throughout the facility and on some medication carts). Licensed Staff F stated she used Purell wipes (non-alcohol) and the dispenser on the wall (alcohol-based); Licensed Staff R stated she used the Purell wipes and the dispensers on the wall; Licensed Staff H stated he uses the Purell wipes and the dispensers on the wall; Licensed Staff I stated she used a pump-bottle on her medication cart (alcohol-based gel) and the dispensers on the wall; and Licensed Staff S stated she used the pump-bottle on her cart (alcohol-based gel), Purell wipes, or the dispensers on the wall. During an interview on 1/12/23 at 9:51 a.m., the DON stated the facility had removed the Purell wipes from the medication carts. The DON stated she thought that Purell was a good brand and stated she was unsure what the facility policy was regarding alcohol-based hand sanitizers. During an interview on 1/12/23 at 10:02 a.m., the DON stated the facility's infection control committee had not vetted the Purell wipes (non-alcohol based formula) for appropriateness of use. The DON stated staff should be using a product containing 70% alcohol (to hand sanitize) and verified staff had been using Purell (non-alcohol, containing Benzalkonium) for the previous two months. During an interview on 1/12/23 at 10:24 a.m., the IP stated the facility had educated staff yesterday about the need to use alcohol-based hand sanitizers. IP stated she thought Purell was standard and did not know Purell created a product with Benzalkonium; she stated she did not know the Purell wipes (on the medication carts) had no alcohol. Review of Center for Disease Control and Prevention (CDC) website indicated, Hand hygiene is a critically important prevention measure in all healthcare settings. Each year between 1 and 3 million residents of nursing homes or skilled nursing facilities develop healthcare acquired infections and as many as 380,000 people die of these infections . Alcohol-based hand sanitizer (ABHS) effectively kills most germs carried on the hands of healthcare workers and is recommended for use by the CDC.(https://www.cdc.gov/handhygiene/firesafety/index.html#:~:text=Each%20year%20between%201%20and%203%20million%20residents,and%20is%20recommended%20for%20use%20by%20the%20CDC). 5). During an observation of the ice machine and concurrent interview on 1/12/23 at 3:45 p.m., the ice machine had visible scale buildup (caused from hard water). The Maintenance Director described his process maintaining the ice machine and displayed the products he utilized. Both products were cleaners (not sanitizers) titled, Ice Machine Cleaners; one bottle was made by the manufacturer (#9405463) of the ice machine, the other was made by another company (no part number). Photographs were taken of the two cleaners. The Maintenance Director stated he did not descale the machine. When asked to view a copy of the manufacturer's guidelines for the machine maintenance, the Director stated he did not have one. When asked how he knew how to adequately clean/sanitize the machine, the Maintenance Director stated he watched a YouTube video (to educate himself) and followed the directions on the inside door of the machine. Review of manufactures guidelines (later provided by the facility) titled (Company Name), subtitled, Interior Cleaning and Sanitizing [3-4] (revised 8/2003) indicated, You are responsible for maintaining the ice machine in accordance with the instructions in this manual . (Company name) Ice Machine Cleaner and Sanitizer are the only products approved for use in (Company name) ice machines . Cleaning/Sanitizing Procedure starts on Page 3-8 .[3-8] . Use Ice machine cleaner part number 000000084 (not the part number on Maintenance Director's cleaner) . Use Ice machine sanitizer part number 94-0565-3 . (this part number was not located on either of Maintenance Director's two identified products). Maintenance Director's product made by another company (with no part number) was not located in the manufacturer's guidelines. During a telephone interview on 1/18/23 at 10:52 a.m., the Registered Dietitian (RD) was asked about the ice machine maintenance. The RD stated she was not aware the Maintenance Director was utilizing unapproved products (by the manufacturer) to clean the ice machine. When asked how she knew the ice machine was sanitized adequately, the RD stated the correct products needed to be used. The RD was informed the Maintenance Director had stated he self-educated himself on ice machine maintenance by viewing a YouTube video. The RD stated he needed to be trained properly. When asked if she thought YouTube was an appropriate educational method in a healthcare facility, the RD stated, Probably not, but I have not seen (the) YouTube. When asked if germs (microorganisms) could spread in ice, the RD agreed that they could. During an interview on 1/18/23 at 12:25 p.m. the IP stated she agreed the ice machine had not been cleaned per manufacturer's guidelines. When asked how she knew the ice machine was sanitized adequately, the IP stated she would follow up with the Administrator. During the same interview on 1/18/23 at 12:25 p.m., the IP stated the facility did not have a policy and procedure for ice machines. Online review of the the CDC website titled, Guidelines for Environmental Infection Control in Health-Care Facilities, subtitled, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), further subtitled, 7. Ice Machines and Ice [U.S. Department of Health and Human Services Centers for Disease Control and Prevention . (Updated: July 2019)] indicated, Microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferal of organisms from hands . Ice from contaminated ice machines has been associated with patient colonization (presence of microorganism in the body), blood stream infections, pulmonary (lungs) and gastrointestinal (stomach and intestines) illnesses, and pseudoinfections (presence disease-causing microorganisms in the absence of infection; c) . Ice-making machines .maintenance is important to proper performance. The manufacturer ' s instructions for both the proper method of cleaning and/or maintenance should be followed. These instructions may also recommend an EPA-registered disinfectant to ensure chemical potency, materials compatibility, and safety. The document indicated ice may be contaminated with microorganisms that include Legionella (disease-causing microbe that causes Legionnaires' disease, is a severe form of pneumonia - lung inflammation), Pseudomonas (*), Cryptosporidium (*), Giardia (*), Salmonella (*), staphylococci (*) [*disease-causing microorganism]. (https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines-P.pdf) Online review of CDC website titled, Environmental Infection Control Guidelines, subtitled, Guidelines for Environmental Infection Control in Health-Care Facilities, further subtitled, .D.IX. Ice Machines and Ice (Reviewed: July 23, 2019) indicated recommendations for ice machines including, . D.IX. F. Clean, disinfect, and maintain ice-storage chests on a regular basis . D.IX. F.1.Follow the manufacturer's instructions for cleaning . D.IX. F.2. Use an EPA-registered disinfectant suitable for use on ice machines, dispensers, or storage chests in accordance with label instructions . (https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html)

CONCERN (E)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to offer the pneumococcal vaccine recommended by the Advisory Committee on Immunizations Practices (ACIP- provides advice and guidance to the Director of the CDC [Centers for Disease Control] regarding use of vaccines and related agents for control of vaccine-preventable diseases in the civilian population of the United States.) for 6 of 19 sampled residents (Resident 17, 4, 39, 19, 9, and 118) and 6 randomly selected residents (Resident 2, 173, 24, 20, 174, and 175). This failure had the potential risk for residents to acquire and transmit pneumococcal bacteria that could result in serious respiratory infections. The Centers for Disease Control and Prevention (CDC) recommended revaccination of PPSV23 (Pneumococcal polysaccharide vaccine - also known as Pneumovax 23) at least 1 year after PCV13 (Pneumococcal conjugate vaccine) dose and at least 5 years after any PPSV23 dose for resident over [AGE] years old with underlying medical condition or other risk factor including: Alcoholism, Chronic Heart Disease, Chronic Liver Disease, Chronic Lung Disease, Cigarette Smoking, Diabetes Mellitus, and Cochlear Implant. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf Findings: Resident 2 During a record review for Resident 2, the Face sheet (A one-page summary of important information about a resident) indicated Resident 2 was admitted on [DATE] with diagnoses including Diabetes Mellitus (disease that result in too much sugar in the blood); Hemiplegia and Hemiparesis (paralysis of one side of the body), Hypertension (High Blood Pressure). During an electronic record review for Resident 2, the Immunization Tracking Log indicated Resident 2 received PPSV23 (pneumococcal polysaccharide vaccine - protects against 23 types of pneumococcal bacteria) on 1/23/2017 Resident 173 During a record review for Resident 173, the Face sheet indicated Resident 173 was admitted on [DATE] with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD - diseases that cause airflow blockage and breathing-related problems) and Congestive Heart Failure (CHF - blood often backs up and fluid can build up in the lungs, causing shortness of breath). During an electronic record review for Resident 173, the Immunization Tracking Log indicated Resident 173 received PPSV23 on 9/09/2013. Resident 24 During a record review for Resident 24, the Face sheet indicated Resident 24 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Heart Failure. During an electronic record review for Resident 24, the Immunization Tracking Log indicated Resident 24 received PPSV23 on 9/03/2019. Resident 17 During a record review for Resident 17, the Face sheet indicated Resident 17 was admitted on [DATE] with diagnoses including Diabetes Mellitus and Hypertension. During an electronic record review for Resident 17, the Immunization Tracking Log indicated Resident 17 received PPSV23 on 7/08/2013 Resident 4 During a record review for Resident 4, the Face sheet indicated Resident 4 was admitted on [DATE] with diagnoses including Diabetes Mellitus and Malignant Neoplasm (cancerous tumor) of the Breast. During an electronic record review for Resident 4, the Immunization Tracking Log indicated Resident 4 received PPSV23 on 10/24/2019. Resident 20 During a record review for Resident 20, the Face sheet indicated Resident 20 was admitted on [DATE] with diagnoses including Diabetes Mellitus and Chronic kidney disease (gradual loss of kidney function over time). During an electronic record review for Resident 20, the Immunization Tracking Log indicated Resident 20 received PPSV23 on 1/01/2019. Resident 174 During a record review for Resident 174, the Face sheet indicated Resident 174 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Hypertension. During an electronic record review for Resident 174, the Immunization Tracking Log indicated Resident 174 received PPSV23 on 4/15/2012. Resident 39 During a record review for Resident 39 the Face sheet indicated Resident 39 was admitted on [DATE] with diagnoses including Diabetes Mellitus and Chronic kidney disease. During an electronic record review for Resident 39, the Immunization Tracking Log indicated Resident 39 received PPSV23 on 1/01/2012. Resident 19 During a record review for Resident 19 the Face sheet indicated Resident 19 was admitted on [DATE] with diagnoses including Diabetes Mellitus, Hypertension and Chronic kidney disease. During an electronic record review for Resident 19, the Immunization Tracking Log indicated Resident 19 received PPSV23 on 6/12/2012. Resident 9 During a record review for Resident 9 the Face sheet indicated Resident 9 was admitted on [DATE] with diagnoses including Diabetes Mellitus, and Hypertension. During an electronic record review for Resident 9, the Immunization Tracking Log indicated Resident 9 received PPSV23 on 9/08/2015. Resident 175 During a record review for Resident 175 the Face sheet indicated Resident 175 was admitted on [DATE] with diagnoses including Diabetes Mellitus, and Asthma (condition in which your airways narrow and swell and may produce extra mucus). During an electronic record review for Resident 175, the Immunization Tracking Log indicated Resident 175 received PPSV23 on 1/01/2012. Resident 118 During a record review for Resident 118 the Face sheet indicated Resident 118 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, and Asthma. During an electronic record review for Resident 118, the Immunization Tracking Log indicated Resident 118 received PPSV23 on 4/09/2015. During an interview and concurrent record review with the Infection Preventionist Nurse (IPN) on 1/12/2023 at 2:54 p.m. when asked about her process for making sure resident's pneumococcal status were up to date, she stated she would go through resident's history whether resident had the pneumococcal vaccine in the past and would offer the resident a second dose if they got it before age [AGE]. The IPN verified the immunization tracking log for Resident 2 indicated Resident 2 received PPSV23 vaccine on 1/23/2017. The IPN stated she was not aware of the ACIP Pneumococcal vaccine recommendation therefore residents were not offered of the PPSV23 vaccine. The IPN stated she will start working on the consents to be sent to the residents and to the resident's representatives. During an interview with the IPN on 1/17/2023 at 10:04 a.m. when was asked about the importance of pneumococcal vaccine for the residents, the IPN stated, so residents won't catch Pneumonia (lung inflammation caused by bacterial or viral infection) and other serious respiratory issues. During an interview with the Medical Director on 1/17/2023 at 5:32 p.m. when asked if she was aware of the ACIP recommendation for Pneumococcal vaccine, she stated she was not aware of the new ACIP recommendation for Pneumococcal vaccine. The Medical Director stated the facility will start offering PPSV23 vaccine to residents to make sure the facility is in compliance with the ACIP recommendations. Review of the Facility policy titled Policies and Practices - Infection Control revised in October 2018 indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the Facility policy titled Pneumococcal Vaccine revised in October 2019 indicated, Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

CONCERN (E)

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

Smoking Policies (Tag F0926)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure 1) residents who smokes cigarettes were allowed to smoke in the designated smoking area only for 3 out of 3 sampled residents (Resident 119, 28 and 53), and 2) residents who smoke have a smoking safety screen completed quarterly for six out of eight sampled residents (Resident 50, 53, 28, ,224, 225 and 226). These failures were a safety risk that could lead to unsafe smoking practices. Findings: During a smoking safety screen record review on 1/10/22 at 10:30 a.m., the following residents had late smoking safety screen assessment: Resident 53's last assessment was on 8/4/21, Resident 28's last assessment was 8/10/22, Resident 224 last smoking assessment was on 8/9/22, Resident 225's last assessment was on 8/9/22, Resident 50's last assessment was on 4/7/22 and resident 226's last assessment was on 8/10/22. During an observation on 1/10/23 at 11:30 a.m., Resident 53 was observed to be smoking in a non-designated smoking area, on the side of the facility building a few feet away from the exit door. This area had no fire extinguisher or fireproof blanket noted nearby. During an observation and interview on 01/10/23 at 11:42 a.m., Resident 119, Resident 28, Resident 53 and Resident 119's husband were outside smoking. No staff were present. No fire extinguisher was present; Resident 119 confirmed there was no fire extinguisher. When asked why they were outside smoking, Resident 119 stated smoking times were 9 a.m., 2 p.m., and 6 p.m. and stated, we just came out to smoke. During an interview on 1/11/23 at 10:15 a.m., the Assistant Director of Nursing (ADON) verified the side of the building a few feet away from the exit door was the unofficial smoking spot alternative. ADON verified this spot had no fire extinguisher nearby. ADON stated the alternative smoking spot should have a fire extinguisher in place in case of emergency. The ADON verified smoking safety screen assessment was done upon admission and quarterly. ADON stated if this assessment was not done, the facility was not in compliance. The ADON verified this was a safety risk, as resident could end up with burn or inhalation injury. During an interview on 1/12/23 at 11:00 a.m., the Activity Director (AD) verified the designated smoking area was at the back of the building. The AD verified smoking assessments should be completed quarterly and as needed for resident's safety and to take note of changes to keep resident's safe when smoking. During an interview on 1/12/23 at 11:10 a.m., the Director of Nursing (DON) verified that smoking safety screen assessment should be completed quarterly. The DON verified resident's smoking assessment were late. The DON stated she was able to do some this week. The DON stated if this assessment was not done timely, it could compromise resident safety, because staff would not know if there were any changes in resident status that could impact the resident's ability to smoke safely. The DON verified the designated smoking area was at the back of the building. The DON stated residents who smoke should not even smoke on the side building despite the bad weather, since this location was not 20 feet away from resident's general area. During an interview with Licensed Staff B on 1/12/23 at 3:18 p.m., Licensed Staff B stated the smoking safety screen was to be completed upon admission and quarterly. Licensed Staff B stated if smoking assessment were not completed or if it was done late, then the facility policy was not followed. Licensed Staff B stated this was a safety risk for resident because if there were changes on resident's capacity to smoke safely, staff will not be aware and changes would not be initiated. During an interview on 1/12/23 at 4:55 p.m., the Administrator verified residents should only smoke at the designated smoking area located at the back of the building. The Administrator verified residents should not be smoking at the side of the building because it was not 20 feet away from the residents general area. However, the Administrator stated that since it was raining, the residents were allowed to smoke on the side of the building. When asked whether the facility was compliant with the smoking policy, the Administrator stated well what do you want me to do? I am not going to give you an answer that could result to a deficiency. During a concurrent observation and interview on 1/13/23 at 9:18 a.m., Unlicensed Staff K verified the cigarette fumes/ smell was immediately noticeable once she opened the exit door by the side of the building. When asked if this was acceptable, Unlicensed Staff K was silent. During a concurrent interview and Smoking policy review on 1/13/23 at 9:40 a.m., the DON verified the facility was not compliant when they allowed the resident to smoke at the side of the building. The DON verified the smoke could enter the building and the smell could get stuck at the walls. The DON stated if the exit door by the side of the building was opened after or while the residents were smoking, the smoke could enter the building. The DON stated this was a safety hazard for other residents due to second hand smoke. During a concurrent interview and smoking safety screen assessment record review on 1/13/23 at 2:52 p.m., the Director of Staff Development (DSD) verified this assessment was done by the nurses upon admission and quarterly. The DSD verified the smoking safety screen assessment for Residents 50, 53, 28, ,224, 225 and 226 were completed late. The DSD stated this assessment was supposed to be completed timely for resident's safety. The DSD stated if the smoking safety assessment was not done or not done timely it could lead to accidents such as burn injury. The DSD stated this assessment could also tell you if residents were safe to smoke by themselves or if they needed staff to supervise them. During an interview on 1/13/23 at 3:25 p.m., the Infection Preventionist (IP) verified residents who smokes need to have smoking safety screen assessment upon admission and quarterly thereafter. The IP stated this assessment was important to ensure residents safety. The IP stated the facility policy was not followed if this assessment was not done timely. During a review of the facility's policy and procedure (P&P) titled Smoking Policy-Residents, undated, the policy indicated smoking is only permitted in designated resident smoking area which is located at the back of the building .the resident's ability to smoke safely will be re-evaluated quarterly.

CONCERN (F)

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

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to ensure a Quarterly Minimum Data Set ((MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) was completed for 9 of 19 sampled residents (Resident 22, 41, 58, 14, 3, 23, 46, 33, and 36) and 2 randomly selected residents (Resident 178, and 176). This failure resulted in inadequate monitoring of Residents 22, 41, 178, 176, 58, 14, 3, 23, 46, 33, and 36's progress and decline, and the lack of resident specific information to CMS (Centers for Medicare & Medicaid Services) for payment and quality measure monitoring. Findings: During an electronic record review for Resident 178, the MDS Tracking indicated a quarterly MDS assessment for Resident 178 dated 11/26/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 22, the MDS Tracking indicated a quarterly MDS assessment for Resident 22 dated 10/19/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 41, the MDS Tracking indicated a quarterly MDS assessment for Resident 41 dated 11/20/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 176, the MDS Tracking indicated a quarterly MDS assessment for Resident 176 dated 12/29/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 58, the MDS Tracking indicated a quarterly MDS assessment for Resident 58 dated 12/16/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 14, the MDS Tracking indicated a quarterly MDS assessment for Resident 14 dated 10/28/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 3, the MDS Tracking indicated a quarterly MDS assessment for Resident 3 dated 11/27/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 23, the MDS Tracking indicated a quarterly MDS assessment for Resident 23 dated 10/20/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 46, the MDS Tracking indicated a quarterly MDS assessment for Resident 46 dated 11/15/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 33, the MDS Tracking indicated a quarterly MDS assessment for Resident 33 dated 10/10/2022. The assessment status indicated, In Progress. During an electronic record review for Resident 36, the MDS Tracking indicated a quarterly MDS assessment for Resident 36 dated 11/28/2022. The assessment status indicated, In Progress. During an interview with the MDS Coordinator (MDSC) on 1/18/23 10:15 a.m., the MDSC was asked when to complete a quarterly MDS assessment for the residents. MDSC stated quarterly assessments were scheduled every three months and should be completed within 14 days from the assessment reference date (ARD -last day of the observation [or look back] period that the assessment covers for the resident). During a record review and concurrent interview with the MDS Coordinator (MDSC) on 1/18/23 at 10:29 a.m., the MDSC verified Resident 178's MDS tracking indicated the status of the quarterly assessment dated [DATE] was In Progress. The MDSC was asked what in progress mean. The MDSC stated, assessment was not completed. Review of the Facility policy and procedure titled Resident Assessments revised in November 2019 indicated, The Resident Assessment Coordinator is responsible for ensuring that the interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to OBRA (Omnibus Budget Reconciliation Act - a schedule of assessments that will be performed for a nursing facility resident at admission, quarterly, and annually, whenever the resident experiences a significant change in status, and whenever the facility identifies a significant error in a prior assessment) required assessments. The policy indicated, Quarterly Assessment - Conducted not less frequently than three (3) mouths following the most recent OBRA assessment of any type.

CONCERN (F)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident 172 During an observation on 1/09/2023 at 4:06 p.m. in Resident 172's room, Resident 172 had a low bed approximately one foot from the floor and a landing pad (used to reduce fall related trauma) beside the bed. Resident 172 was awake, lying across the landing pad on the floor. Resident 172 did not respond when spoken to. Resident 172's television was off. During an observation on 1/13/2023 at 2:05 p.m. in Resident 172's room, Resident 172 was lying top of the landing pad, awake. Resident 172's television was off. During an observation on 1/17/23 at 9:57 a.m. in Resident 172's room, Resident 172 was lying in bed with his head on foot part of the bed. Resident 172 was facing the wall, appeared sleeping. During a record review for Resident 172, the Face sheet (A one-page summary of important information about a resident) indicated Resident 172 was admitted on [DATE] with diagnosis including Vascular Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 172, the document titled Activities - Quarterly/Annual Participation Review dated 6/04/2021 indicated, [Resident 172] benefits from daily in room visits with assistance: coffee, hydration, sensory, aromatherapy, movies/music at bed side, outdoor opportunities following CDC (Centers for Disease Control) guidelines. During a record review for Resident 172, the Activity Care Plan initiated revised in 11/05/2021 indicated, [Resident 172] is independent for meeting emotional, intellectual, physical, and social needs. The Care Plan interventions indicated: - Resident will benefit from daily in room visits with offers/assistance: a la carte activities, movies/ music at bedside, phone/ video calls, coffee, hydration, outdoor opportunities. - The resident's preferred activities are: to watch at his favorite tv programs, wheel CNA (Certified Nursing Assistant) himself around the facility, attend to modified group programs of choice at his own comfort. During a record review for Resident 172, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 5/15/2022 indicated Resident 172 had a BIMS score of 9 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 - 15 is cognitively intact, 08 - 12 is moderately impaired, and 00 - 07 is severe impairment). The MDS indicated it was very important for Resident 172 to: listen to music; do his favorite activities; go outside to get fresh air when the weather is good. The MDS indicated it was somewhat important for Resident 172 to be around animals such as pets; keep up with the news; participate in religious services or practices. During a record review for Resident 172, the document titled Empres-Activity Progress Note dated 11/18/2022 indicated, [Resident 172] has been stable with participation in independent activities at his own leisure When in his room he enjoys to either lay on his bed or/on a floor mat per choice. He enjoys to watch at his favorite tv programs, movies/music at bed side provided by activity staff at his request. He continues to enjoys to wheel himself around the facility, a time he will go to the activity room out to the courtyard where he enjoys to socialize with staff, by reminiscing and/or listening to rock & roll music. He benefits from daily in room visits with offers/assistance: a la carte activities, movies/music at bed side, phone/video calls, coffee, hydration, outdoor opportunities. During an interview with Unlicensed Staff D on 1/17/2023 at 11:16 a.m. when asked how much assistance does Resident 172 need to get out of bed, Unlicensed Staff D stated Resident 172 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assistance with transfers. Unlicensed Staff D stated resident did not get out of bed for activities. Unlicensed Staff D stated there had been no group activities due to the dining room had been closed since Covid. Unlicensed Staff D stated activity staff provides in room visit for Resident 172 to provide music and movies. Resident 181 During an observation on 1/09/2023 at 4:12 p.m. in Resident 181's room, Resident 181 was in bed with eyes closed. During an observation on 1/17/23 at 9:57 a.m. in Resident 181's room, Resident 181 was in bed with eyes closed. Resident 181's television was off. During an observation on 1/17/23 at 4:16 p.m. in Resident 181's room, Resident 181 was in bed with eyes closed. Resident 181's television was off. During a record review for Resident 181, the Face sheet indicated Resident 181 was admitted on [DATE] with diagnoses including Alzheimer's Disease (type of dementia that causes problems with memory, thinking and behavior), Psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and Hypertension (High Blood Pressure). During a record review for Resident 181, the Activity Care Plan revised in 8/11/2022 indicated, [Resident 181] is dependent on staff for meeting emotional, intellectual, physical, and social needs related to Cognitive deficits, Disease process, Immobility (state of not being able to move around), Physical Limitations. Care Plan interventions indicated: - During COVID-19 resident will benefit from daily in room visits with offer/assisted: coffee, hydration, music/movies at bedside, phone/video calls, sensory, range of motion, aromatherapy, outdoor. - He benefits from 1:1 (one staff to one resident) in room visits 2-3 times a week for social stimulation. During a record review for Resident 181, the Minimum Data Set, dated [DATE] indicated Resident 181 had Short term memory (capacity to store a small amount of information in mind and keep it available for a short time) and Long-term memory (the memory process in the brain that takes information from the short-term memory store and creates long lasting memories) problem. The MDS indicated Resident 181 had severely impaired (never/rarely made decisions) cognitive skills for decision making. The MDS indicated it was very important for Resident 181 to: listen to music; do things with groups of people; do his favorite activities and participate in religious services or practices. It was somewhat important for Resident 181 to be around animals such as pets; and go outside to get fresh air when the weather is good. During a record review for Resident 172, the document titled Empres-Activity Progress Note dated 11/10/2022 indicated, [Resident 181] has been stable accepting of soothing activities, range of motion, sensory, aromatherapy, music at bed side, assistance to turn tv and/or music devices on. He benefits from daily in room visits with offers/assisted: coffee, hydration, music/movies at bedside, phone/video calls, sensory, range of motion, aromatherapy, outdoor. He benefits from 1: 1 in room visits 2-3x a week for social stimulation. During a record review for Resident 172, the document titled Activity Participation Log for 1/17/2023 indicated Resident 181 provided the following activities: television, reading, family/ friends, outdoors, music and coffee/hydration. During an interview with the Activity Director on 1/17/23 at 4:24 p.m. when asked what activities were provided for Resident 181, the Activity Director stated Resident 181 received range of motion, music at bed side, sensory and low stimulation activities. When Activity Director was asked what activities were provided today for Resident 181, she stated Resident 181 received range of motion and music today. During an interview with the Activity Director on 1/17/23 at 4:29 p.m. When asked how much time was spent with residents when providing activity, the Activity director stated the activity assistants visits all dependent residents and spends at least 10 - 15 minutes each day. Based on observation, interview, and record review, the facility failed to provide activities that met individual resident's needs and preferences, per facility Activity policy and procedure, when 1.a.) 5 of 5 Confidential Residents (CR 1, 2, 3, 4, and CR 5) and 1 of 3 Unsampled Resident (Resident 57) were not provided group/social activities per their liking, 1.b.) Leadership personnel (Infection Preventionist and Activity Director) canceled scheduled group/social activities despite State liberalization of Covid mitigation measures (interventions designed to decrease spread of COVID 19, viral pandemic (widespread disease epidemic over several countries) that began in 2020) and 2) 2 of 3 Unsampled Residents (Resident 172 and Resident 181) were not provided individual activities per their care plans. These failures contributed to Resident 57, CR 4, CR 2, and CR 5 feeling bored, prevented residents who desired organized group activities from socializing, and potentially caused Residents 172 and Resident 181 to experience decreased sensory stimulation and quality of life. Findings: 1) During an interview on 1/09/23 at 10:50 a.m., Resident 121 was asked about the activities at the facility. Resident 121 stated they used to have Bingo often (but they no longer did) and stated she thought it might be due to Covid. During an interview on 01/09/23 at 11:34 a.m., Resident 2 stated there was not as much Bingo but he goes when he can. During an interview on 1/09/23 at 12:04 p.m. Unlicensed Staff N was asked about the use of dining rooms (where group/social activities occurred) at the facility. Unlicensed Staff N stated the facility had two dining rooms but they were not using them. When asked why the dining rooms were not in use, Unlicensed Staff N stated they had not been using them due to Covid. When asked how long the dining rooms were not in use, Unlicensed Staff N shrugged and stated they were opened last year (2022) and then closed again. During an observation and concurrent interview in the dining room on 01/09/23 at 12:15 p.m., three residents were in the large dining room (Station 3). When asked if it was normal to have only three residents in the dining room, Resident 122 stated there was usually not many people in there. During an observation on 01/10/23 at 9:18 a.m., the large dining room had no residents or staff inside and the doors were closed. The activity board (located outside the dining room) indicated the current activity was Coffee at your door (in-room coffee delivery). Review of the facility activity calendars for December 2022 and January 2023 indicated the facility offered two group/social activities daily: Sing Along group at 10 a.m. and Bingo group at 2 p.m. (occasionally at 2:30 p.m.). Other activities on the calendar, offered Monday through Friday, were individual activities that included Coffee at your door (coffee delivery) . 9am - 5pm in room visits .1pm hydration at your door (beverage delivery) .3:30pm Pretty nails at you door. The calendar indicated Bible study at your door was offered every other Wednesday; Devotions with Fernando and Catholic communion at you door were offered on Sundays; Resident birthday greeting were intermittently offered; Food committee and Resident Council were each offered once a month. During a confidential interview on 01/10/23 at 10:00 a.m., five confidential residents (CR 1, CR 2, CR 3, CR 4, and CR 5) were asked about activities at the facility. Confidential Resident (CR) 4 stated he missed Bingo and stated it had been a long time since they had played. CR 4 stated he could not remember the last time there was Bingo and stated it may have been before Covid (2020). When asked how he felt about the lack of Bingo, CR 4 stated, it's boring. Review of CR 4's medical record revealed he had a BIMS score (Brief Interview for Mental Status; assessment tool for cognitive status - mental processes of perception, memory, judgment, and reasoning ) on 12/26/22 of 15 (cognitively intact). During the same confidential interview on 01/10/23 at 10:00 a.m., CR 2 stated there were no group activities at the facility. CR 2 stated she wanted group activities and it was, boring (without them). Review of CR 2's medical record indicated they had a BIMS score on 12/20/22 of 14 (cognitively intact). During the same confidential interview on 01/10/23 at 10:00 a.m., CR 3 stated he wanted to play Bingo but there was no Bingo. Review of CR 3's medical record indicated they had a BIMS score on 12/26/22 of 09 (moderate cognitive impairment). During the same confidential interview on 01/10/23 at 10:00 a.m., CR 5 stated she was bored and wanted some group activities. Review of CR 5's medical record indicated they had a BIMS score on 11/29/22 of 15 (cognitively intact). During the same confidential interview on 01/10/23 at 10:00 a.m., CR 1 stated it had been six months since the facility had group Bingo and she wanted Bingo back. When asked why there was no Bingo, CR 1 stated she thought it was about Covid. Review of CR 1's medical record indicated they had a BIMS score on 12/2/22 of 13 (cognitively intact). During the same confidential interview on 01/10/23 at 10:00 a.m., five out of five confidential residents (CR 1, CR 2, CR 3, CR 4, and CR 5) stated group activities at the facility did not change with or without a Covid outbreaks in the building (social activities did not increase when the building was Covid-free). Review of CR 4's Activity Care Plan (information about a resident's diagnosis, progress, goals, and needs), initiated and revised on 2/23/21, indicated, The resident is independent with involvement and participation in activities at his own leisure .will maintain involvement in . social activities .Resident will benefit from daily in room visits: coffee, hydration . The inclusion of social activities, and his desire for Bingo, were not located in the Care Plan. Review of CR 4's documented Care Conference (scheduled meetings with residents/resident responsible party, leadership staff [nursing, dietary, activity, etc.] where the team reviews/addresses resident's overall care, goals, issues, etc.), subtitled, Activities, dated 12/15/22 indicated, Resident enjoys daily in room visits with offers of: coffee, hydration, a la carte activities, music/movies at bedside, phone/video calls . He enjoys to watch at his favorite tv programs, listen to music and/or movies using his own personal tablet either in his room or out in the dining room. Review of CR 2's Activity Care Plan (dated 5/7/20) indicated, Activities: Invite the resident to activity programs that encourage physical activity . such as exercise group, walking activities to promote mobility. Review of CR 2's Care Conference notes (dated 11/23/22) indicated, Activities .Resident will benefit from daily in room visits with offers: coffee, hydration, a la carte activities (reading material, movies/music at bed side, video/phone calls, pretty nails, range of motion [improving movement of specific joints], sensory, aromatherapy), music/movies at bedside, phone/video calls, sensory, aromatherapy, outdoor, pretty nails. Review of CR 3's Care Plan (revised 7/31/22) indicated, (Resident 3) is dependent on staff for meeting .social needs . (Resident 3) will maintain involvement in social activities . Invite the resident to scheduled activities .Resident will benefits (sic) daily in room visits .The resident needs assistance/escort to activity functions . Review of CR 3's Care Conference documentation (dated 10/21/22) indicated, Activities .Resident will benefits (sic) from daily in room visits with offers/assistance: a la carte activities, movies/music at bedside, phone/video calls, hydration, coffee. CR 3's desire to play Bingo was not located in his Care Plan or Care Conference notes. The Care Conference notes did not indicate how staff assisted Resident 3 in maintaining involvement in social activities (as outlined in the care plan). Review of CR 5's Activity care plan indicated she was independent with activity participation and would, maintain involvement in . social activities . Resident will benefit from daily in room visits with offers: coffee, hydration, a la carte activities, music/movies at bedside, phone/video calls, sensory, aromatherapy, outdoor, pretty nails. Review of CR 5's Care Conference notes, subtitled Activities (dated 11/29/22) indicated, Resident enjoys daily in room visits with offers: coffee, hydration, a la carte activities, music/movies at bedside, phone/video calls, sensory, aromatherapy, outdoor, pretty nails. Also attend to small group programs of choice when scheduled. Neither the Care Plan nor the Care Conference notes indicated CR 5 was bored, wanted some small group activities and did not indicate how staff assisted her in maintaining involvement in social activities (per Care Plan). Review of facility documents titled, Activity Participation Record (for Residents 1, 2, 3, 4, and 5) indicated from September 1, 2022 through January 10, 2023 (greater than a four-month period), the facility scheduled two daily social/group activities (Sing Along and Bingo); all scheduled social activities during this four-plus month timespan were canceled, with the exception of an eleven-day stretch (11/17/22 - 11/28/22). The records indicated in September, 2022, all days (approximately thirty days) of the month were marked with a C (indicating Sing Along and Bingo were were scheduled, but canceled in September). The October, 2022 Sing Along and Bingo records indicated all days of the month (approximately thirty-one days) were marked with a C (canceled). The November Sing Along and Bingo records were blank from 11/1/22 through 11/16/22; the record indicated residents attended Sing Along and Bingo from from 11/17/22 through 11/28/22 (eleven days); the two group activities were again canceled (marked with a C) on 11/29/22 - 11/31/22. The December Sing Along and Bingo records indicated all days of the month (approximately thirty-one days) were marked with a C (canceled). During January, 2023, the records indicated Sing Along and Bingo were canceled from 1/1/23 - 1/9/23 (the facility was Covid-free on 1/9/23). The records indicated Sing Along and Bingo were resumed on 1/10/23 (the day after survey initiation). During an interview on 1/11/23 at 09:40 a.m., the Infection Preventionist (IP) stated the facility was currently Covid-free and their last Covid positive (staff) was approximately 12/29/22. She stated when they have a positive case, they isolate (residents) in the exposure area (where the positive staff worked). The last Covid positive staff was charge nurse and had worded all over the building. The IP stated they used the dining room for very small groups. When asked when Bingo occurred, the IP stated they had Bingo when they had no Covid outbreak. The IP stated residents could do stuff (activities) in the hallway. The IP stated the facility was following State, Federal, and local Covid guidelines. During an observation on 1/11/23 at 10:20 a.m., an exercise class was occurring in the large dining room. Five unidentified residents (out of an approximate census of ninety-two) were present. During an observation and concurrent interview on 01/13/23 at 10:34 a.m., Resident 57 was lying in bed watching television and stated she had not gotten up for a few days. When asked why she had not gotten up, Resident 57 stated she did not have access to the chair (a wheel chair was next to her bed). When asked if she would get up to a chair every day if staff helped her, she stated, no, it's boring just sitting in her room. When asked if she liked Bingo and music, Resident 57 stated, yes and stated she used to play piano. When asked if she would get up to a chair to play Bingo and listen to music, Resident 57 stated, I might. Resident 57 stated if music was in the building, I think I would get up. Review of Resident 57's medical record revealed on 12/2/2022 she had a BIMS score of 14 (cognitively intact). Review of Resident 57's Nursing Care Plan indicated, (Resident 57) will maintain involvement in . social activities as desired . Invite the resident to scheduled activities . During an interview on 01/17/23 at 10:30 a.m., Unlicensed Staff K stated she assisted with activities for multiple years at the facility. Unlicensed Unlicensed Staff K was asked to describe activities at the facility and she stated they conducted small group activities in the morning like stretches, reading, and pod casts. She stated during the day, activity staff provided room visits, hydration, and sometimes painted nails. She stated Bingo was played at 2 p.m. Unlicensed Staff K stated Bingo and Sing along (with exercise) were canceled during Covid outbreaks. She stated morning exercising and afternoon Bingo (the two scheduled social activities) were canceled almost the entire month of December (2022) but she was unsure about social activities in November. Unlicensed Staff K stated they (staff and residents) masked and social distanced during social activities. Review of AFL (All Facilities Letter; State healthcare guidelines) 22-07.1 (dated 10/6/2022) indicated, Communal Dining and Group Activities: Communal activities . may occur in the following manner: . Residents who are not in isolation may participate in group/social activities together without face masks or physical distancing, regardless of vaccination status. Facilities should consider, in consultation with their local health department, reimplementing limitations on communal activities and dining based on the status of COVID-19 infections in the facility . During an interview and concurrent review of AFL 22-13.1 (dated October 5, 2022) on 1/17/23 at 4:19 p.m., the IP stated she was not aware AFL's (State guidelines) had been updated to change isolation requirements for residents regarding activities. Review of AFL 22-13.1 (dated October 5, 2022) indicated, Post-Exposure and Response Testing .CDPH (California Department of Public Health) continues to recommend immediate investigation as a potential outbreak when one (or more) COVID-19 positive individuals (resident or HCP [healthcare personnel]) is identified in a facility. SNFs should perform contact tracing within the facility to identify . residents who may have had high-risk close contact with the individual with SARS-CoV-2 (Covid) infection . Residents who are close contacts, regardless of vaccination status, should wear source control when outside their room but do not need to be quarantined, restricted to their room . A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach with quarantine for exposed groups should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. During an interview on 1/17/23 at 4:36 p.m., the Medical Director stated she was not aware the facility was not following updated AFL guidance regarding activities. During an interview on 01/18/23 at 10:00 a.m., the Activity Director (AD) was asked to describe social activities at the facility. The AD stated they had one social activity in the morning (singing and exercising) and one in the afternoon (Bingo). She stated the Coffee listed on the activity calendar used to be social (in the dining room) but it was changed to coffee in resident rooms; she stated residents enjoyed the room visits with coffee delivery. When asked why group activities were important, the AD stated they provided residents with an, opportunity to engage with staff and peers and was good for emotional health. The AD stated residents loved Bingo so they scheduled it daily. She stated during the pandemic (beginning in 2020), they did Bingo in the hallway (rather than the dining rooms). The AD stated hallway-Bingo was popular but was noisy, and some residents thought it was too loud. The AD stated they needed a dining room for Bingo so they could close the doors and decrease noise. The AD stated they canceled group activities during Covid outbreaks. When asked who instructed her to cancel activities, she stated she thought it was the Infection Preventionist. During the same interview 01/18/23 at 10:00 a.m., the AD was asked why there were only two social activities (morning exercise/music and afternoon Bingo) on the calendar. The AD stated, I need to modify my calendar. When asked why she had not yet modified the variety of activities, the AD stated residents enjoyed personal visits (individual). She stated she was thinking of adding more group activities to increase variety. Review of facility policy titled, Activity Programs (revised June, 2018) indicated the, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being of each resident. Under subtitle, Policy Interpretation and Implementation, the policy indicated, 1. The Activities Program is provided to support . community interaction . 2 .based on the comprehensive resident-centered assessment .3.is ongoing and includes facility-organized group activities . 5. Our activity programs are . geared to the individual resident's needs . 7. Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident .

CONCERN (F)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, intervention and record review, the facility: 1). Failed to ensure the Registered Dietitian (RD) provided services to meet the needs of the residents when nutritional assessments (overall nutritional status of patients) were routinely done remotely, without direct observation of the resident and without resident (or responsible party) interviews; 2) Failed to ensure the Registered Dietitian (RD) provided adequate oversight in the kitchen, per job description, when a) dietary staff, did not have documented job related competencies (verified skills required to perform duties) in their employee file and b) the dietary manager was evaluated by the Administrator; and 3) Failed to ensure the RD addressed resident complaints regarding food quality/palatability. These failures potentially prevented accurate and timely resident nutritional assessments, contributed to inadequate oversight of dietary services, contributed to poor food quality and palatability, and potentially negatively affected residents overall quality of life. Findings: 1) During an interview in the kitchen on 1/09/23 at 0930 a.m., the Dietary Manager (DM) stated the RD works from home and came in (to facility) now and then and as needed. When asked how long has she had been working form home, the DM stated since Covid and stated she comes in (to the facility) one to two times per month. During an interview on 01/12/23 at 10:48 a.m., DON and IP stated they were not aware when the RD had last been in the building. During a telephone interview on 01/13/23 at 04:01 p.m., the RD stated she worked an average of eight to twelve hours per week (to address the nutritional needs of approximately ninety-two residents) and her job included assessing new admissions, quarterly/annual nutritional assessments, assessing residents with weight changes, skin issues, and significant changes. She stated she worked from home during severe Covid outbreaks. When asked why she did not come to the facility during a Covid outbreak, the RD stated I'll still go in but she used her judgement. When asked to define a severe outbreak, the RD stated, I can't say exactly. She stated she worked full-time for another skilled nursing home and she followed their requirements (the other facility's requirements). The RD stated she typically went into the facility every three weeks, on weekends and after her other, full-time job (evenings). During an interview on 1/17/23 at 4:36 p.m., the Medical Director stated she was unaware the RD was primarily working remotely and not coming into the building (to assess patients). The MD stated she was not aware resident nutritional assessments were primarily done remotely. The MD did not know what was included in the RD's job description. During an interview on 01/17/23 at 5:02 p.m., the Administrator stated he was not aware how often the RD came to the building (to work onsite). During a telephone interview and record review on 01/18/23 at 10:52 a.m., the RD reviewed her timesheets. When asked if she had come to the facility in June (2022) and December (2022), the RD stated she was not sure if she had come to the facility in June and stated, I can't answer specifically for that month. The RD stated she was ill in December and was not able to be onsite. The RD confirmed she had no contract but had a signed job description. During the same telephone interview on 01/18/23 at 10:52 a.m., the RD was asked how she performed her onsite visits. She stated she would follow up with residents she needed to check with, put eyes on the kitchen and check in with the Dietary Manager. When asked how she performed her Resident assessments and asked if they were done remotely, via record review (review of the medical record), the RD stated, Everything is electronic. She stated she reviewed PCC (computerized medical record) including the lab results. When asked if she observed and interviewed residents, the RD stated she probably performed 30% - 50% resident assessments in person. When asked who performed resident eating observations (ability to chew/swallow food safely), the RD stated, I don't observe actual eating. When asked who observes resident's ability to eat, she stated the nursing aids document how much is eaten. The RD stated, I can't assess dysphagia (difficulty swallowing). She stated the Interdisciplinary Team (team of healthcare staff - nursing, activity, dietary, etc.) gave her information on adaptive devices (residents who require special equipment to eat). The RD stated if someone clinically needed a visit, I would try and arrange the visit. During the same telephone interview on 01/18/23 at 10:52 a.m., the RD was informed that the industry practice (by comparable skilled nursing facilities) was for weekly onsite visits (that allowed for direct resident observation/interview) by the RD. When asked why she did not follow this practice, the RD stated she worked weekly (remotely) and stated since she started working at the facility, she had been coming onsite every two to three weeks. When asked what professional standards she followed indicating that was an acceptable practice, she stated she had discussed the practice with the facility owner. The RD did not identify a professional standard (for example, American Dietetic Association: standards of practice and standards of professional performance for registered dietitians) that she was following. When asked to identify what RD standards she was following to perform remote resident assessments (versus in-person), the RD stated regardless of the frequency of her facility visits, people would be admitted or discharged (and she might not be able to see them in-person). When asked if she interviewed residents (or their responsible parties), she stated, if I find the need. She stated she did not interview all residents but she interviewed residents and families, if I need to. During the same telephone interview and medical record review on 01/18/23 at 10:52 a.m., the RD was asked about Resident 19, who was admitted [DATE] with a food ulcer (wound) and Diabetes (both requiring an RD assessment). The RD electronically reviewed her documentation and confirmed she did not reevaluate Resident 19, after her initial assessment. When asked if she had met or interviewed Resident 19 since her admission (approximately four weeks earlier), the RD stated, no and stated she had not spoken to Resident 19. The RD stated she had assessed her without seeing her. When asked if she had interviewed her, the RD stated, no, not yet. Review of Resident 19' medical record revealed she was admitted on [DATE] with diagnosis including infection, Diabetes, and a diabetic foot ulcer (wound). A Nutritional Evaluation Form (dated 1/2/23 - approximately twelve days after admission) indicated, admitted with .Diabetic ulcer to R (right) heel, R foot 5th digit (toe), L foot 2nd digit (non pressure wounds) . Excellent PO (by mouth) intake . Unable to assess estimated nutritional needs and BMI (body mass index) at this time r/t (related to) awaiting admit and current weight. Resident likely meeting estimated needs r/t excellent PO intakes. Will f/u (follow up) with further nutritional interventions pending weights and and further weight changes. At risk of weight changes . The note was electronically signed by the RD. Review of the RD's signed (on 1/1/2021) Dietician Consultant job description indicated, . Interview residents or family members, as necessary, to determine diet history . Visit residents periodically to evaluate the quality of meals served, likes and disliked, etc. Involve the resident/family in planning dietary objectives and goals . 2) During an observation and concurrent interview on 1/12/23 at 03:45 p.m., the kitchen sanitizer was noted to be a non-quaternary (common kitchen sanitizer) formula. The Dietary Manager stated the sanitizer had changed during Covid. Photos were taken of the sanitizer. (The sanitizer had a one minute contact time - time required for the product to remain wet on a surface to ensure adequate sanitizing and killing of disease-causing microorganisms). During and interview on 1/13/23 at 3:42 p.m., Dietary Staff Z, AA, and BB (via interpreter) stated they were unaware of the sanitizer's one minute contact time. The Dietary Manager stated he was unaware of the one minute contact time and stated staff were not tracking wet time; he stated they let the surfaces air dry. During a telephone interview on 01/13/23 at 04:01 p.m., the RD was informed dietary staff had not known the contact time of the sanitizer or that surfaces were supposed to stay wet for a minute. The RD stated no one watches for one minute but the surface likely stayed wet for one minute. When asked if she performed monthly kitchen inspections, she stated she observed trayline (staff preparing and serving meals - assess accuracy of food type, textures, allergies, etc.) . on and off. During an employee file review on 01/17/23 at 11:03 a.m., the DSD (Director of Staff Development) stated the RD did not have an employee file. The Dietary Manager, Dietary Staff Z, Dietary Staff AA, Dietary Staff CC, and Dietary Staff DD did not have documented competencies regarding the sanitizer's contact time. The Dietary Manager's last evaluation (dated 9/8/21) was conducted and signed by the Administrator (not the RD). The Employee Performance review indicated, Has employee met goals set during last evaluation? . Yes, (Dietary Manager) has kept food costs per patient per day as low as possible . When asked if the Administrator had the educational background (in nutritional services) to evaluate the Dietary Manager's job performance, the DSD agreed the Administrator did not possess the required education to perform the evaluation. When asked if staff should have documented competencies in their file, the DSD stated, I suppose. During an interview on 1/17/23 at 4:36 p.m., the Medical Director stated she was not aware dietary staff were missing competencies. During a telephone interview and record review on 01/18/23 at 10:52 a.m., the RD was asked why she had no employee file and stated she did not know. When asked if she had a background check or fingerprinting or abuse training, she stated, I don't know . I can't answer . Review of facility policy titled, Personnel Records (dated 1/2008) indicated, 1. Federal and state regulations require that our facility maintain an individual personnel record for each employee . Review of the RD's signed (on 1/1/2021) Dietician Consultant job description indicated, .Conduct departmental performance evaluations .Develop and participate in . in-service training classes that provide instructions on how to do the job, and ensure a well-educated dietary services department . Monitor dietary service personnel to assure that they are following established safety regulations in the use of .supplies . Ensure that dietary service work areas are maintained in a clean and sanitary manner . 3) During a confidential interview on 01/10/23 at 10:00 a.m., five residents (Confidential Residents 1,2,3,4, and 5) were asked about food at the facility. Confidential Resident (CR) 4 stated the food was, god-awful and breakfast was terrible. CR 2 stated the food was, bad. CR 5 stated the food was not great, the gravy, was a mess, and she thought the gravy lumps were mushrooms, but she was not sure. The residents complained of uncooked noodles, tough meat, poor-tasting water, lack of ice, daily canned peaches, lack of variety, and fresh fruit not served daily (sometimes a half of a banana was served). Resident 3 stated the lack of variety made him want to go home. The Ombudsman (patient advocate at the facility) stated she had spoken to the Administrator about the food quality in the past (with no improvement in food quality). Five out of five residents stated no one (from the dietary department) had spoken to them about their food preferences. Resident 5 stated someone spoke to her about her allergies on admission, but nothing since. The residents stated the dietary manager did not come to Resident Council (resident group where grievances can be discussed and addressed). During an interview on 1/17/23 at 10:20 a.m., the Dietary Manager was asked if he was aware of resident food complaints. The Manager stated, yes and stated he told residents staff had to follow the recipes and, sometimes they are bland. During a telephone interview on 01/18/23 at 10:52 a.m., the RD was asked if she was aware of resident food quality complaints. The RD stated, I'm aware, I know they exist and stated she was not told of every complaint. When asked what complaints she was aware of, the RD stated, I don't know off the top of my head. When asked how she was addressing food complaints, she stated she ensured food was more palatable and observed that staff followed recipes. When asked is she was involved in developing a system to address the palatability, the RD stated, Yes .I'm a part of helping. When asked how she helped, the RD stated she communicated and worked with the Dietary Manager and looked at food temperatures and textures. When asked if she was aware residents wanted more fresh fruit, the RD stated, I've been told. The RD stated she was, not in charge of the kitchen. The RD stated she oversees the Dietary Manager but he runs the kitchen. Review of the RD's signed (on 1/1/2021) Dietician Consultant job description indicated, The primary purpose of your job position is to assist planning, organizing, developing, and directing the overall operation of the Dietary Department .Make written oral reports/recommendations to the Administrator .concerning the operation of the Dietary Department .Review complaints and grievances made by the resident and make a written oral reports/recommendations to the Administrator indicating what action(s) were taken to resolve the complaint or grievance . Make inspections of all dietary functions to assure that quality control measures are continually maintained .

CONCERN (F)

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

Deficiency F0920 (Tag F0920)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide activities that met individual resident's needs and preferences when 2 confidential residents (CR 2 and and CR 5) were not provided social dining per their preference and the facility routinely closed the dining room despite State liberalization of Covid mitigation measures (interventions designed to decrease spread of COVID 19, viral pandemic beginning in 2020). These failures caused Confidential Residents 2 and 5 to feel isolated and prevented all residents desiring group dining from socializing in the dining room during meals. Findings: Review of facility document (untitled/undated; provided by facility upon survey entrance on 1/9/2023) indicated the facility had three dining rooms. The document indicated, Locations of Dining rooms . 1. Back Dining room [ROOM NUMBER]. RNA Dining room [ROOM NUMBER]. Station #3 Dining Room. The document was updated on 1/11/2023 and indicated, Locations of Dining Rooms .Large Dining Room = Station 3. During an interview 1/09/23 at 10:50 a.m., Resident 121 was asked about the dining at the facility and stated she ate in her room as there was no eating in the dining room During an interview on 1/09/23 at 11:34 a.m., Resident 2 stated there was no eating in the dining room because of Covid. During an interview on 1/09/23 at 12:04 p.m. Unlicensed Staff N was asked about the use of dining rooms at the facility. Staff N stated the facility had two dining rooms but they were not using them. When asked why the dining rooms were not in use, Staff N stated they had not been using them due to Covid. When asked how long the dining rooms were not in use, Staff N shrugged and stated they were opened last year (2022) and then closed again. During an observation on 01/09/23 at 12:15 p.m., three residents were in the large dining room (Station 3).When asked if it was normal to have only three residents in the dining room, Resident 122 stated, yes. Resident 122 stated he usually had his own table and there was usually not many people in there. During an observation on 01/09/23 at 12:24 p.m., the back dining room (located near the building's entrance) was full of supplies and was being used as a conference room for the survey team (State surveyors). During an interview on 1/09/23 at 12:27 p.m., Licensed Staff B was asked were the dining rooms were located and stated one was closed and the other one was the large dining room. Staff B stated he had spoken to the IP and she had allowed some residents to go there. When asked why the dining rooms were not all open, Staff B stated he didn't know but stated it started with Covid restrictions. During an observation on 01/10/23 at 9:18 a.m., the large dining room had no residents or staff inside and the doors were closed. The activity board (located outside the dining room) indicated the current activity was Coffee at your door (in-room coffee delivery). During a confidential interview on 01/10/23 at 10:00 a.m., five residents (Confidential Residents [CR] 1, 2, 3, 4, and 5) were asked about social dining at the facility. Two out of five residents (CR 2 and 5) stated they would eat in the dining room if it was open. CR 2 and 5 stated they liked to socialize while they ate and they sometimes felt isolated. During the same confidential interview on 01/10/23 at 10:00 a.m., five out of five confidential residents stated group/social dining at the facility did not change with or without a Covid outbreaks in the building (social dining did not increase when the building was Covid-free). During an observation on 01/10/23 at 12:04 p.m., Resident 122 and two unidentified residents (one male and one female) were in the large dining room. Resident 122 stated he and his friend (the female) were the only ones that ate in the dining room that day (for lunch). He stated his male friend had eaten in his room. During an observation on 1/10/23 at 12:19 p.m., Resident 39 was in bed eating his lunch. He stated he did not like his lunch. During an interview on 01/11/23 at 09:35 a.m., CNA T stated dining room [ROOM NUMBER] is the only one in use. When asked why this was the case, CNA T stated they were closed because of Covid. When asked when the other dining rooms had been open, she stated it had been over a year. During an interview on 1/11/23 at 09:40 a.m., the Infection Preventionist (IP) stated the facility was currently Covid-free and their last Covid positive (staff) was approximately 12/29/22. She stated when they have a positive case, they isolate (residents) in the exposure area (where the positive staff worked). The last Covid positive staff was charge nurse and floated (worked) all over the building. The IP stated they used the dining room (large dining room) for very small groups. The IP stated during Covid outbreaks, dining was not open and when they were Covid-free, dining was back. IP stated the back dining room (currently being used for storage and the survey team) was not open; she stated it used to be open but was now used for PPE (personal protective equipment - worn by staff) storage and for visitors. She stated RNA dining (nursing aids assist residents with eating) was no longer open and RNA dining occurs inside resident rooms. When asked why only a few residents were eating in the dining room (on 1/9/23), the IP stated Rehabilitation residents (who tend to be short-term residents who eventually go home) were less interested in social dining and long term residents (who tend to live permanently at the facility) had gotten used to isolation. She stated it had been a struggle (for the facility), getting back to normalcy. The IP stated the facility was following State, Federal, and local Covid guidelines. During an interview on 01/11/23 at 10:25 a.m. RNA U stated they (staff) used to use the RNA dining room (for residents needing RNA services), but not since Covid (2020). She stated there were currently no RNA residents in the facility. When asked when was the last time the dining room was open, RNA U stated, maybe six months. During an observation on 01/13/23 at 09:15 a.m., the large dining room was empty and both doors were closed. Unlicensed Staff K was taking coffee to resident rooms. During an observation on 01/13/23 at 11:46 a.m., lunch carts were coming out of the kitchen. The Dining room (large) had one resident inside (Resident 39) During an observation on 01/13/23 at 11:57 a.m., lunch trays were being passed in the hall containing room [ROOM NUMBER]. Four residents (out of a census of approximately ninety-two) were in the large dining too (Resident 36, Resident 122, Resident 173, and one unidentified female). During an observation and concurrent interview on 01/13/23 at 12:14 p.m., Resident 13 was in bed and stated she wanted to sit in a chair. When asked if she had ever been to the dining room, Resident 13 stated, I don't think I've ever been there. Resident 13's medical record revealed she had a BIMS score of 13 (cognitivly intact). During an interview on 01/13/23 at 12:20 p.m. Unlicensed Staff V was asked why he was not getting residents up to eat in the social dining room. Unlicensed Staff V stated the dining room was closed during Covid. He stated some residents do not want to (go to the dining room) and stated they have rights. Unlicensed Staff V stated, I can't force them. During an interview on 01/13/23 at 12:25 p.m., Unlicensed Staff W was asked why more residents were not eating in the social dining room. Unlicensed Staff W stated he would take them if they asked. When asked how many resident used to eat in social dining room prior to Covid (2020), Unlicensed Staff W stated the dining rooms were full (all three dining rooms). During an interview on 01/13/23 at 12:27 p.m., Unlicensed Staff X stated they had not opened the dining rooms. She stated prior to the pandemic (2020), we took everybody to the dining room; she stated now we take them if they ask. Unlicensed Staff X stated they used to have two additional dining rooms (RNA dining and the back dining room) and, they were full of residents. Unlicensed Staff X stated they have not given us orders to do that again. During an interview on 01/13/23 at 12:59 p.m., Unlicensed Staff Y stated the dining room was closed but a couple (of residents) will eat in there. When asked if the dining room was closed, Unlicensed Staff Y stated, I think so. He stated prior to the pandemic, the facility had two dining rooms and one RNA dining room and they were full of residents. When asked why more residents were not eating in the dining room, Unlicensed Staff Y stated he did not know and suggested the DSD (Director of Staff Development ) may know. During an interview on 01/13/23 at 03:08 p.m., Licensed Staff G was asked why more residents were not eating in the dining room. Licensed Staff G stated residents used to get up to the large dining room, small dining room, and RNA dining room. When asked why they were not getting up now, he stated he did not know; he stated it started in Covid and we got used to it (having residents eat in their rooms/beds). Licensed Staff G stated when there was a Covid outbreak, it's like we go into a mini-lockdown. Review of AFL (All Facilities Letter; State healthcare guidelines) 22-07.1 (dated 10/6/2022) indicated, Communal Dining and Group Activities: Communal activities and dining may occur in the following manner: . Residents who are not in isolation may participate in group/social activities together without face masks or physical distancing, regardless of vaccination status. Facilities should consider, in consultation with their local health department, reimplementing limitations on communal activities and dining based on the status of COVID-19 infections in the facility . During an interview on 01/17/23 at 10:41 a.m., the IP stated the facility did not have a policy and procedure for dining. During an interview on 1/17/23 at 4:19 p.m., the IP stated she was not aware AFL's (State guidelines) had been updated to change isolation requirements for residents regarding social dining. Review of AFL 22-13.1 (dated October 5, 2022) indicated, Post-Exposure and Response Testing .CDPH continues to recommend immediate investigation as a potential outbreak when one (or more) COVID-19 positive individuals (resident or HCP [healthcare personnel]) is identified in a facility. SNFs should perform contact tracing within the facility to identify . residents who may have had high-risk close contact with the individual with SARS-CoV-2 (Covid) infection . Residents who are close contacts, regardless of vaccination status, should wear source control when outside their room but do not need to be quarantined, restricted to their room . A facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility) approach with quarantine for exposed groups should be considered if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. During an interview on 1/17/23 at 4:36 p.m., the Medical Director stated she was not aware the facility was not following updated AFL guidance.

Mar 2020 10 deficiencies

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a record review on 3/9/20 at 11AM, Resident 71's Face Sheet indicated, Resident 71 was a long term, dependent resident, admitted on [DATE]. Resident 71's diagnosis included hand/body tremors and Dementia (a disease characterized by cognitive and memory decline inhibiting an individual's capacity to care for themselves). The record indicated a BIMS (Brief interview for mental status to assess residen's attention, orientation, and ability to recall information) of 9 During a record review on 3/10/20 at 10:30 a.m., Emergency Department Report dated 1/10/20 indicated, the facility sent the Resident 71 to the hospital for left knee pain. X-ray (picture of inside of knee) was completed and indicated Resident 71 had left fractured knee cap. Resident 71 was fitted and placed in a knee immobilizer and returned to the facility. During an interview on 3/10/20 at 11:20 a.m., Administrative Staff B stated Resident 71 was a fall risk due to her tremors and uneven gait. Since her left knee fracture it was even harder for her to ambulate with the knee immobilizer and since she was non weight bearing on the left leg she is traveling by wheel chair only. During a record review on 3/10/20 at 11:15 a.m., Resident 71's, Physical Therapy Progress Notes, dated 2/27/20 indicated, Resident 71 had an MD order to start Physical Therapy. During a record review on 3/10/20 at 11:30 a.m., Resident 71's knee care plan had been marked as being resolved the same day it was started on 1/9/20. Review of Resident 71's clinical record indicated, on 1/10/20 there was a knee immobilizer (brace that stops the knee from bending) and Physical Therapy ordered but neither were on the care plan. During an interview on 3/11/20 at 9AM, Nursing Staff K stated there are no further care plans that address Resident 71's knee orders after returning from the emergency department. Nursing Staff K stated her tremors are worse now and she only travels by wheelchair. During an interview on 3/11/20 at 10:10 am, Resident 71 was alert to name and place. Resident 71 stated, I do not get help getting into my chair and they never come to help me when I call. When asked about her knee brace she responded they never help me put it on and I can't walk alone. During a concurrent interview and record review, on 3/12/20, at 11:09 a.m., in the conference room Administrative Staff G stated, I will be the first to tell you that the facility's care planning is a work in progress and we are aware of what we need to improve upon. When she was shown Resident 71's knee care plan dated 1/9/20 and resolved 1/9/20, Administrative Staff G stated, the word resolve should have never been written on that care plan off to the side like that. Instead, that care plan should have been updated to include the post emergency visit orders. When Administrative Staff G was asked if there was another care plan that included Resident 71's post emergency visit orders she stated, no. She said the knee care plan dated 1/9/20 should have been revised to include the multidisciplinary team such as physical therapy, the resident representative notification, and the CNA (certified nursing assistance). Resident 71 needed more assistance with activities of daily living and transfer assistance due to none weight bearing on the left leg. Administrative G was shown Resident 71's care plan dated 1/9/20 where it had one goal which stated, will have 0 complications. Underneath that goal were pre-printed re-evaluation boxes to be checked as they were reassessed and dated every 30 days, 60 days and 90 days. These boxes were blank. Administrative Staff G stated the goal was not acceptable and the boxes should have been filled in as part of the care plan revision. During an interview on 3/17/20 at 12PM the Public Guardian (court appointed decision maker for Resident 71) stated she was aware that Resident 71 had been seen in the emergency dept. for left knee pain and was diagnosed with a fracture and received a knee brace but the facility had not notified her of the new plan of care. Review of the facility's policy and procedure titled, Base Line Plan of Care, dated 1/2019 indicated, the facility developed and provided a plan of care to each resident or their representative that included directives for promoting safe delivery of care. The document indicated nursing provided continuous evaluations and reassessments in response to the patient's changing needs. Based on interview and record review, the facility failed to revise and update nursing care plans when: 1. One of six sampled residents (Resident 13) suffered a fall at the facility, and his revised care plan did not include permanent effective interventions to prevent further falls, and; 2. One of six sampled residents (Resident 71) had a care plan that did not match her physician orders. These failures could have resulted in further falls with possible injuries to Resident 13, and lack of compliance with physician orders for Resident 71, leading to poor quality of care and harm. Findings: 1. Resident 13 was admitted to the facility on [DATE] with medical diagnoses including Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior) and Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow), according to the facility Face Sheet (Facility demographic). A facility document titled, SBAR Communication Form, dated 2/10/20, indicated Resident 13 suffered a fall on 2/08/10. According to this document, Resident 13 was found sitting on the floor facing the hallway, by the bedside. A skin tear was noted in his left arm. No other injuries were noted. The long-term care plan for falls initiated on 10/03/19 was revised after the fall on 2/08/20, but only included the following new intervention, POC (Plan of care) Reviewed *Labs. This intervention did not indicate what labs were going to be taken, and whether or not the labs were going to be obtained periodically at specific intervals. Prior to this fall on 2/08/20, Resident 13 had suffered two other falls at the facility, according to his care plans for falls. One fall occurred on 12/01/19 and another on 12/03/19. During an interview on 3/12/20 at 11:32 a.m., the Director of Staff Development (DSD) confirmed labs could prevent falls, if the fall was due to a medical disease or condition captured by labs, but it was not a permanent solution unless labs were done on a schedule, therefore it was not an effective permanent intervention to prevent further falls. A request was made to the Director of Nursing (DON) on 3/12/20 for a policy on care planning. The DON provided the policy requested but it only included information on baseline care plans. The policy, published in January of 2019 indicated, A baseline plan of care is developed and provided to each Resident and/or his/her Representative, following admission. The policy did not address comprehensive, person centered care plans, after 48 hours of admission. Neither did it address the need to revise or update care plans as needed based on a resident's change of condition. The facility policy titled, Fall Evaluation (Morse Scale) and Management, last updated in March of 2018, indicated, The Center implements a fall management plan based on medical history review and resident evaluation .Post-Fall Documentation: 1. After the resident has been evaluated and cared for and appropriate notifications have been made, the licensed nurse: f. Reviews and updates the care plan with newly identified interventions, as needed.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 11) received her scheduled baths. This failure had the potential to result in discomfort, body odor, and increased risk for infection. Findings: Resident 11 was admitted to the facility on [DATE] with medical diagnoses including End-Stage Renal Disease (Renal insufficiency of a degree that requires dialysis (The process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) or kidney transplantation for survival) and Diabetes Mellitus, according to the facility Face Sheet (Facility demographic). During an observation on 3/10/20 at 8:52 a.m., Resident 11 was in bed, and appeared to be sleeping. Resident 11 was unable to be interviewed due to her declining health. Resident 11's hair appeared greasy and soiled. Small whitish particles of what appeared to be dead skin cells or dandruff were visible on Resident 11's scalp. Resident 11 was wearing a gown and otherwise, appeared clean. An interdisciplinary note dated 2/11/10 indicated Resident 11 received only bed baths due to her medical status, as her health was declining due to end-stage renal disease with dialysis. A nursing care plan on self-care deficit initiated on 3/04/20 indicated, Shower, as scheduled or bed bath .Assist c (with) all hygiene. The facility's shower schedule last updated on 4/24/19, indicated Resident 11 was scheduled for a bath twice a week on Tuesdays and Fridays. A facility document titled, RESIDENT FUNCTIONAL PERFORMANCE RECORD, dated 3/20, indicated Resident 11 had received no bed baths/showers or tub baths from 3/01/20 to 3/13/20. Staff had documented N/A (Not applicable) for baths, on most shifts (Some boxes were left blank), in the section titled, BATHING. This document indicated, Indicate type of bath provided in lower box of SP. *T=Tub, S=Shower, B=Bed Bath. During an interview on 3/13/20 at 11:50 a.m., Unlicensed Staff N and Unlicensed Staff O, who were in the room with Resident 11, confirmed there was no documentation in the RESIDENT FUNCTIONAL PERFORMANCE RECORD indicating Resident 11 had received any bed baths or showers from 3/01/20 to 3/13/20. Unlicensed Staff N stated some nursing assistants did not know how to document bed baths, and instead documented, NA which meant Not applicable. Unlicensed Staff O stated nursing assistants were frequently in serviced on documenting activities of daily living correctly. During an interview on 3/13/20 at 12:08 p.m., the Director of Staff Development (DSD) confirmed documentation in the RESIDENT FUNCTIONAL PERFORMANCE RECORD did not provide evidence showing that Resident 11 received any bed baths or showers from 3/1/20 to 3/13/20. The DSD stated nursing assistants received training on clinical documentation requirements. The DSD also stated personnel from Medical Records were responsible for auditing residents' medical records. During an interview on 3/13/20 at 2:19 p.m., Administrative Staff L, Medical Records Coordinator, stated she had no clinical experience, and while she audited other medical records, she had not been checking the RESIDENT FUNCTIONAL PERFORMANCE RECORD which included documentation on activities of daily living, such as baths. The education nursing book titled, Clinical Nursing Skills SEVENTH EDITION, by F. [NAME], D. Duell and B. [NAME], published in 2008 indicated, Routine bathing is an essential component of daily care. It is essential to prevent body odor, because excessive perspiration interacts with bacteria to cause odor. Dead skin cells can lead to infection if impaired skin integrity occurs .Relaxation and improved circulation are benefits of bathing and play a therapeutic role in the care of clients on bedrest (pg. 175).

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to consistently ensure expiration dates were on opened medication bottles, expired medications were discarded, and residents' personal medication had their names on the label. These failures could potentially lead to staff administering expired medications or treatments to residents, or potentially administering the wrong medication to a resident. Findings: A tour of the facility's Medication Storage Room, on 3/10/20, at 2:45 p.m., indicated some medications and over-the-counter items were expired. These included: 1. A bottle containing packing for wound treatment, with an expiration date of 10/2019. 2. A bottle labeled, Mucus Relief, with an expiration date of 1/2020. During a concurrent interview, the Director of Nursing, DON, and Assistant Director of Nursing, ADON, verified both bottles were expired. 3. One Foley catheter, used to insert in an individual's bladder for urination, did not have an expiration date. In a concurrent interview, the DON verified that it did not have an expiration. During an inspection of Medication Cart #3, on 3/11/20, at 3 p.m., the following medication items were not labeled with resident names and identifiers, were expired or discontinued: 1. Eye gel, labeled Systal, had a room number, but did not have resident's name on the bottle and the box in which it came had a room number, 124B, but not the resident's name. During a concurrent interview, when asked what happened if a resident was transferred from one room to another room, and a new resident admitted to 124B, Nursing Staff J indicated she understood that without a resident's name, nursing staff could mistakenly administer one residents medications to another. 2. A liquid form of a diabetic medicine, Lispro, did not have either the resident's room number or name on the label but did have the resident's name inside the box in which the medication originally came. During a concurrent interview, when asked what happened if the bottle was separated from the box, Nursing Staff J indicated she understood the box could potentially be separated from the bottle, and bottle unidentified. 3. A medication container had an oral antibiotic medicine, Cipro 250mg, with multiple tablets left. In a concurrent interview, Nursing Staff J stated, the resident was discharged to the hospital approximately 5 days ago . I don't know why this medication was not removed. When asked what's your policy when opening a medication?, Nursing Staff J stated, we don't have any Policy for dating. Nursing Staff J stated, I agree the name of resident and an open date should be labeled on the medication container. Nursing Staff J stated, it was not part of our training.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure staff followed proper infection control practices when: 1) Nursing Staff P's hair contaminated her sanitized hands, residents' medications, and a cup of juice for resident comsumption. 2). Vital signs equipment was not sanitized before use. Findings: 1. During an observation while on initial tour of the facility on 3/9/2020, Nursing Staff P's hair was not tied away from her face while passing medication. During a medication pass observation on 3/11/2020 at 11:30 a.m., Nursing Staff P sanitized her hands before preparing medication. Nursing Staff P's hair touched her sanitized hands. Nursing Staff P poured juice into a plastic cup, her hair strand touched the opening of the juice cup and the medication cup containing medications. The Director of Nursing (DON) approached Nursing Staff P while preparing medication and stated You are doing fine. The DON did not comment that Nursing Staff P's hair was not tied away from her face. A review of Policy and Procedure titled Personal Appearance and dress code updated April 2007 indicated that all employees report to work appropriately dressed and well groomed. On page 48, under Personal Appearance and Behavior, #5 indicated, Employees involved in direct resident care must have long hair secured away from their faces. A review of the Policy and Procedure titled Infection Control Policies and Practices published in May 2015 indicated, This Facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Under Procedure: #2 indicated, The objectives of our infection control policies and practices are to: Prevent, detect, investigate and control infections in the facility. #4, All Personnel are trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and pertinent procedures and equipment related to infection control. A review of the document titled Licensed Staff Orientation Checklist dated 10/4/2006, submitted by the Director of Staff Development (DSD) indicated that Infection Control was not one of the topic discussed during the Staff Orientation. 2). During an observation on 3/09/20 at 10:11 a.m., essential vital signs equipment was observed in one of the facility's hallways, exposed and unattended, for an undetermined amount of time. The equipment was charging from an electrical outlet. A few moments later, at 10:15 a.m., Unlicensed Staff M was observed taking the vital signs equipment, and entering a residential room with it. Unlicensed Staff M proceeded to take vital signs on Resident 92, which included putting a blood pressure cuff around Resident 92's partially uncovered arm, without disinfecting the equipment prior to the task. After taking vital signs on Resident 92, Unlicensed Staff M was observed disinfecting the equipment and using it on another resident. During an interview on 3/09/20 at 10:23 a.m., Unlicensed Staff M confirmed not having disinfected the vital signs equipment prior to using it on Resident 92. During an interview on 3/12/20 at 11:18 a.m., with the Director of Staff Development (DSD), she stated vital signs equipment left charging in the facility's hallways had to be disinfected prior to using it on residents. The facility policy titled, Cleaning and Disinfecting Environmental Surfaces, last revised in May of 2015, indicated, Non-critical items are those that come in contact with intact skin but not mucous membranes .Non-critical surfaces are disinfected with an EPA (Environmental protection agency)-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions .Intermediate and low-level disinfectants for non-critical items include: Ethyl or isopropyl alcohol; Sodium hypochlorite (A chlorine compound often used as a disinfectant).

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and a review of resident medical records, the facility failed to properly obtain consent for (a) the administration of psychotropic drugs for four residents (33, 78, 84 and 85); (b) the administration of an influenza vaccine for one resident (84); (c) implementation of Physician Orders for Life-Sustaining Treatment (POLST) for one resident (84); and (d) a Device Informed Consent for one resident (84). These failures had the effect of violating the rights of these residents to be informed of the risks, benefits and alternatives of treatment decisions prior to receiving those treatments, or (if these residents did not have the capacity to make their own decisions) to have a Responsible Party be informed on their behalf. Findings: In a 3/11/20 review of Resident 33's medical record, it was identified that she was admitted to the facility on [DATE] with diagnoses of CVA (a cerebral vascular accident or stroke, where a loss of blood to parts of the brain cause damage to the brain tissue and can lead to speech, thinking or movement problems); bipolar disorder (a mental condition marked by alternating periods of extreme happiness and extreme sadness); schizoaffective disorder (a chronic mental health condition characterized by symptoms of schizophrenia, such as hallucinations or delusions or thoughts that are not real); obsessive-compulsive disorder (a mental health condition with symptoms of excessive orderliness, perfectionism and attention to detail); and developmental delay (a mental or physical development delay that is not normal for the person's age and affects speech, movement and thinking ability). In a 3/10/20 9:30 a.m. review of Resident 33's medical record, there was no evidence of an informed consent having been obtained from the resident's Responsible Party for administration of the anti-psychotic drug, Seroquel. (Anti-psychotic drugs affect the chemicals in the brain and are used to treat behavioral conditions like psychosis and dementia. Psychosis is a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality. Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury and is marked by memory disorders, personality changes, and impaired reasoning.) In an interview on 3/11/20 at 4:22 p.m., Administrative Staff L was asked if there were any unfiled consents in the Medical Records Department for Resident 33's Seroquel administration. In an interview on 3/13/20 at 11:50 a.m., the Director of Nursing and the Assistant Director of Nursing, both stated that a signed informed consent for Seroquel for Resident 33 had not been located in either Resident 33's medical record or in the Medical Records Department. A document was observed in Resident 33's medical record that was titled, Psychotropic Drug and Behavior Review Form - Quarterly and PRN. Dated 2/8/19, the form listed Seroquel as a medication being administered to Resident 33. Under the column which stated Consent Y/N (Consent Yes/No), neither Y nor N was checked for consent presence. A second copy of this document, dated 4/23/19, had neither Y nor N checked for consent presence for Seroquel. A third copy of this document, dated 8/14/19, listed the generic name of Seroquel, Quetapine, but Y is checked for consent presence (in error, since no consent form could be located). A fourth copy of this document, dated 12/13/19, had neither Y nor N checked for presence of a consent for Seroquel. A facility policy titled, Informed Consent for Psychotropic Drugs - California Only (updated 9/17), stated in the Policy Statement section, When the physician has ordered the use of Anti-Psychotic .Drug, the Physician .obtains informed consent from the resident or responsible party. An informed consent is obtained before the drug prescribed is administered at the Center. A document titled, Order Summary Report - February 28, 2020, indicated that Resident 33 began receiving the medication Seroquel on 3/11/18, despite not having a signed consent from her Responsible Party to receive this medication. In an interview with the Director of Nursing (DON) on 3/11/20 at 9:24 a.m., the DON stated that psychotropic drugs were not to be administered unless the signature of a Responsible Party was present (in the event the resident lacked his/her own decision-making capacity). In a 3/11/20 review of Resident 84's the medical record, it was identified that she was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (an irregularity of the heart's rhythm); Type 2 diabetes ( a life-long condition that affects the way the body breaks down sugar (glucose) in the body); congestive heart failure (a chronic condition where the heart muscle can no longer pump blood effectively through the body); coronary artery disease (a narrowing of the blood vessels of the heart); major depressive disorder (a condition characterized by a persistent feeling of sadness and loss of interest in one's surroundings); and non-Alzheimer's dementia (a condition characterized by impaired judgment, slowness, difficulty planning and organizing tasks and some degree of memory loss.) On 3/10/20 at 10:00 a.m., a document was observed in Resident 84's medical record that was titled, Order Summary Report - Active Orders as of 3/1/2020. On Page 3 of 4 of this document, the following statement was present: Resident has capacity to understand choices and make healthcare decisions: NO. This entry was dated 2/9/19. This form was signed by Resident 84's physician and dated 3/3/20. On 3/10/20 at 10:00 a.m., a document was observed in Resident 84's medical record that was titled, Psychotropic Drugs Disclosure and Consent - California Only. The consent was for the administration of 15 mg of the medication mirtazapine. (The abbreviation mg stands for milligrams, a unit of measurement.) This consent, signed by the physician and dated 2/10/20, was also signed by Resident 84, who dated the consent 120-20-20. However, it had been previously determined that Resident 84 lacked the capacity to give informed consent or make medical decisions for herself due to her medical condition. On 3/10/20 at 10:10 a.m., a second document was observed in Resident 84's medical record that was titled, Psychotropic Drugs Disclosure and Consent - California Only. The consent was for the administration of 15 mg qd of the medication mirtazapine. (The abbreviation qd stands for every day.) This second consent was not signed by the resident's Responsible Party. It was only signed by Resident 84's physician and was not dated. A facility policy titled, Informed Consent for Psychotropic Drugs - California Only (updated 9/17), stated in the Policy Statement section, When the physician has ordered the use of Anti-Psychotic .Drug, the Physician .obtains informed consent from the resident or responsible party. An informed consent is obtained before the drug prescribed is administered at the Center. A document titled, Order Summary Report - February 28, 2020, indicated that Resident 84 was administered the medication mirtazapine beginning 1/31/20, despite no authorized consent having been obtained from Resident 84's Responsible Party to do so. On 3/10/20 at 10:15 a.m., a document was observed in Resident 84's medical record that was titled, Physician Orders for Life-Sustaining Treatment (POLST). (A POLST provides guidance to healthcare providers regarding a resident's wishes for treatment at the end of life or in the event of a medical emergency.) The POLST was signed by Resident 84 on 11/13/18. However, it was previously determined that Resident 84 lacked the capacity to give informed consent or make medical decisions for herself due to her medical condition. On 3/10/20 at 10:15 a.m., a document was observed in Resident 84's medical record that was titled, Influenza Vaccine Informed Consent. The consent was signed by Resident 84 and dated 9/12/19. Elsewhere in this record it was identified that the influenza vaccine was administered to Resident 84 on 10/22/19. However, it had been previously determined that Resident 84 lacked the capacity to give informed consent or make medical decisions for herself due to her medical condition. On 3/10/20 at 10:00 a.m., a document was observed in Resident 84's medical record that was titled, Device Informed Consent. This was a consent to initiate a Wanderguard device on Resident 84, so she would be able to walk around within the facility. (A Wanderguard is a device worn by a resident that triggers an alarm should the resident attempt to leave the facility through an alarm-activated door.) The medical reason listed for use of the device was, Poor impulse control and dementia (dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury and is marked by memory disorders, personality changes, and impaired reasoning). The consent was signed by Resident 84 and dated 60/17/19. However, it had been previously determined that Resident 84 lacked the capacity to give informed consent or make medical decisions for herself due to her medical condition. On 3/10/20 at 10:00 a.m., a document was observed in Resident 84's medical record that was titled, Inter-Facility Transfer Report and dated 11/9/18. This document was from the hospital that transferred Resident 84 to the facility, and the transferring physician (who prepared the document) stated (on Page 5 of 7), Because of a physical, mental or emotional condition, does this person have serious difficulty concentrating, remembering or making decisions? Yes. This statement was dated 11/8/18 at 1550 (3:50 p.m.). In the above 3/10/20 review of Resident 84's medical record, a document titled, Cognitive Pattern(s) Care Plan was observed. An entry on 11/11/18 indicates that Resident 84 had No capacity to make health care decisions. In a 3/11/20 review of Resident 85's medical record, it was identified that she was admitted to the facility on [DATE] with diagnoses of diabetes (a condition that affects the way the body uses or breaks down sugar or glucose); anxiety (a condition where feelings of worry, nervousness, or unease are present); psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality); depression (an illness characterized by a persistent feeling of sadness and loss of interest in one's surroundings); schizophrenia (a chronic mental illness that impairs thoughts and behavior and can lead to hallucinations and disorganized thinking); developmental delay (mental or physical development that is not normal for the person's age and affects, speech, movement and thinking); and breast cancer. On 3/10/20 at 10:20 a.m., a document was observed in Resident 85's medical record that was titled, Order Summary Report - Active Orders as of 3/1/2020. On Page 3 of 5 of this document, the following statement was present: Resident has capacity to understand choices and make healthcare decisions: NO This was dated 10/16/18. Another document in the record, titled Encounter - Nursing Home Visit Date of Service 11/13/18 and written by Resident 85's physician, stated, on page 5 of 5, Decision Making Capacity: Without. In a 3/10/20 10:15 a.m. review of Resident 85's medical record, a document titled, Psychotropic Drugs Disclosure and Consent - California Only, indicated Disclosure of the Risks and Benefits regarding the use of Psychotropic Drugs. This was a consent form for the medication Ativan 1 mg. (Ativan is the brand name for the medication lorazepam, and is given to treat anxiety, a condition where feelings of worry, nervousness, or unease are present. The abbreviation mg stands for milligrams, a unit of measurement.) The consent had not been signed by Resident 85's Responsible Party. The consent was signed only by Resident 85's physician and was undated. In a 3/10/20 10:20 a.m. review of Resident 85's medical record, a document titled, Psychotropic Drugs Disclosure and Consent - California Only, indicated Disclosure of the Risks and Benefits regarding the use of Psychotropic Drugs. This was a consent form for the medication Zoloft (Sertraline) 150 mg. (Zoloft is the brand name and sertraline is the generic name for a medication used to treat depression. Depression is an illness characterized by a persistent feeling of sadness and loss of interest in one's surroundings.) The consent had not been signed by Resident 85's Responsible Party. The consent was signed only by Resident 85's physician and was undated. In a 3/10/20 10:22 a.m. review of Resident 85's medical record, a document titled, Psychotropic Drugs Disclosure and Consent - California Only, indicated Disclosure of the Risks and Benefits regarding the use of Psychotropic Drugs. This was a consent form for the medication Zyprexa Zydis 20 mg. (Zyprexa Zydis is the brand name and olanzapine is the generic name for this medication that is used to treat certain mental/mood conditions such as schizophrenia, a chronic mental illness that impairs thoughts and behavior and can lead to hallucinations and disorganized thinking.) The consent had not been signed by Resident 85's Responsible Party. The consent was signed only by Resident 85's physician and was undated. In a 3/10/20 10:22 a.m. review of Resident 85's medical record, a document titled, Psychotropic Drugs Disclosure and Consent - California Only, indicated Disclosure of the Risks and Benefits regarding the use of Psychotropic Drugs. This was a consent form for the medication Haloperidol 2 mg. (Haloperidol is the generic name for a medication that affects chemicals in the brain and is used to treat behavioral conditions like psychosis. The consent had not been signed by Resident 85's Responsible Party. It was signed only by Resident 85's physician and was undated. Also observed was a second copy of this form, which was a consent for Haloperidol 2 mg BID. (The abbreviation BID means twice a day.) This second consent was signed by Resident 85 and dated 5/5/17. However, it had already been determined that Resident 85 lacked the capacity to make medical decisions for herself due to her medical condition. Facility policy titled, Informed Consent for Psychotropic Drugs - California Only (updated 9/17), stated in the Policy Statement, When the physician has ordered the use of Anti-Psychotic .Drug, the Physician .obtains informed consent from the resident or responsible party. An informed consent is obtained before the drug prescribed is administered at the Center. This policy was violated when (a) Resident 85 was administered haloperidol without the informed consent of Resident 85's Responsible Party and (b) when she was allowed to sign her own consent when it had been determined that she lacked the capacity to make healthcare choices and medical decisions for herself. Resident 78's Medication Administration Record for January 2020 reflected that the dose of her Zyprexa medication was increased to 20 mg once per day, beginning 1/22/20. (Zyprexa is the brand name of a medication used to treat certain mental/mood conditions such as schizophrenia, a chronic mental illness that impairs thoughts and behavior and can lead to hallucinations and disorganized thinking.) However, no informed consent document was found in the record to indicate that Resident 78 (or a Responsible Party) had given the consent for this medication dosage change. In an interview with the Director of Nursing (DON) on 3/13/20 at 11:50 a.m., the DON acknowledged (a) the forms without dates (of physician orders/entries) and (b) improper management of consents and stated, We've identified there are opportunities for improvement.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of accidents/hazards when: 1. Resident 92, who had suffered three falls at the facility, and was care planned to receive one-to-three oversight (Supervision of one staff to three residents), was left alone in her room for an undetermined period of time, and; 2. Eight of sixteen sampled and unsampled residents (Resident 5, Resident19, Resident 8, Resident 58, Resident 42, Resident 40, Resident 45, and Resident 33), at high risk for falls, were not included in a program initiated by the Director of Nursing, for staff to identify residents at high risk for falls. This failure had the potential to result in further falls with fractures, and possible death, to the facility residents at risk for falls. Findings: 1. Resident 92 was admitted to the facility on [DATE] with medical diagnoses including Osteoporosis (A condition that causes the bones to become weak and brittle) and Moderate Protein-Calorie Malnutrition (A condition caused by inadequate quantity of protein and energy in the diet), according to the facility Face Sheet (Facility demographic). First Fall: A fall short-term care plan initiated on 1/27/20 indicated Resident 92 suffered a fall with no injury at the facility on 1/27/20. The care plan indicated, No injury lost balance while ambulating. Second Fall: A fall short-term care plan initiated on 2/7/20 indicated Resident 92 suffered a fall on 2/7/20 at the facility, which resulted in compression fractures. This was corroborated by a discharge summary (A document that outlines the details of the hospitalization of a patient) from an acute care facility dated 2/27/20 at 6:28 p.m., which indicated Resident 92 had a fall at the facility on 2/7/20 and suffered vertebral fractures at the level of T12 (The twelfth thoracic vertebra in the spine), L2 (Second lumbar spinal vertebra, within the lower back) and L3 (Third lumbar spinal vertebra, within the lower back) as a result of the fall. Third Fall: A facility document titled, IDT (Interdisciplinary) FALL REVIEW, dated 2/24/20 indicated Resident 92 suffered a fall at the facility on 2/24/20. The discharge summary of the acute care facility where she was transferred, indicated Resident 92 suffered a left humerus (Long bone that extends from the shoulder to the elbow) fracture as a result of the fall on 2/24/20. A care plan for alteration in safety for Resident 92, initiated on 2/24/20 and revised on 2/27/20 (After Resident 92's fall on 2/24/20), indicated, IDT review 2/27/20 1/3 oversight (One-to-three oversight). A fall risk care plan for Resident 92, initiated on 2/27/20, indicated, One to one oversight (Supervision of one staff to one resident) reeval (Reevaluate) as needed. One care plan indicated Resident 92 was required to receive one-to-three oversight while the other care plan indicated Resident 92 was required to receive one-to-one oversight. During an observation on 3/11/20 at 2:51 p.m., Resident 92 was noted to be in bed, with no staff present in the room or in the hallway supervising her. Resident 92's curtain was partially covering her bed, which made it impossible to see her from the nursing station. It was unknown for how long Resident 92 was left alone prior to this observation. At 2:53 p.m. a nursing assistant (Unlicensed Staff O) came to supervise Resident 92 and stood in the hallway. When asked why Resident 92 was left unsupervised, Unlicensed Staff O stated she was standing in the hallway, which was not observed. Unlicensed Staff O later stated she was receiving an in-service at the nursing station but another nursing assistant (Unlicensed Staff N) was assigned to supervise Resident 92. Unlicensed Staff N was interviewed and confirmed she was supervising Resident 92 earlier, but stated the assignment was handed over to Unlicensed Staff O. When asked if she notified Unlicensed Staff O that she was handing over the assignment of supervising Resident 92, Unlicensed Staff N confirmed she did not. During an interview on 3/11/20 at 3:02 p.m., Resident 92's assigned nurse, Nursing Staff J stated that the staff supervising Resident 92 had to be in the room with Resident 92 to make sure she did not suffer another fall. He confirmed Resident 92 could not be observed from the nursing station, as her curtains were partially covering her bed, where she was laying. During an interview on 3/13/20 at 10:36 a.m., the Director of Nursing (DON) stated Resident 92 was under one-to-three oversight. The DON stated staff was highly encouraged, not to leave the Resident 92's room when Resident 92 was inside, and stated staff was encouraged to find other staff to replace them if they were to leave Resident 92's room. When asked for their policy on one-to-one supervision and one-to-three oversight, the DON stated they did not have one. The DON was asked if they had a written description of these types of supervision, to which the DON replied they did not. The DON stated staff was verbally instructed about one to three oversight. 2. A document provided by facility management dated 3/09/20, indicated sixteen residents had suffered falls at the facility. According to this document, three had suffered falls with injuries. During an interview on 3/11/20 at 1:40 p.m., Nursing Staff J was asked how they identified residents at high risk for falls. Nursing Staff J stated he would have to find out. Five minutes later, at 1:45 p.m., Nursing Staff J stated they had a form on the residents' Medication Administration Record that listed the residents at high risk for falls. The Director of Nursing (DON) was present, and mentioned a board, which was part of a new program they had initiated to prevent falls, which was posted on the employee break room that also included the names of the residents at high risk for falls, for staff awareness. During an interview on 3/11/20 at 2:59 p.m., Nursing Staff J stated he had worked at the facility for about ten years and prior to the interview on 3/11/20 at 1:40 p.m., did not know about the form listing the residents at high risk for falls which was filed in the Medication Administration Record. During an interview on 3/12/20 at 2:32 p.m., Nursing Staff P was asked how she identified residents at risk for falls. Nursing Staff P mentioned the board that listed the residents at high risk for falls, posted in the employee breakroom. Nursing Staff P did not mention the list filed on the Medication Administration Record. During observation on 3/12/20 at 2:35 p.m., in the employee breakroom, a board titled, HIGH RISK FALL RESIDENTS, listed the following residents: 1. Resident 39 2. Resident 92 3. Resident 143 4. Resident 73 5. Resident 87 6. Resident 28 7. Resident 13 8. Resident 71 These same residents were listed on the undated document titled, Alert-This list is High risk for Falls, filed in the residents' Medication Administration Record. A document provided by facility management dated 3/09/20, listed the following residents as having fallen at the facility but were not on the list of residents at high risk for falls, in the Medication Administration Record or employee breakroom mentioned above: 1. Resident 5 A facility document titled, IDT (Interdisciplinary) FALL REVIEW, dated 2/26/20 indicated Resident 5 suffered a fall on 2/25/20. A facility document titled, MORSE FALL SCALE (A scale used by the facility for assessing a patient's likelihood of falling) dated 12/04/19, indicated Resident 5 received a score of 65. The document indicated, Fall Scoring: High Risk 45 and higher. 2. Resident 19 The undated facility document titled, IDT FALL REVIEW, indicated Resident 19 suffered a fall on 2/06/20. Resident 19's MORSE FALL SCALE dated 3/11/20 indicated she received a score of 50, placing her at high risk for falls. 3. Resident 8 A facility document titled, IDT FALL REVIEW, dated 12/09/19 indicated Resident 8 suffered a fall on 12/08/19. Resident 8's MORSE FALL SCALE dated 3/10/20 indicated she received a score of 50, placing her at high risk for falls. 4. Resident 58 A facility document titled, IDT FALL REVIEW, dated 1/09/20 indicated Resident 58 suffered a fall on 1/08/20. Resident 58's MORSE FALL SCALE dated 1/08/20 indicated she received a score of 55, placing her at high risk for falls. 5. Resident 42 A facility document titled, IDT FALL REVIEW, dated 9/19/19 indicated Resident 42 suffered a fall on 9/17/19. Resident 42's MORSE FALL SCALE dated3/07/20 indicated he received a score of 55, placing him at high risk for falls. 6. Resident 40 A facility document titled, IDT FALL REVIEW, dated 11/12/19 indicated Resident 40 suffered a fall on 11/10/19. Resident 40's MORSE FALL SCALE dated 1/3/20 indicated he received a score of 75, placing him at high risk for falls. 7. Resident 45 A facility document titled, SBAR Communication Form, dated 11/21/19 indicated Resident 45 suffered a fall on 11/21/19. Resident 45's MORSE FALL SCALE dated 1/06/20 indicated she received a score of 55, placing her at high risk for falls. 8. Resident 33 A facility document titled, IDT FALL REVIEW, dated 12/18/19 indicated Resident 33 suffered a fall on 12/17/19. Resident 33's MORSE FALL SCALE dated 12/29/19 indicated she received a score of 105, placing her at high risk for falls. During an interview on 3/13/20 at 10:29 a.m., the DON was asked the reason for including only some high risk patients on the list in the Medication Administration Record and employee breakroom, and excluding others that had fallen at the facility. The DON stated it was based on a decision taken by the interdisciplinary team (IDT) based on each resident's individual risk. She was asked to provide evidence of IDT meetings that would show the excluded residents at high risk for falls were discussed and chosen not to be on the list. The DON was unable to provide evidence. An undated document titled, High Risk Fall Prevention Best Practice, provided by the DON on 3/13/20 at 10:29 a.m., indicated, Staff will be alerted to high risk for fall residents. The facility policy titled, Fall Evaluation (Morse Scale) and Management, last updated in March of 2018 indicated, If the total Morse Scale score is greater than 45, the resident is considered as having High Potential for falls. Implement appropriate care plan interventions for fall management .Post-Fall Documentation: After the resident has been evaluated and cared for and appropriate notifications have been made, the licensed nurse: e. Updates the Morse Scale. f. Reviews and updates the care plan with newly identified interventions as needed.

CONCERN (E)

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

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected multiple residents

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Based on interview and a review of facility records, the facility failed to ensure that attending physicians consistently dated their orders, as required by facility policy. Fifteen orders for five residents (Residents 33, 78, 84, 85, 94) were undated. Undated orders could lead to confusion as to the timing when orders are expected to take effect and could potentially compromise resident medical management and and compromise resident health and well-being. Findings: The attending physician did not date the following eleven forms , all titled, Psychotropic Drugs Disclosure and Consent: (a) A form titled, Psychotropic Drugs Disclosure and Consent, for mirtazapine 15 mg qd for Resident 84 was signed by the physician but was not dated. (Mirtazapine is a medication used to treat depression, a condition characterized by persistent feelings of sadness and a loss of interest in one's surroundings; the abbreviation mg means milligrams, a unit of measure for medications; qd is an abbreviation that means every day.) (b) A form titled, Psychotropic Drugs Disclosure and Consent, for 1 mg Ativan for Resident 85 was signed by the physician but was not dated. (Ativan is the brand name of a medication used to treat anxiety.) (c) A form titled, Psychotropic Drugs Disclosure and Consent for lorazepam 1 mg q 12 hrs for Resident 85 was signed by the physician but was not dated. (Lorazapam is the generic name for Ativan, a medication used to treat anxiety; q is an abbreviation that means every; hrs is an abbreviation that means hours.) (d) A form titled, Psychotropic Drugs Disclosure and Consent for Zoloft (sertraline) 150 mg for Resident 85 was signed by the physician but was not dated. (Zoloft is the brand name and sertraline is the generic name of a medication used to treat depression.) (e) A form titled, Psychotropic Drugs Disclosure and Consent for Sertraline 150 mg for Resident 85 was signed by the physician but was not dated. (Sertraline is the generic name of a medication used to treat depression.) (f) A form titled, Psychotropic Drugs Disclosure and Consent for Zyprexa zydis 20 mg for Resident 85 was signed by the physician but was not dated. (Zyprexa zydis is a medication that affects chemicals in the brain and is used to treat behavioral conditions like psychosis, which is a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.) (g) A form titled, Psychotropic Drugs Disclosure and Consent for Haloperidol 2 mg for Resident 85 was signed by the physician but was not dated. (Haloperidol is the generic name for a medication that affects chemicals in the brain and is used to treat behavioral conditions like psychosis.) (h) A form titled, Psychotropic Drugs Disclosure and Consent for Haloperidol 2 mg bid for Resident 85 was neither signed nor dated by the physician. It was signed by the resident on 5/5/17. (Haloperidol is the generic name for a medication that affects chemicals in the brain and is used to treat behavioral conditions like psychosis; bid is an abbreviation that means twice a day.) (i) A form titled, Psychotropic Drugs Disclosure and Consent for Haloperidol 2 mg bid for Resident 85 was signed by the physician but was not dated. It was signed by the resident's Responsible Party on 7/28/19. (j) A form titled, Psychotropic Drugs Disclosure and Consent for olanzapine 20 mg for Resident 85 was signed by the physician but was not dated. It was also signed by the resident's Responsible Party on 7/28/19. (Olanzapine is another medication that affects chemicals in the brain and is used to treat behavioral conditions like psychosis.) (k) A form titled, Psychotropic Drugs Disclosure and Consent for olanzapine 2.5 mg qd for Resident 85 was signed by the physician but was not dated. It was also signed by the resident's Responsible Party on 7/28/19. (Olanzapine is another medication that affects chemicals in the brain and is used to treat behavioral conditions like psychosis; qd is an abbreviation that means every day.) (l) A form titled, Psychotropic Drugs Disclosure and Consent for Zyprexa 10 mg two times a day for Resident 78 was initialed by the resident on 8/4/16. Resident 78's physician initialed the consent but did not date it. (Zyprexa is a medication that affects chemicals in the brain and is used to treat behavioral conditions like psychosis, which is a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.) In addition to the above twelve items, a seven-page form titled Order Summary Report (for Resident 33), for Active Orders as of 3/1/2020, was signed by the physician but was not dated. A document titled Note to Attending Physician/Prescriber, was sent to the physician by a consultant pharmacist (on 1/28/20) who requested an order for a thyroid profile for Resident 94. (The thyroid is a large gland in the neck which secretes hormones that regulate growth and development.) The physician checked the box, Agree, signed the order, but did not date it. A document titled Note to Attending Physician/Prescriber, was sent to the physician by a consultant pharmacist (on 2/18/20) who requested an order for a Gradual Dose Reduction (GDR) for Resident 85. (A GDR is a process whereby medication doses are periodically reduced in order to wean a patient off that medication.) The physician checked the box No Change, signed the order, but did not date it. A facility policy titled, Physician Visits (dated 2/2008) stated, under section 3. a.,Orders have physician's signature and are dated. The facility did not follow its own policy. In an interview with the Director of Nursing (DON) on 3/13/20 at 11:50 a.m., the DON acknowledged (a) the forms without dates (of physician orders/entries) and (b) improper management of consents and stated, We've identified there are opportunities for improvement.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and review of facility documents, the facility did not ensure food was stored in accordance with professional safety standards, when the facility kitchen's walk-in refrigerator contained 7 expired sandwiches. This failure had the potential to place residents at risk for food borne illness. Findings: During an observation and kitchen tour, on 3/9/20, at 9:30 AM, the walk-in refrigerator contained four peanut butter and jelly sandwiches and 3 cheese sandwiches with used-by dates of 3/8/20. During an interview on 3/9/20, at 9:40 AM, Administrative Staff F stated the four peanut butter and jelly sandwiches and the 3 cheese sandwiches should never have been placed in the refrigerator because they were yesterday's snacks and should have been discarded on 3/8/20. He stated placing expired items in the refrigerator could potentially expose residents to food a borne illness. During a review of the facility's policy and procedure titled, Food Storage revised 10/2017, it indicated, Items that have use by dates indicated on them should be discarded prior to that date.

CONCERN (E)

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

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility did not have policies for medication storage and labeling, clinical documentation requirements, one-to-one supervision (Supervision of one staff to one resident), comprehensive care planning, and one-to-three oversight (Supervision of one staff to three residents), which was implemented for three of six sampled residents for safety (Resident 143, Resident 92 and Resident 11). This failure had the potential to result in lack of guidance for competent care, inadequate nursing services, and lack of compliance with state and federal regulations. Findings: A request was made to the Director of Nursing (DON), and Administrative Staff G several times throughout the survey, starting on 03/09/20 at 3:12 p.m., for the following facility policies, which would have contained guidance for deficiencies found during the annual recertification survey: 1. Medication Storage & Labeling 2. Clinical Documentation 3. One-to-One Supervision 4. One-to-Three Oversight 5. Comprehensive Care Planning During an interview with the DON and Administrative Staff G on 03/13/20 at 10:10 a.m., they stated not having the policies requested above. They provided a care planning policy, but the policy only contained information on baseline care plans, and did not cover comprehensive care planning for residents. The policy did not cover requirements for care plan revisions or updates. The DON and Administrative Staff G confirmed having three residents (Resident 143, Resident 92 and Resident 11) on one-to-three oversight but stated not having a policy or written document describing this type of supervision.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure clinical documentation was complete and accurate when: 1. A nursing assistant documented the amount of food consumed by a resident (Resident 41), at risk for nutritional deficiencies, inaccurately in the medical record, 2. The POLST (Physician Orders for Life Sustaining Treatment-a document that states a person's end-of-life wishes) for six of twenty-two sampled residents (Resident 65, Resident 143, Resident 13, Resident 11, Resident 7 and Resident 41) did not indicate if the residents had, or did not have Advanced Directives (A legal document providing instructions as to the type and degree of medical care to be administered in the event that the person signing the document becomes incapacitated), 3. Nursing notes were not timed for one of six sampled residents (Resident 143) These failures could have resulted in inability for the interdisciplinary team and clinicians to obtain a picture of the residents' progress, including their response to treatments and services, changes in their condition, plan of care goals, objectives and interventions. Findings: 1. Resident 41 was admitted to the facility on [DATE] with medical diagnosis including Severe Protein-Calorie Malnutrition (Inadequate quantity of protein and energy in the diet) and Anemia (A decrease in the total amount of red blood cells or hemoglobin in the blood, or a lowered ability of the blood to carry oxygen), according to the facility Face Sheet (Facility demographic). A facility document titled, WEIGHT RECORD, indicated Resident 41 had refused to have her weight taken since 9/10/19 until the present, but her last documented weight taken on 9/04/19 was 80 pounds. The facility's winter menu, indicated that on 3/09/20 for lunch, residents received, SPAGUETTI SAUCE WITH MEAT BUTTERED SPAGUETTI TOSSED SALAD DRESSING GARLIC BREAD ICE CREAM COFFEE OR TEA MILK GARNISH. During an observation on 3/09/20 at 12:50 p.m., Resident 41 was observed in bed. Her lunch tray was sitting on top of her bedside table, which Resident 41 had pushed away. Resident 41 stated she was done eating. It was observed that Resident 41 only ate the spaghetti, which accounted for one third of the food on her plate. Resident 41 left the other two entrees on her plate (Garlic bread/spaghetti sauce with meat and salad in pureed form) untouched, as well as her dessert. She drank half a cup of water, which accounted for approximately 60 ml of fluid. Resident 41 stated the meal was salty, and she would not eat the rest. During an observation on 03/09/20 at 1:05 p.m., Resident 41's tray was taken away by Unlicensed Staff Q. A facility document titled, MEAL MONITOR FLOWSHEET, for March of 2020, indicated Resident 41 consumed 60% of her lunch on 3/09/20 and ingested 240 milliliters of fluid. This was documented by Unlicensed Staff Q. This document had an area for alternate percentage, which was documented as N (no), and an area for MD (Medical Doctor) ordered supplements, which was documented as N (no). During an interview on 3/11/20 at 9:35 a.m., Unlicensed Staff Q confirmed Resident 41 had only eaten the spaghetti on her tray on 3/09/20 for lunch, but stated Resident 41 had drank a supplement, brought by her son, at around 10:30 that morning, so she counted the supplement as 40% of Resident 41's lunch meal. Unlicensed Staff Q stated she counted the spaghetti on Resident 41's tray as 20 % of her lunch meal, so by adding up the supplement plus the spaghetti, she documented Resident 41's meal consumption as 60% on 3/09/20 for lunch. Unlicensed Staff Q was asked if she had been provided training indicating supplements were to be counted as 40% of a resident's meal, to which Unlicensed Staff Q stated she had not. Unlicensed Staff Q stated she assumed the supplement was 40% of a meal. During an interview on 3/11/20 at 10:30 a.m., Administrative Staff I, Registered Dietician, stated if Resident 41 had only eaten spaghetti from her tray, that would be considered 15-20% of the meal. Administrative Staff I stated supplements were not to be included with the lunch meal percentage. Administrative Staff I also stated if a resident ate less than 50%, the nursing assistant was supposed to offer something to the resident, which could be a supplement. A facility document titled, Guidelines for Food Intake-Lunch and Dinner, last updated in February of 2015, indicated the pasta portion of a meal accounted for 10% of the meal. This document indicated, If 50% or less of meal is consumed, offer alternate menu items. If alternate is not accepted, offer a supplement. Document % consumed. 2. A facility document titled, Physician Orders for Life-Sustaining Treatment (POLST), was left unanswered under section D which inquired for information on Advanced Directives for the following residents: 1. Resident 65 2. Resident 143 3. Resident 13 4. Resident 11 5. Resident 7 6. Resident 41 Section D of the POST asked if the resident had an Advanced Directive, did not have an Advanced Directive or the Advanced Directive was not available. All three questions were left blank in the residents' POLST listed above. During an interview on 3/12/20 at 9:00 a.m., Administrative Staff C, Social Services Director, stated all areas of the POLST were required to be filled out. She stated that initially, the physician went over the form with the residents upon admission, and during the first interdisciplinary meeting for each resident, the POLST was audited for completeness. She confirmed that assuming residents did not have Advanced Directives because they could not be located on the residents' medical records was not a good idea, and stated the POLST needed to be complete in regards to Advanced Directives. She confirmed the POLST for the above clients, were filled out at the facility. 3. Resident 143 was admitted to the facility on [DATE] with medical diagnoses including Hypertension (High blood pressure) and Repeated Falls according to the facility Face Sheet. A nursing note for Resident 143, dated 2/25/20, with no time documented, indicated, V/s (Vital signs) refused. Resident [Resident 143] was brought at 6:18 pm from [Acute Care Facility]. Based on the information contained in the note, this appeared to be an admission nursing note. A physician progress note for Resident 143 dated 3/09/20 at 8:20 p.m. indicated, RECENTLY admitted AT SNF (Skilled Nursing Facility) FOR REHAB . S/P (Status post) FALL FROM EDGE OF BED RESULTING IN LEFT IT (Sic) FEMUR (Thigh bone) FRACTURE. A second nursing note dated 2/26/20, with no time documented, indicated, I was endorsed from Noc (Night) shift and reported that Resident [Resident 143] had fall @ (at) 0645 (6:45 a.m.). I had quickly went into the room and found Resident in a upright position yelling in pain and found left low extremity in abducted (An extremity moved away from the midline of the body) position. The note was dated but did not include the time when it was documented, and instead indicated, AM (A.m. shift). During a concurrent interview and record review on 3/11/20 at 9:58 a.m., the Director or Nursing (DON) confirmed the nursing notes on 2/25/20 and 2/26/20 were not timed, but stated these notes were summaries of the shifts, and did not have to be timed. During an interview on 3/12/20 at 10:10 a.m., Administrative Staff G, Regional Nurse Consultant, stated that absolutely, all nursing notes had to be timed, and stated that although they did not have a specific policy on it, they followed [NAME] (Online source for evidence-based procedure guidance in nursing) practices, and [NAME] stated licensed nurses should time their entries. The DON was asked for a policy on clinical documentation on 3/11/20 at 10:30 a.m. and 03/12/20 at 08:50 a.m. The DON stated she could not find one on 3/12/20 at 8:50 a.m., but provided an undated document published by the National Committee of Quality Assurance (Nonprofit organization that works to improve health care quality) titled, Guidelines for Medical Record Documentation, which indicated, Consistent, current and complete documentation in the medical record is an essential component of quality patient care.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 42% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $132,836 in fines. Review inspection reports carefully.
• 85 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $132,836 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
• Grade F (3/100). Below average facility with significant concerns.

Bottom line: Trust Score of 3/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is North Bay Post Acute's CMS Rating?

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

How is North Bay Post Acute Staffed?

CMS rates NORTH BAY POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 42%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at North Bay Post Acute?

State health inspectors documented 85 deficiencies at NORTH BAY POST ACUTE during 2020 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 82 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates North Bay Post Acute?

NORTH BAY POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 98 certified beds and approximately 92 residents (about 94% occupancy), it is a smaller facility located in PETALUMA, California.

How Does North Bay Post Acute Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, NORTH BAY POST ACUTE's overall rating (1 stars) is below the state average of 3.1, staff turnover (42%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting North Bay Post Acute?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is North Bay Post Acute Safe?

Based on CMS inspection data, NORTH BAY POST ACUTE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at North Bay Post Acute Stick Around?

NORTH BAY POST ACUTE has a staff turnover rate of 42%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was North Bay Post Acute Ever Fined?

NORTH BAY POST ACUTE has been fined $132,836 across 3 penalty actions. This is 3.9x the California average of $34,407. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is North Bay Post Acute on Any Federal Watch List?

NORTH BAY POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 98
Avg. Residents: 92
Occupancy: 94.6%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Immediate Jeopardy citation: -12
2 Actual Harm citations: -10
85 Deficiencies: -10
Fines ($132,836): -15
Final Score: 3/100

Nearby Alternatives

CLOVERDALE HEALTHCARE CENTER 5-star PETALUMA POST-ACUTE REHABILITA... 5-star SUMMERFIELD HEALTH CARE CENTER 5-star

View all in PETALUMA →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056120