What is BAYSHIRE RANCHO MIRAGE's CMS rating?

BAYSHIRE RANCHO MIRAGE has a four-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does BAYSHIRE RANCHO MIRAGE have?

BAYSHIRE RANCHO MIRAGE has 39 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at BAYSHIRE RANCHO MIRAGE?

BAYSHIRE RANCHO MIRAGE has a two-star staffing rating from CMS with 0.42 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 BAYSHIRE RANCHO MIRAGE located?

BAYSHIRE RANCHO MIRAGE is located in RANCHO MIRAGE, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does BAYSHIRE RANCHO MIRAGE have?

BAYSHIRE RANCHO MIRAGE has 45 certified beds.

Who owns BAYSHIRE RANCHO MIRAGE?

BAYSHIRE RANCHO MIRAGE is a for profit - individual facility and is part of the BAYSHIRE SENIOR COMMUNITIES chain.

Is BAYSHIRE RANCHO MIRAGE safe?

BAYSHIRE RANCHO MIRAGE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at BAYSHIRE RANCHO MIRAGE stick around?

BAYSHIRE RANCHO MIRAGE has average staff turnover at 36%, which is typical for the nursing home industry.

Was BAYSHIRE RANCHO MIRAGE ever fined?

Yes, BAYSHIRE RANCHO MIRAGE has been fined $15,524 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is BAYSHIRE RANCHO MIRAGE on any federal watch list?

No, BAYSHIRE RANCHO MIRAGE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at BAYSHIRE RANCHO MIRAGE?

Medicare inspectors have found 39 deficiencies at BAYSHIRE RANCHO MIRAGE: 39 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting BAYSHIRE RANCHO MIRAGE?

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

How does BAYSHIRE RANCHO MIRAGE compare to other nursing homes?

BAYSHIRE RANCHO MIRAGE has a 4-star overall rating, placing it above average compared to other nursing homes in CA. Higher-rated facilities typically have better inspection results and staffing levels.

BAYSHIRE RANCHO MIRAGE | 68/100 (Grade C+)

Apr 2025 7 deficiencies

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were administered in accordance wi...

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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 medications were administered in accordance with professional standards of practice for one of five residents observed for medication administration (Resident 17) when the staff turned on the nebulizer machine (a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) before the resident placed the facemask over nose and mouth. This failure had the potential to result in the resident receiving less than the prescribed amount of medication, leading to ineffective drug therapy and a medication error due to inadequate medication administration. Findings: On April 21, 2025, at 9:01 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN 1), LVN 1 was observed administering sodium chloride 3% inhalation solution (medication used in a nebulizer to help loosen mucus in the lungs, making it easier to clear from the lungs) to Resident 17 via nebulizer. It was observed LVN 1 added the inhalation solution into the nebulizer cup. LVN 1 then walked over to the nebulizer machine, which was located behind the resident's recliner, where the resident was seated, and turned on the machine. Mist began to be released immediately after the machine was turned on. LVN 1 then handed the face mask to Resident 17 from behind the recliner. Resident 17 was observed applying the face mask while mist was already being emitted from the nebulizer. A review of Resident 17's medical record titled admission Record, indicated Resident 17 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD, lung disease causing difficulty breathing) with acute exacerbation (sudden worsening of the existing COPD symptoms with increased difficulty breathing, increased mucus production and coughing), pneumonia (lung infection), chronic respiratory failure with hypoxia (chronic lung condition with deficiency of oxygen). A review of Resident 17's medical record indicated there was a physician order on April 9, 2025, for Sodium Chloride Inhalation Solution 3%, with the direction to inhale 1 inhalation solution via nebulizer two times a day for COPD. On April 21, 2025, at 3:20 p.m., during an interview with LVN 1, LVN 1 stated due to limited space and clutter around the resident's recliner, he turned on the nebulizer machine first and handed the facemask from behind the recliner to the resident as quickly as possible. LVN 1 confirmed the mist was already being released from the mask after turning on the machine, before the resident had secured the mask. LVN 1 stated he should have observed the resident properly place the facemask over the nose and mouth before turning on the nebulizer machine. LVN 1 acknowledged some medication might have dispersed into the room and the resident might not have received the full dose of medication. On April 24, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated the staff should have first observed the resident properly apply the face mask before turning on the nebulizer machine. The DON acknowledged there was a likelihood some medication was released into the airs within the resident's room and the resident might have inhaled less than the prescribed dose. The facility's policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised, October 2010, was reviewed, and it indicated: .Dispense medication into nebulizer cup .Turn on the nebulizer and check the outflow port for visible mist .Ask the resident to hold the mouthpiece gently between his/her lips (or apply face mask) . The National Institutes of Health (NIH, the United States' primary biomedical and public health research agency) publication titled, How to use a nebulizer, dated October 2021 indicated: .Put the prescribed amount of medicine into the nebulizer cup. Place the mouthpiece in your mouth and close your lips around it to form a tight seal. If uses a mask, make sure it fits snugly against the face and covers the nose and mouth. Turn on the nebulizer machine. You should see a light mist coming from the back of the tube opposite the mouthpiece or from the mask .

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the tubing, feeding bottle, and water bag were...

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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 tubing, feeding bottle, and water bag were labeled and dated for one of two residents (Resident 238) who receive enteral feeding (nutrition provided through a tube inserted into the stomach). This failure had the potential to cause food borne illness to Resident 238. Findings: On April 21, 2025, at 9:24 a.m., Resident 238 was observed receiving Jevity 1.2 CAL tube feeding nutrition and water through an electronic pump delivery system (e-pump), while sitting up in bed. The Jevity bottle, water bag and tubing were observed not labeled and dated. On April 21, 2025, at 9:36 a.m., in an concurrent observation and interview, Licensed Vocational Nurse (LVN) 2 confirmed the Jevity bottle, water bag and tubing were not labeled and dated. She stated these should have been labeled with date, time and the resident's name. On April 24, 2025, at 9:25 a.m. an interview with the Director of Nursing (DON) was conducted. The DON stated that the tubing, tube feed bottles, and water bag should be labeled with resident's name, orders, date and time it was opened. Resident 238's record was reviewed. Resident 238 was admitted to the facility on [DATE], with diagnoses which included dysphasia (condition that affects your ability to produce and understand spoken language), encephalopathy (a disease process that alters brain function) and cervical spine fracture (broken neck). A review of Resident 238's physician orders indicated .one time a day Jevity 1.2 60ml(milliliters-unit of measure)/hr for 10 hours Flush 20ml/hr for 10 hours, off at 1800 (6:00 pm) and on at 0400 .Change G-Tube Enteral Feeding Bag and Tubing every day . A review of (name of brand) Jevity 1.2 Cal product information, dated 7/22/2024, indicated, .consume within 24 hours . A review of Lippincott procedures, dated 2022, titled, Initiating Enteral Nutrition, indicated, .Label the container and administration set with the date and time it was first hung .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the ne...

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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 pharmacy services were provided to meet the needs of the residents when three medications with holding parameters were not administered in accordance with the physician's orders for one resident (Resident 14). This failure had the potential to significantly lower the blood pressure to cause dizziness, confusion, fainting and a fall. Findings: On April 24, 2025, a review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN - high blood pressure) and atrial fibrillation (AFib - irregular heartbeat). A review of Resident 14's medical record indicated there were physician's orders for the following medications: - Benazepril (blood pressure medication) 5 mg (milligram, unit of measurement) with the direction to give 1 tablet by mouth at bedtime every 2 days for HTN, and hold for SBP (systolic blood pressure - the top number in blood pressure reading which measures how hard the heart pumps blood into arteries) less than 110 (mmHg, milliliter of mercury - unit of blood pressure measurement), dated March 21, 2025; - Terazosin (blood pressure medication) 5 mg with the direction to give 1 capsule by mouth at bedtime for HTN, and hold for SBP less than 110, dated March 21, 2025; and - Amiodarone (medication for irregular heart rhythm) 400 mg with the direction to give 1 tablet by mouth every 12 hours for AFib, hold for SBP less than 110 and/or HR (heart rate) less than 60. A review of Resident 14's Medication Administration Record (MAR), for March 2025 and April 2025, indicated Benazepril, Terazosin, and Amiodarone were administered to Resident 14 when the SBP was below 110 on the following dates and times: For Benazepril 5 mg: - March 23, 2025, at 2100 (9 p.m.), SBP 103; - March 25, 2025, at 2100 (9 p.m.), SBP 109; and - April 6, 2025, at 2100 (9 p.m.), SBP 104. For Terazosin 5 mg: - March 23, 2025, at 2100 (9 p.m.), SBP 103; - March 25, 2025, at 2100 (9 p.m.), SBP 109; - April 9, 2025, at 2100 (9 p.m.), SBP 96; and - April 13, 2025, at 2100 (9 p.m.), SBP 106. For Amiodarone 400 mg: - March 26, 2025, at 2100 (9 p.m.), SBP 93; - April 3, 2025, at 0900 (9 a.m.), SBP 108; - April 4, 2025, at 0900 (9 a.m.), SBP 105; - April 6, 2025, at 2100 (9 p.m.), SBP 104; - April 9, 2025, at 2100 (9 p.m.), SBP 96; and - April 13, 2025, at 2100 (9 p.m.), SBP 106. On April 24, 2025, at 2:45 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON verified the medications were documented as administered on the MAR for March 2025 and April 2025, despite the physician's order to hold the dose if the resident's SBP was below 110 mmHg. The DON acknowledged the physician's orders were not followed, and doses should have been held when the resident's SBP was below 110 mmHg. On April 24, 2025, at 3:15 p.m., during a concurrent interview with the facility's Consultant Pharmacist (CP), the CP stated he had not reviewed these medications since they were ordered after his most recent medication regimen review, completed on March 16, 2025. The CP stated if he had identified the holding parameters were not being followed for the blood pressure (BP) medications, he would have recommended for the physician to review the BP readings. The CP further stated he would have advised adjusting the medications or dosages as necessary to ensure safe administration. A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated: .Medications are administered in accordance with prescriber orders .

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medicatio...

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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 unnecessary medications for one of five residents (Resident 14) when two medications from the same therapeutic (drug) class, proton pump inhibitors (PPI - a class of drug that reduce the amount of acid made by the stomach), were ordered and administered for the same indication. This deficient practice had the potential for unnecessary duplicate therapy or additive medication adverse effects including bone fractures and gastrointestinal (stomach and intestines) infections. Findings: On April 24, 2025, a review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included gastroesophageal reflux disease (GERD - condition in which the stomach acid and contents flow back up into the esophagus and causes heartburn). A review of Resident 14's medical record indicated there was a physician orders for the following medications: - Pantoprazole (medication called proton pump inhibitor, PPI) 40 mg (milligram, unit of measurement), give 1 tablet by mouth in the morning for GERD, dated March 21, 2025; and - Omeprazole 20 mg (medication called PPI), give 1 tablet by mouth at bedtime for GERD, dated March 21, 2025. A review of Resident 14's Medication Administration Record (MAR), for March 2025 and April 2025 indicated both Pantoprazole 40mg and Omeprazole 20mg were administered daily from March 22 through April 23, 2025, with exception of April 8 and April 10, when Omeprazole 20 mg was not administered due to unavailability, as documented on the MAR with chart code 11 (med not available). There was no documented clinical rationale to justify the use of two different proton pump inhibitors, Pantoprazole 40mg in the morning and Omeprazole 20mg at bedtime, for the management of GERD. On April 24, 2025, at 2:45 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON verified both Pantoprazole and Omeprazole were documented on the MAR as administered daily. The DON acknowledged the medications are from the same therapeutic class and have similar mechanisms of action (how the drug works to produce a desired effect in the body). On April 24, 2025, at 3:15 p.m., during a telephone interview with the facility's Consultant Pharmacist (CP), the CP stated he had not reviewed these medications since they were ordered after his most recent medication regimen review, completed on March 16, 2025. The CP added he would have questioned the duplicate PPI medication use and would have asked for clinical justification. The CP also stated if there was no documented clinical justification, he would have recommended the physician to discontinue one of the PPI medications and, if clinically indicated, adjust the dosing regimen of the remaining PPI to be administered twice daily. The CP further stated there is no benefit in administering two different PPI medications, as they belong to the same therapeutic class and have similar mechanism of action. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns . A review of Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Pantoprazole tablets, revised January 2025, retrieved from DailyMed (internet database operated by the U.S. National Library of Medicine providing labeling for prescription and nonprescription drugs), indicated: .Protonix (brand name for pantoprazole) is a proton pump inhibitor indicated for short-term treatment of GERD .Dosage for GERD .40 mg once daily for up to 8 weeks .suppresses the final step in gastric (stomach) acid production .Bone Fracture: Long-term and multiple daily dose PPI therapy may be associated with an increased risk for osteoporosis-related (a disease that weakens the bones) fractures of the hip, wrist or spine . A review of Prescribing Information for Omeprazole tablets, revised September 2012, retrieved from DailyMed, indicated: .Prilosec (brand name for omeprazole) is a proton pump inhibitor indicated for treatment of GERD .Dosage for GERD: 20mg once daily for 4 to 8 week .suppresses gastric acid secretion .PPI therapy may be associated with increased risk of Clostridium difficile associated diarrhea .Bone fracture: Long-term and multiple-daily dose PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist or spine . A review of the National Institute of Health (NIH)'s National Library of Medicine (NLM, a nationally recognized source of medical information), titled Interchangeable Use of Proton Pump Inhibitors Based on Relative Potency, dated December 16, 2019, indicated: .consensus conferences have suggested that PPIs are more similar than different .The World Health Organization Collaborating Centre for Drug Statistics Methodology proposed that 20 mg omeprazole .40 mg pantoprazole .were equivalent for the treatment of GERD .

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the [NAME] followed the recipe for preparing pureed bread for dinner on April 21, 2025. This failure had the potential...

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Based on observation, interview, and record review, the facility failed to ensure the [NAME] followed the recipe for preparing pureed bread for dinner on April 21, 2025. This failure had the potential to compromise the nutritional needs for one resident (Resident 138) reviewed for pureed diet. Findings: On April 21, 2025, at 3:54 p.m., the Cook, with the presence of the Dietary Manager (DM), was observed to prepare pureed bread for a resident who was on pureed diet (Resident 138). The [NAME] had the recipe for pureed bread in front of her as she read the directions. The [NAME] was observed conducting the following: a. Put five (5) slices of white bread, cut in small pieces, in the blender, and added three quarters (3/4) cup of regular milk and turned on the blender. b. Turned off the blender, used a wooden spoon to stir the contents in the blender which was of thick consistency. c. Added three more cups of regular milk and turned on the blender. d. Poured the contents of the blender in a metal container and added two spoonsful of thickener to the mixture and stirred it with the wooden spoon. The [NAME] used a disposable spoon to measure the thickener instead of using the appropriate measuring spoon. The pureed bread was runny and with a watery consistency. The [NAME] stated she followed the recipe for pureed bread and it was the right consistency. The DM who was present during the observation was asked to check the pureed bread made by the Cook. The DM used the wooden spoon to stir the pureed bread and stated it had the right consistency for pureed bread. The Registered Dietician (RD) was called to verify the consistency of the pureed bread. On April 21, 2025, at 4:08 p.m., the RD walked in the kitchen to verify the consistency of the pureed bread made by the Cook. The RD stated the pureed bread made by the [NAME] was watery and did not have the right consistency for pureed diet. She stated pureed diet should have a pudding-like consistency which is cohesive with no lumps. She stated when you scoop the pureed food with a spoon, the puree should hold its shape and form. She stated when you tilt the spoon, the puree will slide off easily. On April 24, 2025, at 9:03 a.m., during an interview with the RD, she stated the [NAME] did not follow the recipe for making pureed bread. She stated the [NAME] should have followed the recipe for pureed diet to get the right consistency and thickness. During review of the facility document titled, PUREED Bread Products, revised October 06, 2021, indicated, .Yields .5 (five servings) .Ingredients .Bread product .5 Each .Broth*, Milk*, or Juice* .3/4 cup .Thickener**, food .1 ½ (one and a half) Tsp (teaspoon) .Directions .Remove portions required form the regular prepared recipe and place in food processor. Gradually add liquid to bread while processing and process until smooth. All liquid may not be required .Ensure mixture achieves smooth, lump free and extremely thick consistency . A review of the facility policy and procedure titled, STANDARDIZED RECIPES, revised August 31, 2018, indicated, .Standardized recipes will be used .Recipes note how to prepare the food items in order to preserve vitamins, taste, and appearance . A review of the facility policy and procedure titled, Mechanically Altered Diet Explanation (3 Levels), revised May 6, 2019, indicated, .Puree all foods to the consistency of smooth, moist mashed potatoes or pudding-like consistency .

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications and...

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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 proper labeling and storage of medications and devices in accordance with the facility's policies and procedures and/or manufacturer's instructions when: 1. One discontinued medication was stored in the Red Medication Cart with other active medications available for use; 2. A total of three expired medications and devices were stored in the Red Medication Cart, IV Cart (a cart used to store medications and supplies needed for intravenous medications given through a vein), Treatment Cart (a cart used to store medication and supplies needed for wounds treatment), and Medication Room; and 3. A total of three medications with incorrect expiration dates were stored in the IV Cart and refrigerator in the Medication Room. These failures had the potential for residents to receive discontinued, expired, or ineffective medications, leading to medication errors and compromised treatment outcomes. Findings: 1. On April 21, 2025, at 3:35 p.m., during an inspection of Red Medication cart in the Red Hall with Licensed Vocational Nurse (LVN 3), a blister card containing Calcium Acetate (supplement) 667 mg (milligram, unit of measurement) capsules were observed stored in active stocks, despite the order being discontinued. The label on the blister card indicated it was prescribed for Resident 24 with the direction to give one capsule by mouth with meals for supplement. The pharmacy fill date (the date the pharmacy dispensed the medication) on the label indicated 03/22/2025 (March 22, 2025) and four capsules remained in the blister card. During a concurrent interview and record review with LVN 3, LVN 3 verified the order for calcium acetate 667 mg capsules was discontinued on April 5, 2025. LVN 3 further stated the order had been changed to calcium acetate 667 mg tablets, with the direction to give three tablets before meals for supplement. Two blister cards containing the tablets for the active order were observed stored in the same medication cart. LVN 3 acknowledged the discontinued medication should not have been stored in the medication cart and should have been removed from the medication cart and properly disposed of in the pharmaceutical waste bin located in the medication room. The facility's policy and procedure (P&P) titled Discontinued Medications, revised November 2022, was reviewed, and indicated: .Staff shall destroy discontinued medications .Discontinued medications are destroyed .with facility policy and state regulations . 2a. On April 21, 2025, at 4:13 p.m., during an inspection of Red Medication cart in the Red Hall with LVN 3, an unused 3-mL Basaglar KwikPen (Insulin Glargine - a long-acting insulin used to prevent high blood sugar) 100 units/mL (units per milliliter, unit of measurement) for injection was observed stored at a room temperature with the open date written for 3/7/25 (March 7, 2025). The label on the insulin pen indicated it was prescribed for Resident 24 with the direction to Inject 6 units subcutaneously (Sub-Q - injection given in the fatty tissue under the skin) every night at bedtime for DM (Diabetes Mellitus - a condition where the body has trouble regulating blood sugar levels). During a concurrent interview with LVN 3, LVN 3 verified the insulin pen was expired. LVN 3 stated it should not have been stored in the medication cart beyond 28 days and should have been removed and properly disposed of in the pharmaceutical waste bin located in the medication room. The facility's P&P titled, Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date . A review of the manufacturer's Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for BASAGLAR KwikPen, revised November 2023, indicated: .Storage and Handling .Not In-Use (Unopened) Room Temperature .28 days . 2b. On April 22, 2025, at 9:15 a.m., during an inspection of IV cart with the Assistant Director of Nursing (ADON), a total of six syringes of expired Heparin Lock Flush Solutions (solution to keep the IV line open by preventing blood clots from forming, and help fluids or medications keep flowing freely), 50 USP units/5mL (USP units per milliliter, unit of measurement) in 0.9% sodium chloride were identified. The manufacturer's expiration dates on the syringes indicated June 2024. During a concurrent interview with the ADON, the ADON confirmed the Heparin lock flush syringes were expired. The ADON stated it should not have been stored in the IV cart and should have been removed and properly disposed of in the pharmaceutical waste bin located in the medication room. 2c. On April 22, 2025, at 10:08 a.m., during an inspection of the Treatment cart conducted with LVN 4, a bottle of Adapt Stoma Powder (drug used to absorb moisture from broken or irritated skin around a stoma, a surgically created opening on the abdomen) was observed stored with the manufacturer's expiration date of June 2024. During a concurrent interview with LVN 4, LVN 4 confirmed the medication was expired and acknowledged the expired treatment medication should not have been stored in the treatment cart and should have been removed and properly disposed of in the pharmaceutical waste bin located in the medication room. 2d. On April 22, 2025, at 3: 26 p.m., during an inspection of the medication room conducted with the Director of Nursing (DON), additional expired Heparin lock flush syringes were identified in the bottom cabinet located under the sink. One partial and one full box of Heparin lock flush syringes had the manufacturer's expiration date of June 2024. During a concurrent interview with DON, the DON confirmed the Heparin lock flush syringes were expired. The DON stated the expired syringes should not have been stored in the medication cabinets and should have been removed and placed in the designated disposal cabinet for medications located in the same medication room. The facility's P&P titled Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .If the facility has .outdated .medications ., the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . The facility's P&P titled Discarding and Destroying Medications, revised April 2019, was reviewed, and indicated: .Medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals .Staff shall contact the provider pharmacy if they are unsure of proper disposal methods for medications . 3a. On April 22, 2025, at 9:28 a.m., during an inspection of the IV cart conducted with ADON, the following IV diluent bags (small IV fluid bags used to dilute medications) for Resident 24 were observed stored out-of-overwrap (outside of the manufacturer's overwrap) without a documented beyond-use date (BUD - the date after which a medication that has been opened, mixed, or prepared should no longer be used, as its safety and effectiveness may no longer be guaranteed): - Nine bags of [NAME] 0.9% Sodium Chloride (NS - normal saline) 100 mL (milliliter, unit of measurement) sterile single-dose VIAFLEX (type of container) containers were observed for Resident 24 with the direction to use as directed with daptomycin (drug used to treat infection). The label indicated the pharmacy fill date of 03/28/2025 (March 28, 2025), and the expiration date of 4/26 (April 2026), matching the manufacturer's expiration date; and - Six bags of [NAME] NS 100 mL sterile single-dose VIAFLEX containers were observed for Resident 24 with the direction to use as directed with ceftriaxone (drug used to treat infection). The label indicated the pharmacy fill date of 03/28/2025 (March 28, 2025), and the expiration date of 4/26 (April 2026), matching the manufacturer's expiration date. On April 24, 2025, at 3:34 p.m., a telephone interview was conducted with Pharmacist 1. The Pharmacist 1 stated the pharmacy was not aware of this storage limit until the question was raised. According to a reference from the American Society of Health-System Pharmacists (ASHP - a nationally recognized organization that provides evidence-based guidance on safe medication use and storage practices in healthcare setting)'s publication titled, Applying Stability Data in Sterile Compounding, in the 7th edition of Extended Stability for Parenteral Drugs, dated on September 29, 2022, indicated: .Table 7: Manufacturer Storage of Commercial IV Solution Containers after Removal from Protective Overwrap .Viaflex containers .Volume ? 100 mL .Maximum Storage Time (Room Temperature) 30 d (days) . 3b. On April 22, 2025, at 9:59 a.m., during an inspection of the Medication Room conducted with the ADON, a total of eight compounded Ceftriaxone bags for IV infusion were observed stored in the medication refrigerator with the expiration date of 04/21/26 (April 21, 2026) which was one year from the pharmacy's fill date of 04/21/2025 (April 21, 2025). The labels on the bags indicated the medications were for Resident 24, with the direction to administer ceftriaxone 1 gm (gram - unit of measurement) (50ml) intravenously over 30 minutes once daily via PICC (peripherally inserted central catheter - a type of long, thin tube placed in a large vein in the arm to give medications or fluids over a long period of time) line using gravity tubing (a way to give fluids or medicine through an IV by using gravity) as directed at bedtime for bone infection. During a concurrent interview with ADON, the ADON stated the compounded IV medications were provided by a compounding pharmacy, contracted with the dispensing pharmacy to supply IV medications to the facility. On April 24, 2025, at 3 p.m., during a telephone interview with Pharmacist 2, the Pharmacist 2 stated the expiration date on the label was incorrect and the BUD for the compounded ceftriaxone IV bags should have been 10 days. The Pharmacist 2 stated the compounding pharmacy follows the USP <797> (the United States Pharmacopeia - a set of standards issued by the USP that provides guidelines to ensure the safe preparation, handling, and storage of sterile compounded medications) BUD limits for Category 2 CSPs (compounded sterile preparations - made in sterile condition) with the maximum storage of 10 days at refrigerator. A review of the undated reference titled, USP-797, provided by Pharmacist 2, indicated: .Table 13. BUD Limits for Category 2 CSPs: Compounding method: aseptically processed CSPs, no sterility testing performed and passed, prepared from only sterile starting components: 10 days at refrigerator . The facility's P&P titled, Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .For medications that are prepared or compounded for intravenous infusion, the label contains .date after which the mixture cannot be used . 3c. On April 22, 2025, at 3: 26 p.m., during an inspection of refrigerator in the medication room with the DON, a refrigerated Emergency Kit (E-kit, a sealed container with various medications for use in emergencies) was observed with the label on the outside of the E-kit container indicating an expiration date of 6/26 (June 2026). One of the medications stored in the E-kit was Cathflo Activase (medication used to break down blood clots and help unblock IV tubes, inserted to vein) 2 mg with the manufacturer's expiration date of October 2025. During a concurrent interview with the DON, the DON confirmed the expiration date of the Cathflo and stated the earliest expiration date of the medications stored in the E-kit should be indicated on the outside of the E-kit container to ensure no resident receives expired medication. On April 24, 2026, at 3:15 p.m., during a telephone interview with the facility's Consultant Pharmacist (CP), the CP stated he had checked the facility's E-kit during his visit. The CP also confirmed the earliest expiration date should have been indicated on the outside of E-kit container. On April 24, 2025, at 3:34 p.m., during a telephone interview with Pharmacist 1, Pharmacist 1 confirmed the E-kit had been provided by his pharmacy and acknowledged the earliest expiration date should have been written on the outside of the E-kit. The facility's P&P titled, Emergency Medications, dated April 2021, was reviewed and indicated: .The consultant pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit . The facility's P&P titled, Medication Labeling and Storage, revised February 2023, was reviewed, and indicated: .labeling of medications .dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .The medication label includes, at a minimum .expiration date .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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in accordance with professional standards of pr...

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices were followed in accordance with professional standards of practice when: 1. Four half (1/2) size sheet steam drip metal pans and three eight quarts (8-qts - a unit of measurement) pitchers were stored wet; 2. One cup of undated cut fruits and one five pound (5-lb) tub low fat cottage cheese with an expiration date of April 11, 2025, were found stored in the satellite kitchen refrigerator; and 3. One undated open bottle of reduced fat ultra filtered milk was found stored in the resident's refrigerator. These failures had the potential to cause food-borne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population who received food prepared in the kitchen. Findings: 1. On April 21, 2025, at 9:01 a.m., an initial tour of the main kitchen was conducted with the Dietary Manager (DM). Four ½ size sheet steam drip metal pans and three 8-qts pitchers were observed stored wet. During a concurrent interview with the DM, she stated the ½ size sheet steam drip metal pans and the 8-qts pitchers should not be stored wet. On April 24, 2025, at 9:03 a.m., during an interview with the Registered Dietician (RD), the RD stated all dishes should be air-dried after every wash. She also stated the dishes should not be stored or stacked wet. She stated moist or wet dish can harbor bacteria that could result in food-borne illnesses. The facility policy and procedure titled, DISHWASHING PROCEDURE, revised August 31, 2018, indicated, .Air dry dishes by racking or putting on single trays lined with mesh . A review of Food and Drug Administration (FDA - agency responsible for protecting public health by ensuring the safety of the food supply) Food Code 2022, Section 4-901.11, titled, Equipment and Utensils, Air-Drying Required, indicated, .After cleaning and SANITIZING, EQUIPMENT and UTENSILS .Shall be air-dried . 2. On April 21, 2025, at 9:51 a.m., an initial tour of the satellite kitchen tour was conducted with the Dietary Aide (DA). One undated cup of cut fruits and one 5-lb tub of low-fat cottage cheese with an expiration date of April 11, 2025, were found stored in the refrigerator. During a concurrent interview with the DA, she stated the cup of fresh fruits should have a date and the low-fat cottage cheese should have been discarded on April 11, 2025. On April 24, 2025, at 9:03 a.m., during an interview with the RD, she stated the cut fruits were prepared in the main kitchen and delivered to the satellite kitchen for storage in the refrigerator. She stated the cut fruits should have a date when they were prepared before they were stored in the refrigerator. She stated the date will help the staff ensure the food is fresh and safe for resident consumption. The RD also stated, the kitchen staff should check all the food in the refrigerator. She stated the kitchen staff should check for expiration dates every day. She stated there should be no expired food in the refrigerator. 3. On April 21, 2025, at 10:11 a.m., an inspection of the resident's refrigerator located in the dining area was conducted with the DA. One undated open bottle of reduced fat ultra filtered milk labeled with a resident's name was found in the refrigerator. During a concurrent interview with the DA, she stated the staff should put a date on the resident's food when they put them in the refrigerator. She stated the resident's reduced fat ultra filtered milk should have been dated when it was opened. On April 23, 2025, at 1:46 p.m., the Certified Nurse Assistant (CNA) was interviewed. The CNA stated the staff should label resident's food with the room number, resident's name and the date it was received before storing them in the resident's refrigerator. On April 24, 2025, at 9:03 a.m., during an interview with the RD, she stated all open food containers should have an open date. The RD stated the staff should label all food brought from home with an open date or the date the food was brought in the facility. She stated resident's food should be good for three to five days from the open date. The facility policy and procedure titled, FOOD STORAGE, revised July 11, 2024, indicated, .Any expired or outdated food products should be discarded .All food products should be inspected for safety and quality and should be dated upon receipt, when open, and when prepared .Remember to cover, label and date .

Apr 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Notice of Discharge (a notice informing the resident of t...

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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 Notice of Discharge (a notice informing the resident of their pending discharge date , and their rights to appeal the discharge) was provided to the Long Term Care (LTC) Ombudsman, following resident being notified of their pending discharge date for 5 out of 5 residents' (Residents 1, 2, 3, 4 & 5). This failures could have resulted in Residents 1, 2, 3, 4 & 5 not to be aware of their rights to appeal the discharge and the Ombudsman to not to be able to inform the residents of their rights and options to appeal prior to the resident being discharged . Findings: On March 15, 2024, at 10:00 a.m., an unannounced visit was made to the facility to investigate a Quality-of-Care issue. 1. A review of Resident 1's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of a cerebral infarction (Brain tissue death due to blood vessel blockage), with a BIMS (Brief Interview for Mental Status- an interview used to assess cognitive intactness) score of 0 (severe cognitive impairment). A review of Resident 1's Doctor's (Drs) orders, dated, March 19, 2024, untimed, indicated, . LCD (Last Cover Date for insurance) DC (Discharge) (March 19, 2024) . A review of Resident 1's Notice of Transfer/Discharge, dated, March 11, 2024, untimed, indicated the resident was notified of his discharge date , and signed the notice of discharge on the same date, March 11, 2024, with a pending date of discharge March 13, 2024. A review of Resident 1's, Discharge Summary, dated, March 19, 2024, at 8:53 a.m., indicated the resident discharged from the facility on March 18, 2024, at 10:00 a.m. 2. A review of Resident 2's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of a fractured left femur (upper leg bone), and a BIMS score of 12 (cognitively intact). A review or Resident 2's Drs orders, dated, March 15, 2024, untimed, indicated, . LCD (March 18, 2024) DC (Discharge) to . (Assisted living facility) . A review of Resident 2's, Notice of Transfer/Discharge, dated, March 13, 2024, untimed, indicated the resident was notified of his discharge date and signed the notice of discharge on the same date, March 13, 2024, with a pending date of discharge on [DATE]. A review of Resident 2's, Discharge Summary, dated, March 17, 2024, at 5:32 p.m., indicated the resident discharged from the facility on March 18, 2024, at 1:30 p.m. 3. A review of Resident 3's face sheet, indicated the resident was admitted to the facility on [DATE], with a diagnosis of fracture to the left femur (upper leg bone), and a BIMS score of 0 (severe cognitive impairment). A review of Resident 3's Drs orders, dated, February 13, 2024, untimed, indicated, . LCD (March 14, 2024), DC (March 15, 2024) . A review of Resident 3's, Notice of Transfer/Discharge, dated, March 11, 2024, untimed, indicated the resident's representative was notified via telephone call of the resident's discharge date on March 11, 2024, with a pending discharge date of March 15, 2024. A review of Resident 3's, Discharge Summary, dated, March 15, 2024, at 3:49 p.m., indicated the resident discharged from the facility on March 15, 2024, at 2:00 p.m. 4. A review of Resident 4's face sheet indicated the resident was admitted to the facility on [DATE], with a diagnosis of a urinary tract infection, and a BIMS score of 3 (Severe cognitive impairment). A review of Resident 4's Drs orders, dated, February 8, 2024, untimed, indicated, . Discharge to home with wife . no date given. A review of Resident 4's, Notice of Transfer/Discharge, dated, March 8, 2024, untimed, indicated the resident was notified of his discharge date , and signed the notice of discharge on the same date, March 8, 2024, with a pending discharge date of March 12, 2024. A review of Resident 4's, Discharge Summary, dated, March 11, 2024, at 3:27 p.m., indicated the resident discharged from the facility on March 12, 2024, at 12:00 p.m. 5. A review of Resident 5's face sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of depression, and a BIMS score of 15 (cognitive intactness). A review of Resident 5's Drs orders, dated, February 23, 2024, untimed, indicated, .LCD (February 25, 2024) DC home . A review of Resident 5's, Notice of Transfer/Discharge, dated, February 22, 2024, untimed, indicated the resident was notified of her discharge date , and signed the notice of discharge on the same date, February 22, 2024, with a pending discharge date of February 25, 2024. A review of Resident 5's, Discharge Summary, dated, February 25, 2024, at 5:24 a.m., indicated the resident discharged from the facility on February 25, 2024, at 12:00 p.m. A review of Resident 5's, Discharge Notifications to the Ombudsman, dated, March 01, 2024, indicated, the Ombudsman was notified of Resident 5's discharge on [DATE], on March 01, 2024. On March 15, 2024, at 10:51 a.m., an interview was conducted with the Social Services Director (SSD), who stated the resident &/or resident's representative are notified of their pending discharge, via a Notice of transfer/discharge, form, they sign and are given a copy at the time of their notification. The SSD further stated, once a month, at the end of the month, a copy of all the notice of transfer/discharges are faxed to the LTC Ombudsman for notification. On March 15, 2024, at 3:57 p.m., an interview was conducted with LVN 1 who stated, at the time of discharge, the resident is provided with a copy of their notice of discharge, then a copy is put in the Social Services box, to be faxed to the LTC Ombudsman for notification. On April 3, 2024, at 9:15 a.m., an interview was conducted with the Administrator who stated, Social Services was notifying the LTC Ombudsman of facility-initiated discharges all together once a month, not at the time the resident was notified of their pending discharge date . On April 9, 2024, at 3:50 p.m., an interview was conducted with the SSD, who stated she notified the LTC Ombudsman of all the March facility-initiated discharges in one fax (facsimile - electronic transmission) on April 1, 2024, but did not keep the fax confirmation. A facility policy and procedure titled, Notification to Ombudsman of Transfer and Discharge, revised April 2017, indicated, .Resident discharge to home or other entity .Social Services .will provide notice of discharge .Social services .will ensure receipt of signed notice of discharge .Social Services .will fax notification to Ombudsman .Social Services .to ensure delivery of notice to Ombudsman .Resident transfer to hospital .Social services .will send notification reprt to Ombudsman at a routine interval established by facility (monthly) . A facility Policy and Procedure, titled, Transfer or Discharge Notice, revised, December 2016, indicated, .A copy of the notice (of discharge) will be sent to the Office of the State Long-Term Ombudsman on monthly basis .

Jan 2024 10 deficiencies

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT) assessed and ...

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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 interdisciplinary team (IDT) assessed and documented for Resident 49 being capable of self-administering medications, prior to having the medication stored at the resident's bedside for administering it himself. This had the potential for inadequate drug therapy by allowing the resident to administer doses below or above the prescribed dose by the physician. Findings: On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a manufacturer box for albuterol (medication to treat difficulty in breathing) aerosol inhaler, which had a pharmacy label to indicate it belonged to Resident 49, without the inhaler inside, stored in the bottom drawer of the cart. In a concurrent interview, the Licensed Vocational Nurse (LVN) 1 stated the albuterol inhaler was kept at the resident's bedside inside the resident's room for resident to self-administer the medication. LVN 1 stated there was no order for the resident to keep the medication at bedside for self-administration. On January 10, 2024, at 2:35 p.m., it was noted the inhaler was stored in the drawer of the side table next to the resident's bed. The inhaler was not labeled to indicate it belonged to Resident 49. In a concurrent interview, the Infection Preventionist (IP) stated there was no self-administration of medication for the resident done by the Interdisciplinary Team (IDT). On January 10, 2024, medical record of Resident 49 was reviewed, and the following was noted: The resident was admitted on [DATE], with diagnoses that included asthma (condition that causes difficulty in breathing); There was a physician order on December 4, 2023, for albuterol sulfate aerosol inhaler 108 microgram per actuation with the direction to inhale two puffs by mouth every six hours for shortness of breath; and The electronic medication administration record (eMAR) of the resident for January 2024, indicated the medication was administered daily every six hours. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: .Residents may self-administer their own medications only if the Attending Physician in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan for one of one resident reviewed ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan for one of one resident reviewed for oxygen use (Resident 16) and for one of three residents reviewed for edema [swelling] (Resident 165). This failure had the potential to negatively impact the residents' quality of care and had the potential for staff to not be aware of the residents' care needs and provide appropriate treatment. Findings: 1. On January 8, 2024, at 11:53 a.m., Resident 16 was observed in bed, with oxygen (O2) via nasal cannula (NC - a tube used to deliver oxygen through the nose). Resident 16's oxygen administration was observed at three liters per minute (LPM). In a concurrent interview, Resident 16 stated she uses O2 continuously due to shortness of breath and she takes it off at times during the day. Resident 16's record was reviewed. Resident 16 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - a disease that causes obstructed airflow). The physician's order dated January 4, 2024, indicated, .Oxygen Therapy Continuous - 2 Liters Per/Minute Via Nasal Cannula. May Titrate Oxygen Up to 5 Liters To Maintain O2 Sats > 90% every shift for (SOB [short of breath] Related: COPD) . On January 10, 2024, at 9:03 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 16 had a physician's order for oxygen. In a concurrent review of Resident's 16's record, LVN 1 stated there was no documentation a care plan for oxygen was initiated for Resident 16. LVN 1 stated Resident 16 should have had a care plan for oxygen administration. On January 10, 2024, at 9:20 a.m., the Director of Nursing (DON) was interviewed. The DON confirmed a care plan for oxygen administration for Resident 16 was not initiated. The DON stated a care plan for O2 administration should have been developed for Resident 16. 2. During a concurrent observation and interview, on January 8, 2024, at 12:55 p.m., with Resident 165 in her room, Resident 165 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 165 was observed wearing a left arm compression sleeve (a type of medical garment used to increase blood flow, reduce pain and swelling). Resident 165 was observed with some edema (swelling) of her left hand. Resident 165 stated she had a history of lymphedema (a condition caused by a blockage in the lympahatic system, part of immune and circulatory system) for five years. She stated she had a history of breast cancer, and sometimes the edema was bad. During a review of Resident 165's record, Resident 165 was admitted to the facility on [DATE], with diagnoses which included fracture of fourth lumbar vertebra (bones in the spine). The nursing notes dated January 3, 2024, entered at 10:39 p.m., indicated, .Resident noted to have edema to left upper extremity. Encourage elevation. Resident stated she has edema due to (d/t) history of breast cancer to left breast . The nursing progress notes from January 4, 2024 to January 8, 2024, did not indicate licensed nurse observation and monitoring of Resident 165's left arm edema and the presence of the left arm compression sleeve. The initial social service evaluation dated January 4, 2024, indicated Resident 165 was alert and oriented to person, place, time, and situation. The baseline care plans upon admission did not include the identified assessment of edema on Resident 165's left upper extremity. During a concurrent observation and interview, on January 9, 2024, at 9:05 a.m., with Resident 165, indicated Resident 165 was awake, alert, and able to verbalize her needs. Resident 165's left hand was observed without edema. She stated she felt better having no swelling on her left arm. She stated she wore her compression sleeve all day and all night. During a concurrent observation and interview, on January 9, 2024, at 9:45 a.m., conducted with the Director of Nursing (DON) in the resident's room, the DON acknowledge Resident 165 was wearing a left arm compression sleeve. During a concurrent interview and record review, on January 9, 2024, at 10:05 a.m., with the DON, the nurse's notes from January 3, 2024 to January 9, 2024, were reviewed. The DON confirmed on January 3, 2024, the licensed nurse documented Resident 165 had edema on her left upper extremity. The DON stated there were no further monitoring and assessments of Resident 165's edema on every shift after January 3, 2024. The DON further stated there was no assessment of Resident 165's compression sleeve. A review of Resident 165's care plans indicated there was no documented evidence the baseline care plan for Resident 165's edema and compression sleeve was developed. The DON stated the licensed nurse who admitted Resident 165 should have initiated the baseline care plan for Resident 165's edema of her left upper extremity. He stated there was no physician's order for the compression sleeve. He stated the physician should have been contacted by the licensed staff. During a concurrent observation and interview, on January 10, 2024, at 10:30 a.m., Resident 165 was observed lying in bed, awake, alert, and able to verbalize her needs. Resident 165 stated she just returned from physical therapy. Resident 165 was observed with her left arm compression sleeve on and without edema on the left hand. The facility's policy and procedure titled, Care Plans - Baseline, dated December 2016, was reviewed. The policy indicated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty eight (48) hours of admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plan in using the dignity bag for ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plan in using the dignity bag for resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag for one of one resident reviewed (Resident 164). This failure resulted in Resident 164's indwelling urinary catheter drainage bag's urine being visibly exposed to visitors entering the room and the drainage bag did not have protection from contact with the bed and other equipment at the resident's bedside. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent observation and interview on January 8, 2024, at 12:28 p.m., with Resident 164 in his room, Resident 164 was observed lying in bed awake, alert, and able to verbalize his needs. Resident 164 stated he had infected wounds on his right foot. A wound vac (device used to remove excess fluid and promote healing of the wounds) was observed on resident's right side of his foot dressing. Resident 164 was observed with an indwelling urinary catheter attached to a drainage bag containing yellow urine. The indwelling urinary catheter drainage bag's bottom was touching the floor. The drainage bag was uncovered. During a concurrent observation and interview on January 8, 2024, at 12:30 p.m., with the Director of Nursing (DON), in Resident 164's room, the DON stated the resident's indwelling urinary catheter drainage bag was on the floor. He stated the drainage bag should not be touching the floor and should be covered with the dignity bag. During a concurrent observation and interview on January 8, 2024, at 12:40 p.m., with the Infection Preventionist (IP) in Resident 164's room, the IP stated the indwelling urinary catheter drainage bag should not be touching the floor and should be covered with the dignity bag. On January 8, 2024, Resident 164's record was reviewed. Resident 164 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney disease), and acute Osteomyelitis (bone infection)) of right ankle and foot, and recent right amputation of second and third toes with Methicillin Resistant Staphylococcus Aureus (MRSA - a serious infection that can lead to sepsis or death). During a review of Resident 164's record, indicated a care plan for indwelling urinary catheter, with goal and interventions. The care plan indicated, .Place indwelling urinary catheter bag in dignity/privacy bag . On January 10, 2024, at 10:23 a.m., a concurrent interview and record review was conducted with the DON. The DON reviewed Resident 164's care plan for indwelling urinary catheter. The care plan indicated a goal and interventions which included .Place indwelling urinary catheter bag in dignity/privacy bag . The DON acknowledged the care plan intervention of placing the indwelling urinary catheter drainage bag in dignity/privacy bag was not followed. The facility's policy and procedure titled, Care Plans, Comprehensive Person - Centered, dated December 2016, was reviewed. The policy indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician of resident's left upper extremi...

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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 notify the physician of resident's left upper extremity edema and the compression sleeve, for one of one resident reviewed (Resident 165). This failure had potential to affect Resident 165's blood circulation on her left upper extremity and can lead to skin breakdown and other complications. Findings: During concurrent observation and interview, on January 8, 2024, at 12:55 p.m., with Resident 165 in her room, Resident 165 was observed lying in bed awake, alert, and able to verbalize her needs. Resident 165 was observed wearing a left arm compression sleeve (a type of medical garment used to increase blood flow, reduce pain and swelling). Resident 165 was observed with edema (swelling) of her left hand. Resident 165 stated she had a history of lymphedema (a condition caused by a blockage in the lympahatic system, part of immune and circulatory system) for five years. She stated she had a history of breast cancer. She stated sometimes the edema was bad. Resident 165's record was reviewed. The record indicated Resident 165 was admitted to the facility on [DATE], with diagnoses which included fracture of fourth lumbar vertebra (bone in the spine). The nursing notes dated January 3, 2024, entered at 10:39 p.m., indicated, .Resident noted to have edema to left upper extremity. Encourage elevation. Resident stated she has edema due to (d/t) history of breast cancer to left breast . The physician's orders dated January 3, 2024, indicated there was no specific orders for monitoring of Resident 165's edema of left upper extremity and instructions for the care of compression sleeve. The nursing progress notes from January 4, 2024 to January 8, 2024, did not indicate licensed nurse observation and monitoring of Resident 165's left arm edema and the presence of the left arm compression sleeve. During a concurrent observation and interview, on January 9, 2024, at 9:05 a.m., with Resident 165, Resident 165 was awake, alert, and able to verbalize her needs. Resident 165's left hand was observed without edema. She stated she felt better having no swelling on her left arm. She stated she wore her compression sleeve all day and all night. During a concurrent observation and interview, on January 9, 2024, at 9:45 a.m., conducted with the Director of Nursing (DON) in Resident 165's room, the DON acknowledge Resident 165 was wearing a left arm compression sleeve. During a concurrent interview and record review, on January 9, 2024, at 10:05 a.m., with the DON, the nurse's notes from January 3, 2024 to January 9, 2024, were reviewed. The DON confirmed on January 3, 2024, the licensed nurse documented Resident 165 had edema on her left upper extremity. The DON stated there were no further monitoring and assessments of resident's edema on every shift after January 3, 2024. The DON stated there was no assessment of Resident 165's compression sleeve. A review of the physician's orders from January 3, 2024 to January 9, 2024, indicated there was no physician's order for monitoring of Resident 165's edema every shift and compression sleeve instructions. The DON stated the licensed nurse who admitted Resident 165, should have informed the physician regarding Resident 165's edema of the left upper extremity and the resident's compression sleeve. He stated there was no physician's order for the compression sleeve, and the monitoring of resident's left upper extremity edema. During a concurrent observation and interview, on January 10, 2024, at 10:30 a.m., Resident 165 was observed lying in bed, awake, alert, and able to verbalize her needs. Resident 165 stated she just returned from physical therapy. Resident 165 was observed with her left arm compression sleeve on and without edema on the left hand. The facility's policy and procedure titled, admission Assessment and Follow Up: Role of the Nurse, dated September 2012, indicated, .The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident .Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders that are based on these findings .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when: 1. Two medications for Resident 18 were not a...

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Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the residents when: 1. Two medications for Resident 18 were not administered as ordered by the physician; and 2. One discontinued controlled substance (CS) medication was stored in the medication cart stored with other active medications available for use. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain and constipation, in addition to the potential for ineffective medications to be administered to the resident. Findings: 1. On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to the resident by LVN 2 were as follows: One tablet of amiodarone (medication for irregular heart rhythm) 200 mg (milligram -- unit of measurement); One tablet of Eliquis (a blood thinner) 5 mg; One tablet of carvedilol (medication to control blood pressure) 3.125 mg; One tablet of ezetimibe (medication for high cholesterol) 10 mg; One tablet of losartan (medication to control blood pressure) 50 mg; One tablet of metformin (medication to control blood sugar) 500 mg; One tablet of potassium chloride ER 8 MEq; and One tablet of rosuvastatin (medication for high cholesterol) 10 mg. On January 9, 2024, the medical record of Resident 18 was reviewed, and the following was noted: There was a physician order on December 28, 2023, for docusate sodium (brand name: Colace - medication to treat constipation) 100 mg with the direction to give the resident one capsule by mouth one time a day for bowel management; There was a physician order on December 21, 2023, for lidocaine external patch 5 % (topical patch for pain relief) to be applied to the resident's left knee one time a day and be removed per schedule; and The electronic medication administration record (eMAR) for January 2024, indicated the morning dose of docusate sodium 100 mg and lidocaine 5 % patch were documented as administered to the resident; The eMAR for January 2024, also indicated the lidocaine topical patch was to be applied at 9 a.m., and removed at 9 p.m., each day. On January 9, 2024, at 11 a.m., it was observed Resident 18 still had on her left knee the lidocaine patch that was applied the day before. In a concurrent interview, LVN 2 stated he did not administer the lidocaine patch for the resident because the resident's lidocaine patches ran out, and the resident was going home later that day. LVN 2 stated he did not administer the resident's morning dose of Colace because the resident was going home later that day. LVN 2 stated it was a mistake and he should not have documented as administered the lidocaine patch and the Colace dose in the resident's medical record. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed, and it indicated: .Medications are administered in accordance with prescriber orders, including any required time frame . 2. On January 10, 2024, at 1:45 p.m., during an inspection of the medication cart located in [NAME] Hall with LVN 3, there was a blister pack containing alprazolam (medication to treat anxiety) 0.5 mg tablets for Resident 15 stored in the CS drawer of the cart with other active controlled substance (CS) medications. In a concurrent interview, LVN 3 was not able to find in the resident's medical record an active, ongoing order for alprazolam 0.5 mg. The resident's medical record was reviewed, and it indicated there was a physician order on November 16, 2023, for alprazolam 0.5 mg with the direction to give the resident one tablet every 23 hours as needed for anxiety for 14 days as manifested by episodes of verbalization of feeling anxious. There was no additional order to renew alprazolam 0.5 mg.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medicatio...

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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 unnecessary medications for one resident (Resident 214), when two medications in the same therapeutic class were ordered by the physician and administered to the resident. This failure had the potential for the resident to receive excessive dose of medications and unwanted adverse effects. Findings: On January 10, 2024, medical record of Resident 214 was reviewed, and the following was noted: The resident was admitted to the facility on [DATE], with the diagnoses that included glaucoma (increased pressure in the eyeball that causes gradual loss of sight); There was a physician order on December 28, 2023, for Travatan Z (a medication applied directly to eye to treat glaucoma) 0.004 % eye drop with the direction to instill one drop in both eyes once at bedtime for glaucoma; There was a physician order on December 28, 2023, for latanoprost (brand name: Xalatan - a medication applied directly to eye to treat glaucoma) 0.005 % eye drop with the direction to instill one drop in both eyes once at bedtime for glaucoma; and The electronic medication administration record (eMAR) of the resident for January 2024, indicated both Travatan Z and latanoprost eye drops were administered daily from January 1 to January 10, 2024. Lexicomp, a nationally recognized drug reference, indicated: .Travatan Z .Mechanism of Action . A selective FP (prostaglandin receptor F) prostanoid receptor agonist which lowers intraocular pressure by increasing trabecular meshwork and outflow . Latanoprost .Mechanism of Action . Latanoprost is a prostaglandin F2-alpha analog believed to reduce intraocular pressure by increasing the outflow of the aqueous humor . Avoid combination .Coadministration of latanoprost with additional prostaglandins or prostaglandin analogs (having similar structure) is not recommended . On January 11, 2024, at 2:25 p.m., in an interview, the Pharmacist-in-Charge (PIC) of the provider pharmacy stated the pharmacy identified the therapy duplication with having both Travatan Z and Xalatan ordered at the same time. The PIC stated the pharmacy sent a note to indicate and clarify the therapy duplication along with the delivery of the resident's medications without Travatan Z which was placed on hold. The PIC agreed there was a therapy duplication. On January 11, 2024, at 2:45 p.m., in an interview, the Director of Nursing (DON) was not aware there was a request from the pharmacy to clarify the therapy duplication with Travatan Z and Xalatan. The DON confirmed the resident's eMAR there was documentation both Travatan Z and Xalatan were administered daily in January 2024. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed and it indicated: .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns .

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed ensure residents were free from medication error rate greater than 5 % during medication pass observation when: - Two medication...

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Based on observation, interview, and record review, the facility failed ensure residents were free from medication error rate greater than 5 % during medication pass observation when: - Two medications for Resident 18 were not administered; - One long-acting extended-release formulation medication was crushed and administered; and - One long-acting extended-release formulation medication was administered without a full glass of water being offered. This failure had the potential for inadequate medication treatment that could cause the resident to experience pain, constipation, and stomach upset. The medication error rate was 12.9 percent. Findings: On January 9, 2024, at 8:20 a.m., during a medication pass observation with the Licensed Vocational Nurse (LVN) 2, it was observed, LVN 2 prepared and administered, for Resident 18, her morning medications that included one potassium chloride (potassium supplement) ER (extended release) 8 MEq (milliequivalent - unit of measurement) tablet after crushing a total of eight medications. The eight medications that were administered to the resident by LVN 2 were as follows: One tablet of amiodarone (medication for irregular heart rhythm) 200 mg (milligram -- unit of measurement); One tablet of Eliquis (a blood thinner) 5 mg; One tablet of carvedilol (medication to control blood pressure) 3.125 mg; One tablet of ezetimibe (medication for high cholesterol) 10 mg; One tablet of losartan (medication to control blood pressure) 50 mg; One tablet of metformin (medication to control blood sugar) 500 mg; One tablet of potassium chloride ER 8 MEq; and One tablet of rosuvastatin (medication for high cholesterol) 10 mg. On January 9, 2024, the medical record of Resident 18 was reviewed, and the following was noted: There was a physician order on November 19, 2023, for potassium chloride ER 8 MEq with the direction to give the resident one tablet by mouth two times a day for supplement; There was a physician order on December 28, 2023, for docusate sodium (brand name: Colace - medication to treat constipation) 100 mg (milligram - unit of measurement) with the direction to give the resident one capsule by mouth one time a day for bowel management; There was a physician order on December 21, 2023, for lidocaine external patch 5 % (topical patch for pain relief) to be applied to the resident's left knee one time a day and be removed per schedule; and The electronic medication administration record (eMAR) for January 2024 indicated the morning dose of potassium chloride 8 MEq, docusate sodium 100 mg, and lidocaine 5 % patch were documented as administered to the resident. On January 9, 2024, at 11 a.m., in an interview, LVN 26 stated he did not administer lidocaine patch for the resident because it was not available to administer, and the resident was going home later that day. LVN 2 stated he did not administer the resident's morning dose of Colace because the resident was going home later that day. LVN 2 stated it was a mistake and he should not have documented as administered the lidocaine patch and the Colace dose in the resident's medical record. LVN 2 stated the resident preferred the medications to be crushed and they had been crushed and administered ever since. LVN 2 did not indicate there was a physician order to crush long-acting formulation of potassium chloride and administer to the resident. LVN 2 stated he did not offer fluid after administration of crushed medications that included potassium chloride. The facility's policy and procedure titled, Administering Medications, revised, April 2019, was reviewed, and it indicated: .Medications are administered in accordance with prescriber orders, including any required time frame . According to the manufacturer's prescribing information for potassium chloride ER tablet: . Take potassium chloride extended-release tablets with meals and with a glass of water or other liquid. Do not take on an empty stomach because of its potential for gastric irritation . Swallow tablets whole without crushing, chewing, or sucking .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure: 1. One medication stored at bedside for self-administration was properly labeled for Resident 49; and 2. Opened insul...

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Based on observation, interview, and record review, the facility failed to ensure: 1. One medication stored at bedside for self-administration was properly labeled for Resident 49; and 2. Opened insulin lispro KwikPen (an injectable pen containing insulin, a hormone that regulates blood sugar) dated with 28-day expiration date was not available for use past the expiration date. This had the potential for wrong, and ineffective medications to be administered to residents. Findings: 1. On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a manufacturer box for albuterol (medication to treat difficulty breathing) aerosol inhaler, which had a pharmacy label to indicate it belonged to Resident 49, without the inhaler inside, stored in the bottom drawer of the cart. In a concurrent interview, the Licensed Vocational Nurse (LVN) 1 stated the albuterol inhaler was kept at the resident's bedside inside the resident's room for resident to self-administer the medication. On January 10, 2024, at 2:35 p.m., it was noted the inhaler was stored in the drawer of the side table next to the resident's bed. The inhaler was not labeled to indicate it belonged to Resident 49. In a concurrent interview, the Infection Preventionist (IP) stated the resident's inhaler would be secured in a locked box. The IP also confirmed there was no label on the resident's albuterol inhaler to indicate it belonged to the resident. The facility's policy and procedure titled, Labeling of Medication Containers, revised, April 2019, was reviewed, and indicated: .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations . Labels for individual resident medications include all necessary information, such as: a. the resident's name; b. the prescribing physician's names; c. the name, address, and telephone number of the issuing pharmacy; d. the name, strength, and quantity of the drug; e. the prescription number (if applicable); f. the date that the medication was dispensed; g. appropriate accessory and cautionary statements; h. the expiration date when applicable; and i. directions for use . 2. On January 10, 2024, at 2:10 p.m., during inspection of the medication cart located in Red Hall, there was a 3-ml insulin lispro (a fast-acting insulin used to prevent high blood sugar) 100 Unit/ml (unit of measurement) KwikPen for injection with the open date, 12/11/23, that belonged to Resident 49. The pen also had the following instruction on the label: Discard 1/8/24. Discard unused portion after 28 days. On January 11, 2024, at 9:30 a.m., the IP agreed the multidose insulin pen was only good for 28 days after opening. The facility's policy and procedure titled, Injectable Medications, revised, October 2018, was reviewed, and it indicated: .Multiple use vials (MDV) will expire according to the manufacturer's expiration date printed on the vial except when special considerations are specified by the manufacturer .All other MDV medications will expire 28 days after opening per USP Guidelines unless otherwise specified . According to the manufacturer's prescribing information for insulin lispro 100 units/ml KwikPen: .Storage and Handling .In-Use (Opened) .28 days Room temperature only (Do not refrigerate) .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and implement infection prevention and contr...

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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 and implement infection prevention and control practices when the resident's indwelling urinary catheter (catheter used to drain urine from the bladder into a bag outside the body) drainage bag was touching the floor for one of one resident reviewed (Resident 164). This failure increased the potential to expose Resident 164 for further development of infection and transmission of communicable diseases. Findings: On January 8, 2024, at 12:25 p.m., Resident 164 was observed in a room designated with contact isolation precautions (steps healthcare facility visitors and staff need to follow before going into a patient's room to stop germs from spreading by touching the patient or surfaces in the room). The personal protective equipment (PPE - used to minimize exposure to hazards that cause serious illnesses) cart was observed outside the room. During a concurrent observation and interview on January 8, 2024, at 12:28 a.m., with Resident 164 in his room, Resident 164 was observed lying in bed awake, alert, and able to verbalize his needs. Resident 164 stated he had infected wounds on his right foot. A wound vac (device used to remove excess fluid and promote healing of the wounds) was observed on resident's right side of his foot dressing. Resident 164 was observed with indwelling urinary catheter attached to a drainage bag containing yellow urine. The bottom of the indwelling urinary catheter drainage was touching the floor. The drainage bag was uncovered. During a concurrent observation and interview on January 8, 2024, at 12:30 p.m., with the Director of Nursing (DON), in Resident 164's room, the DON stated the resident's indwelling urinary catheter drainage bag was on the floor. He stated the indwelling urinary drainage bag should not be touching the floor and should be covered with the dignity bag. During a concurrent observation and interview on January 8, 2024, at 12:40 p.m., with the Infection Preventionist (IP), in Resident 164's room, the IP stated the indwelling urinary catheter drainage bag should not be touching the floor and should be covered with the dignity bag. On January 8, 2024, Resident 164's record was reviewed. Resident 164 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease (ESRD - kidney disease), and acute osteomyelitis (bone infection) of right ankle and foot, and recent right amputation of second and third toes with Methicillin Resistant Staphylococcus Aureus (MRSA - a serious infection that can lead to sepsis or death) During a review of the facility's policy and procedure titled, Catheter Care, Urinary, dated September 2014, indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor .

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain the kitchen grill in sanitary and safe operating condition, when the equipment was covered with blackish materials. ...

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Based on observation, interview, and record review, the facility failed to maintain the kitchen grill in sanitary and safe operating condition, when the equipment was covered with blackish materials. This failure had the potential to cause cross contamination and unsanitary condition in the kitchen. Findings: During the initial tour of the kitchen, conducted on January 8, 2024, beggining at 9:30 a.m., with the Culinary Director (CD), the kitchen equipment was observed. During a concurrent observation and inteview on January 8, 2024, at 10:49 a.m., with the CD, the kitchen grill was observed with blackish materials on the surface and at the sides of the grill. The kitchen grill was situated next to the kitchen griddle being used by the cook for food preparation. The CD stated the kitchen grill had not been used for a long time. He further stated the grill should have been cleaned even if not in use. During a review of the facility's policy and procedure titled, GRILL - GAS, dated August 31, 2018, indicated, .SANITATION OF EQUIPMENT .frequency: After each use .Scrape grill to loosen burned-on-particles .clean grill surface .

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect other residents from potential abuse while the investigatio...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect other residents from potential abuse while the investigation was in progress, for two of seven residents reviewed (Resident 1 and Resident 2), when: 1. The Certified Occupational Therapy Assistant (COTA); and 2. Certified Nurse Assistant (CNA) were allowed to continue to work pending the results of the alleged abuse. These failures had the potential to place the other residents in the facility at risk for abuse. Findings: 1. During a review of Resident 1's Progress Notes (PN), dated October 4, 2023 (late entry for October 3, 2023), the PN indicated Resident 1 stated the COTA was rough with him during a shower on September 27, 2023. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included hypertension (high blood pressure) and generalized muscle weakness. During an interview on October 16, 2023, at 10:25 a.m., with the COTA, she stated the Physical Therapy Director (PTD) called her on October 3, 2023, at 5:36 p.m. The COTA stated the PTD told her Resident 1 claimed physical abuse against her. The COTA stated she was taken off Resident 1's schedule and was told to come to work. The COTA stated she was not placed on leave and worked on October 4, 2023. During an interview on October 16, 2023, at 11:18 a.m., with the Physical Therapy Assistant (PTA), she stated to her knowledge, the COTA was allowed to work while the investigation on the abuse allegation was on-going. The PTA stated she thought the COTA should have been taken off the schedule pending the investigation. The PTA stated she was not sure why the COTA was allowed to work while the investigation was still pending. The PTA stated the COTA was removed from Resident 1's scheduled therapies. During an interview on October 16, 2023, at 11:30 a.m., with Resident 1, in his room, Resident 1 stated the COTA was abusive to him. Resident 1 stated the COTA came to his room intentionally slamming things around. Resident 1 stated the COTA offered him to shower. Resident 1 stated the COTA was rough handling the shower chair and they had some verbal exchanges in the shower stall. Resident 1 stated when the COTA brought him back in his room and he went to bed, the COTA slammed the wheelchair to the wall. During an interview on October 16, 2023, at 11:49 a.m., with the Physical Therapy Director (PTD), she stated the COTA was not taken off the schedule and was allowed to work. The PTD stated she asked the administrator (ADM) about taking the COTA off the schedule and was told by the ADM not to remove the COTA from the schedule. The PTD stated the COTA was not assigned to Resident 1 after the allegation. During a review of the Labor Log (LL), dated November 3, 2023, the LL indicated, the COTA worked on the following days: - October 4, 2023; - October 5, 2023; and - October 6, 2023. 2. During an interview on October 16, 2023, at 4:11 p.m., with the CNA, the CNA stated she was told by the Social Service Assistant (SSA) and the ADM not to go to Resident 2's room. The CNA stated she was told Resident 2 accused her of verbal abuse. The CNA stated she was not taken off the schedule. The CNA stated she did not continue to care for Resident 2. During an interview on October 16, 2023, at 4:27 p.m., with the Social Service Director, she stated the CNA was immediately removed from the assignment and Resident 2's care was changed. The SSD stated the CNA stayed and was allowed to work. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included hypertension and atrial fibrillation (irregular, fast heart rate). Resident 2 was discharged to the hospital for an unrelated issue on October 4, 2023, and was not available for interview. During a review of the Labor Allocation (LA), for the pay period of October 1, 2023 to October 15, 2023, the LA indicated, the CNA worked on the following days: - October 4, 2023; - October 5, 2023; - October 6, 2023; - October 7, 2023; - October 8, 2023; and - October 9, 2023. During an interview on October 16, 2023, at 1:45 p.m., with the Assistant Director of Nursing (ADON) she stated from her understanding, if a staff was the alleged abuser, the staff should be removed from the work schedule pending the results of the investigation to protect the alleged victim and other residents from potential abuse. During an interview on October 16, 2023, at 5:07 p.m., with the ADM, she stated neither staff accused of allegedly abusing the resident were removed from the schedule. The ADM was asked how the facility protected the other residents from potential abuse if the staff was allowed to work while the investigation was pending. The ADM stated the facility policy and procedure for abuse did not indicate the staff should be suspended or relieved from work while the investigation was in progress. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, revised January 2023, the P&P indicated, .Policy Interpretation and Implementation .The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented by removing the accused employee from any continued services/treatments .

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and procedure for receipt of controlled substanc...

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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 their policy and procedure for receipt of controlled substances for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 not receiving his medication and medication diversion. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included sjorgren syndrome (a condition that reduces moisture produced by the body) , cognitive communication deficit, and narcolepsy (a disorder affecting sleep cycle). The record further indicated the resident is his own representative. A review of Resident 1's physician orders indicated an order for methylphenidate oral tablet extended release 20 mg (a unit of measure) , give 1 tablet by mouth one time a day for narcolepsy dated June 22, 2023. A review of Resident 1's prescription label by [retail pharmacy] for methylphenidate ER 20 mg tablets indicated the prescription was filled on June 5, 2023, for 30 tablets. A review of Resident 1's controlled substance/narcotic record indicated the facility recorded 9 tablets of methylphenidate ER 20 mg for the resident on June 16, 2023. The record further indicated no signatures on June 16, 2023. A review of Controlled Substance Schedules by the U.S. Department of Justice, Drug Enforcement Administration at https://www.deadiversion.usdoj.gov/schedules/indicated, Examples of Schedule IIN stimulants include amphetamine .and methylphenidate (Ritalin®). On August 7, 2023, at 2:10 p.m., during an interview with Licensed Vocational Nurse (LVN1), she stated if there is a delivery of a controlled medication for the resident, she and another nurse will both sign the narcotic sheet for the medication. She stated both nurses sign to confirm it is the right medication for the right patient and it is the right dose. She stated the nurse assigned to the resident will then use the key and locked the medication in the locked narcotics drawer. On June 23, 2023, at 5:28 p.m., during an interview with the Director of Nursing (DON), he stated for a medication brought from home, the facility would have the pharmacy confirm the medication. Then there would be a determination as to whether the medication would need repackaging. He stated the pharmacy would confirm if there was an order in place for the medication. He stated if the medication requires repackaging, once delivered a licensed nurse would sign off on receipt of the medication with a pharmacy rep. If the medication did not require repackaging medication is a controlled medication, two licensed nurses would sign for the receipt of the medication and confirm the quantity. He stated, if there was an order, the medication would populate on the resident's medication administration record. The medication would be placed into the medication cart for administration. He reviewed the controlled substance record for Resident 1's methylphenidate ER 20 mg indicating no signature by the receiving nurse nor a cosignatory. The DON confirmed the record was not signed by a license nurse nor could the DON confirm the amount of medication received. He reviewed the medication sheet and confirmed the practice was not in accordance with the facility's practice. A review of the facility's policy and procedure titled Controlled Substances revised April 2019 indicated, Controlled substances are reconciled upon receipt .Upon Receipt: The nurse receiving the medication and the individual delivering the medication verify the name, dose, and quantity of each controlled substance being delivered. Both individuals sign the controlled substance record of receipt.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a personalized comprehensive care plans for one of three sam...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a personalized comprehensive care plans for one of three sample residents (Resident 1) when the facility failed to develop care plans with interventions for Resident 1 ' s urinary catheter and infection. This failure had to potential to result in Resident 1 not receiving interventions to promote the resident ' s optimal level of function. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses which included sepsis, pneumonia, urinary tract infection and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS) dated May 22, 2023, indicated the resident had a score of 15 (no cognitive impairment). A review of Resident 1 ' s MDS (Minimum Data Set- an assessment) section I dated June 12, 2023, indicated Resident 1's medical condition included septicemia, urinary tract infection, and pneumonia. A review of Resident 1 ' s MDS section H dated June 12, 2023, indicated Resident 1 had an indwelling catheter (including suprapubic and nephrostomy tube). A review of Resident 1 ' s care plan indicated no entry to address Resident 1 ' s infection nor indwelling catheter. On July 20, 2023, at 3:40 p.m., during an interview with the Director of Nursing (DON), he stated the facility develops care plans for issues like infections. He further stated care plan entries are developed for resident conditions that require interventions. The DON reviewed the care plan for Resident 1 and acknowledged the absence of care plans for Resident 1 ' s urinary tract infection and suprapubic catheter. He stated there should be care plans for Resident 1 ' s infection and urinary catheter. A review of the facility ' s policy 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 the resident ' s physical , psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will: a. include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas .reflect treatment goals, timetables and objectives in measurable outcomes .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and procedure for one of three sampled 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 their policy and procedure for one of three sampled residents (Resident 1) when the facility did not implement interventions to control Resident 1 ' s pain. This failure resulted in Resident 1 experiencing pain for 4 hours. Findings: A review of Resident 1 ' s admission record indicated the resident was admitted to the facility on [DATE] with diagnoses which included sepsis, pneumonia, urinary tract infection and benign prostatic hyperplasia with lower urinary tract symptoms. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS) dated May 22, 2023 indicated the resident had a score of 15 (no cognitive impairment). A review of Resident 1 ' s physician orders indicated orders for the following: oxycodone-acetaminophen (oxycodone w/ acetaminophen- a medication for pain) oral tablet 5-325 mg (milligrams- a unit of measure) 1 tablet by mouth every 6 hours for moderate to severe pain 4-10 dated May 19, 2023. acetaminophen (pain medication) tablet 325 mg, give two tablets every 4 hours as needed for mild pain 1-3. Do not exceed 3000 mg in 24 hrs (hours) dated May 19, 2023. A review of Resident 1 ' s nursing progress note by Licensed Vocational Nurse (LVN1) dated June 11, 2023 at 3:36 p.m. indicated Resident 1 had pain rated by the resident at a level 10 (using a scale of 0-10 with 10 being the highest level of pain). A review of Resident 1 ' s June 2023 Medication Administration Record (MAR) indicated the resident received oxycodone-acetaminophen oral tablet 5-325 mg tablet June 11, 2023 at 3:36 p.m. by LVN1. The MAR further indicated the resident rated his pain at a level of 10. A review of Resident 1 ' s nursing administration note by LVN1 dated June 11, 2023 at 3:36 p.m. indicated Resident 1 received oxycodone-acetaminophen oral tablet 5-325 mg tablet. The note further indicated, Resident verbalized pain at level 10 to upper/lower back areas bi-lat (bilaterally- left and right sides). Lower extremities A review of Resident 1 ' s nursing administration note by LVN1 dated June 11, 2023 at 4:52 p.m. indicated, PRN (as needed) Administration was: Effective, Follow-up pain scale was: 8 No other documentation indicating notification of physician noted. On July 20, 2023, at 3:25 p.m, during an interview with LVN2, she stated the facility ' s practice for administering as needed pain medication is it ask the resident their level of pain or assess for pain. She stated she would then review the resident's physician orders and inform the resident of the medication prescribed for their pain. She stated she would administer the medication and reassess the resident's pain level 30 minutes after the medication administration. She stated she would notify the physician if the medication was not effective if there was no other pain medication ordered. She further stated, depending on the medications ordered, she would potentially wait to administer a second medication due to concerns of the combined side effects of both pain medications. On July 20, 2023, at 3:40 p.m., during a concurrent interview and record review with the Director of Nursing (DON), he stated the process is to notify the physician if a pain medication was not effective to get an order for another intervention or pain medication more effective. He reviewed Resident 1's administration note dated June 11, 2023, at 4:52 pm. He acknowledged the note indicated the pain medication was effective with a pain rating of eight. He stated a pain level of eight is not effective. He stated the nurse should have called the physician to get another treatment option for the resident's pain. He could not indicate if Resident 1's pain was relieved. A review of Resident 1's care plan entry titled Pain Care Plan, is at risk for pain related to generalized body pain, dated May 19, 2023 indicated interventions including administer pain medication as per orders, anticipate the resident's need for pain relief, provide pain interventions and follow up for effectiveness. A review of the facility's policy and procedure titled, Pain Assessment and Management revised 2020 indicated, Pain management is a multidisciplinary care process that includes .recognizing the presence of pain .developing and implementing approaches to pain management .monitoring for the effectiveness of interventions, and modifying approaches as necessary . Acute pain (or significant worsening of chronic pain) should be assessed, on the onset and reassessed as indicated until relieft if obtained .Report the following information to the physician or practitioner .prolonged, unrelieved pain despite care plan interventions.

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 F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the failed to notify the physician of abnormal laboratory results for one of three sampled ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the failed to notify the physician of abnormal laboratory results for one of three sampled residents (Resident 1). This failure had the potential to result in Resident 1 not receiving treatment to address abnormal laboratory values. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture of right humerus (arm bone), difficulty walking, hypertension (high blood pressure), & protein-calorie malnutrition. The record indicated the resident was discharged on March 13, 2023. The record further indicated Resident 1 ' s family member as the responsible party and durable power of attorney. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated March 14, 2023, indicated the resident had a score of 14 (little to no cognitive impairment). A review of Resident 1 ' s physician orders indicated an order for suprapubic catheter size Fr# 18/10 ml balloon for urinary obstruction, neurogenic bladder (lack of bladder control due to nerve damage), monitor for placement and functioning qshift (every shift), report abnormal findings to physician every shift for catheter care dated May 19, 2023. A review of Resident 1 ' s urinalysis with culture (a diagnostic test) collected June 5, 2023, and reported June 9, 2023, indicated the resident had abnormal values. The record indicated the values were reviewed by Licensed Vocational Nurse (LVN3) on June 12, 2023. The report further indicated the resident had a yeast infection. A review of Resident 1 ' s nursing progress notes indicated no notification of Resident 1 ' s laboratory results to the physician. On August 1, 2023, at 10:47 am, during a concurrent interview and record review with the Assistant Director of Nursing (ADON), she stated resident's laboratory results are reported to the physician. She stated if there is an order from the physician, it is inputted and carried out. She stated the representative or power of attorney is notified. She stated notification of the provider should be documented. She reviewed Resident 1's urinalysis collected June 5, 2023. She further reviewed Resident 1's progress notes and could not state if the physician was notified of the resident's urinalysis results. A review of the facility's policy and procedure titled, Catheter Care, Urinary, revised September 2014, indicated, Observe the resident for complications associated with urinary catheters .Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately. A review of the facility's policy and procedure titled, Lab and Diagnostic Test Results- Clinical Protocol revised November 2018 indicated, When test results are reported to the facility, a nurse will first review the results .before contacting the physician, the person who is to communicate results to a physician will gather, review, and organize the information .A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition .Facility staff should document information about when, how, and to whom the information was provided and response. This should be done in the Progress Notes section of the medical record .

Jul 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan which addresses one of three sampled residents'...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan which addresses one of three sampled residents' (Resident 3) edema. In addition, the facility failed to ensure consistent assessment was conducted to monitor changes in status of Resident 3's edema on the bilateral lower extremities. This failure had the potential to negatively affect the resident's health condition. Findings: On June 1, 2023, at 9:00 a.m., an unannounced visit was made to the facility to investigate a quality of care issue. On June 1, 2023, at 11:20 a.m., Resident 3's record was reviewed and indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (CHF-A condition where the heart does not pump, or fill adequately, resulting in symptoms, which includes swollen legs or feet). A review of Resident 3's progress notes, indicated the following: a. On March 16, 2023, .encouraged to elevate BLE(bilateral lower extremities .; and b. March 17, 2023, .remain with edema to BLE/foot .encourage to elevate them . Further review of records did not indicate documentation that the edema on the BLE was being monitored consistently to evaluate whether the edema was improving or worsening. A review of Resident 3's care plans did not indicate a care plan was developed to address the edema of Resident 3. On June 1, 2023, at 3:04 p.m., a concurrent record review of Resident 3's progress notes, and interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 3's patient centered care plans were developed through resident evaluation, and re- evaluation. The ADON stated the nursing staff should have developed a care plan for edema and CHF. She stated this care plan would indicate the specific interventions for the resident's edema. On July 20, 2023, at 10:17 a.m., during a concurrent interview and record review of Resident 3's nursing care plans. The DON verified, there was no edema nursing care plan developed for Resident 3. The DON stated nursing care plans were important to develop for the resident's medical and health conditions, as they provide nursing staff with consistent nursing interventions, which the staff implemented during provision of resident care. A review of the facility Policy titled, Care Plans, Comprehensive Person-Centered, revised, December 2016, indicated, . Policy Statement: A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Policy Interpretation and Implementation . 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the call light system was always functioning properly, when the call light system was observed to be inaudible. This f...

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Based on observation, interview, and record review, the facility failed to ensure the call light system was always functioning properly, when the call light system was observed to be inaudible. This failure has the potential to result in delayed notification of the nurses of the residents' needs which could negatively impact the residents' health condition. Findings: On June 1, 2023, at 9:00 a.m., an unannounced visit was made to the facility for a quality care issue. On June 1, 2023, at 12:35 p.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was observed resting in bed, with the call light by his side. Resident 1 pulled the call light, and a light in the hallway was triggered. Further observation of the call light system, indicated no alarm was triggered at the nursing station. On June 1, 2023, at 12:40 p.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1 and LVN 2. LVNs 1 and 2 were observed sitting at the nurse's station. The call light in Resident 1's room could not be heard at the nurse's station. During interview, LVNs 1 and 2 stated, they were unaware Resident 1's call light was pulled, as no alarm was activated at the nurse's station. LVN 2 stated Resident 1's call light has been triggered, as the room number was lit up on the phone system, however; she stated the alarm was muted. LVN 2 was observed deactivating the call light mute buttton and the call light alarm could then be immediately heard at the nurse's station. LVNs 1 and 2 stated they did not know that the call light was muted, and it should not be muted. On June 1, 2023, at 12:43, during an interview, the ADON stated she was unaware the call light system was muted at the nursing station. The ADON stated the call light system should never be muted. A review of the facility's Policy, titled, Answering the Call Light, revised September 2022, indicated, . Purpose: The purpose of the procedure is to ensure timely responses to the resident's request and needs . General Guidelines: 4. Be sure that the call light is .functioning at all 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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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

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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 medical records were complete and accurately documented, when residents had a fall, for three of four residents (Residents 1, 2 and 3). This failure had the potential for the records not to fully reflect accurate status of the residents after a fall incident which could result in inappropriate interventions or treatments. Findings: On June 1, 2023, at 9:00 a.m., an unannounced visit was made to the facility to investigate a quality care issue. 1. A review of Resident 1's medical record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities in gait, lack of coordination, and chronic fatigue. Further review of records indicated Resident 1 has a Brief Interview for Mental Status (BIMS) score of 14 (meant cognitively intake). A review of Resident 1's Interdisciplinary Team (IDT) Meeting Note dated 5/26/2023, at 10:55 a.m., indicated, . IDT Meeting Notes: Met to discuss fall on 05/25/2023. After investigation it appears that (Resident 1) sustained fall when (Resident 1) attempted to take self to restroom lost his (sic) balance causing (Resident 1) to fall onto buttocks on the floor . A review of Resident 1's record on the resident's fall incident on May 25, 2023, indicated incomplete documentation on the fall incident for Resident 1. On June 1, 2023, at 2:35 p.m., a concurrent record review and interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 1's medical record was missing a post fall nursing note and Change of Condition (COC- A clinical deviation from a mental, physical, or psychological baseline) note on fall incident which occurred on May 25, 2023. 2. A review of Resident 2's medical record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included fracture of right femur (Long leg bone), multiple fractures of right side of ribs, muscle weakness, history of falls, and Parkinson's disease (A brain disorder which causes unintended muscle tremors, lack of coordination, and imbalance). Further review of record indicated the resident has a BIMS score of 14 (cognition intact). A review of Resident 2's nursing progress note, dated May 30, 2023, at 3:35 p.m., indicated Resident 2, . Sustained fall when attempting to close privacy curtain in room. Lost balance and fell onto floor . A review of Resident 2's Interdisciplinary Team (IDT) Meeting Note, dated, June 1, 2023, at 1:37 p.m., indicated, . After investigation it appears that (Resident 2) sustained (a) fall when (Resident 2) attempted to close . privacy [NAME] (sic) without assistance lost . balance causing (Resident 2) to fall onto (sic) floor . On June 1, 2023, at 2:47 p.m., a concurrent record review and interview was conducted with the ADON. The ADON stated Resident 2's record was missing a change of condition documentation and a post fall nursing note on May 30, 2023. 3. A review of Resident 3's medical record, indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included lack of coordination, muscle weakness, unsteadiness on feet, and spinal stenosis (Pressure on the spinal cord, which can result in pain and muscle weakness). A review of Resident 3's nursing note, dated, March 19, 2023, at 1:03 a.m., indicated, . (Resident 3) Fell at 0100 a.m. coming from restroom, sustained injury to right shoulder, fell on (right) shoulder(complaints of) severe pain . Further review of records indicated a Post fall COC was missing from Resident 3's medical records. On June 1, 2023, at 3:04 p.m., a concurrent record review and interview was conducted with the ADON. She verified Resident 3's medical record was Missing a COC, post fall assessment on March 19, 2023. On July 19, 2023, at 11:40 a.m., an interview was conducted with the Director of Nursing (DON), who stated nursing documentation post resident fall should include, at least physician and responsible party, what happened, a COC, and vital signs. At the very least a brief assessment of the resident's condition, including vital signs. A review of the facility's Policy and Procedure, titled, Charting and Documentation, revised May 2017, indicated, Policy Statement . All services provided to the resident . any changes in the resident's medical, physical, or psychosocial condition, shall be documented in the resident's medical record . 2. The following information is to be documented in the resident medical record: d. Changes in the resident's condition; e. Events, incidents, or accidents involving the resident . A review of the facility's Policy and Procedure, titled, Change in Resident's Condition or Status, revised, May 2017, indicated, . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Jul 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to verify personal belongings for one of three sampled residents (Resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to verify personal belongings for one of three sampled residents (Resident 1) when the facility did not review Resident 1's personal possessions upon discharge. This failure resulted in Resident 1 had the potential to cause Resident 1 to lose personal possessions. Findings: A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture of right humerus (arm bone), difficulty walking, hypertension (high blood pressure), & protein-calorie malnutrition. The record indicated the resident was discharged on March 13, 2023. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated March 14, 2023, indicated the resident had a score of 14 (little to no cognitive impairment). On June 7, 2023, at 4:00 p.m., during an interview with the Social Services Director (SSD), she stated the facility's process for personal inventory is to have the Certified Nursing Assistant (CNA) perform an inventory of the resident's personal belongings upon admission. She stated she reviews to see if the inventory is done. If not, she reports to the Assistant Director of Nursing (ADON) who handles it from there. She stated on discharge the items are reviewed with the staff and the family. Then, the family signs the inventory form indicating everything is accounted for. She reviewed Resident 1's Inventory of Personal Effects form. She stated the document does not indicate return of the Resident 1's personal belongings. On June 7, 2023, at 4:15 p.m., during an interview with CNA1, he stated the process for performing a resident inventory is to review the resident's belongings with the resident and family. He stated once the items are verified, the form is signed by both parties. He stated the items are verified prior to discharge and the form is signed by both parties again. On June 7, 2023, at 4:30 p.m., during an interview with the ADON, she stated the process for inventory is to document the inventory with the resident or family member. She stated the staff member and the resident sign the form. She stated the same process applies for discharge. She reviewed Resident Stephan's inventory form and stated if the resident was not coming back, she would call the resident with another nurse to ensure the resident received their belongings and have both nurses sign the form. If a family member comes to get the belongings, the staff and the family member sign the form. She reviewed Resident 1's Inventory of Personal Effects form and could not state whether the resident received their belongings. A review of Resident 1's Inventory of Personal Effects form indicated the resident's personal effects were inventoried on February 26, 2023, and signed by the resident. The document further indicated no inventory of the resident's belongings during or after discharge. A review of the facility's policy and procedure titled, Personal Property revised August 2022 indicated, Resident belongings are treated with respect by facility staff, regardless of perceived value .The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and procedure for one of three sampled 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 their policy and procedure for one of three sampled residents when: 1. The facility did not administer Resident 1's medication as ordered by the physician 2. No assessment was performed prior to Resident 1's transfer to immediate care These failures had the potential to jeopardize the health and safety of Resident 1. Findings: 1. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture of right humerus (arm bone), difficulty walking, hypertension (high blood pressure), & protein-calorie malnutrition. The record indicated the resident was discharged on March 13, 2023. The record further indicated Resident 1's daughter as the responsible party and durable power of attorney. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated March 14, 2023, indicated the resident had a score of 14 (little to no cognitive impairment). A review of Resident 1's physician orders indicated orders for: Normal Saline Flush Intravenous (into the vein) Solution 0.9 % Sodium Chloride Flush dated March 10, 2023, Use 60 cc (cubic centimeters- a unit of measure) intravenously every shift for hydration for 2 days x 2L (liters- a unit of measure) with a status of discontinued. Normal Saline Flush Intravenous Solution 0.9 % Sodium Chloride Flush dated March 11, 2023, use 60 ml/hr (milliliters [a unit of measure] per hour) intravenously every 48 hours for hydration until 3/13/23 23:59 normal saline at 60 ml/hr for 2 days at indicating completed. A review of Resident 1's nursing progress note dated March 10, 2023, at 8:58 pm by Registered Nurse (RN1) indicated, Normal Saline Flush Intravenous (into the vein) Solution 0.9 %. Use 60 cc (cubic centimeters- a unit of measure) intravenously every shift for hydration for 2 Days x 2L (Liters- a unit of measure). No IV (Intravenous) access. Order needs clarification as well. Will start NSS (Normal Saline) tomorrow on day shift. Patient notified and DON (Director of Nursing) notified. A review of Resident 1's March IV (Intravenous) Medications Medication Administration (MAR) indicated the normal saline was not administered. On June 7, 2023, at 2:15 p.m., with the Infection Preventionist (IP), he reviewed Resident 1's physician orders and the resident's MAR. He could not state if the medication was given. He stated if a medication order is unclear and cannot be administered, the facility's practice is to assess the resident and notify the physician to determine how the physician wants to proceed. On June 7, 2023, at 3:00 p.m., during an interview with the Administrator (ADM) she reviewed Resident 1's MAR and nursing progress note dated March 10, 2023, at 8:58 pm and could not verify if the medication was given. She stated there should be a note indicating why the medication was not given. On June 23, 2023, at 3:45 p.m., during an interview with the Director of Nursing (DON), he reviewed Resident 1's physician orders for IV fluids. He stated he was aware there was an issue with obtaining IV access for the resident. He reviewed the nursing progress note for Resident 1 dated March 10, 2023, at 8:58 pm. He stated the progress note does not indicate if the physician was notified. He stated the progress note should indicate the physician was notified. A review of the facility's policy and procedure titled Administering Medications revised April 2019 indicated, Medications are administered in accordance with prescriber orders, including any required timeframes .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified .If the dosage is believed to be inappropriate or excessive for a resident, or a medications has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication will contact the prescriber . 2. A review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture of right humerus (arm bone), difficulty walking, hypertension (high blood pressure), & protein-calorie malnutrition. The record indicated the resident was discharged on March 13, 2023. The record further indicated Resident 1's daughter as the responsible party and durable power of attorney. A review of Resident 1's Brief Interview for Mental Status (BIMS) dated March 14, 2023, indicated the resident had a score of 14 (little to no cognitive impairment). A review of Resident 's nursing progress note dated March 13, 2023, at 4:00 pm by the Director of Nursing (DON) indicated, Res to be transported to EMC ER from DOHC Immediate Care for localized abdominal pain and elevated WBC count to rule out appendicitis On June 7, 2023, at 2:15 p.m., during a concurrent interview and record review with the Infection Preventionist (IP), he reviewed Resident 1's nursing progress note dated March 13, 2023, at 4:00 p.m. he could not indicate if the resident had an assessment done. On June 23, 2023, at 3:45 p.m., during a concurrent interview and record review with the Director of Nursing (DON), He stated the facility process for sending a resident out to a higher level of care is to notify the physician, assess the resident, prepare transfer documents, and remove the resident's drugs from the medication cart. He further stated the RP is notified. The DON reviewed Resident Stephan's records and stated there was no assessment done prior to discharge to immediate care. A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revised May 2017 indicated, The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital/treatment center .prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when .there is a significant change in the resident's physical, mental, or psychosocial status .it is necessary to transfer the resident to a hospital/treatment center.

Jun 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently assess and monitor changes in the skin condition for t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to consistently assess and monitor changes in the skin condition for two of three residents (Residents 1 and 2). Resident 1 had a skin tear on the right lower lower leg and Resident 2 had a skin tear on the right lower extremity. This failure had the potential for the facility staff not to be aware of the current status of the skin tears resulting in delayed treatment subsequently causing skin infection. Findings: On April 20, 2023, at 9:55 a.m., an unannounced visit was made to the facility to investigate a quality care issues. 1. On April 20, 2023, a review of Resident 1 ' s medical records indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and difficulty walking. A review of Resident 1's admission Evaluation dated February 21, 2023, at 11:30 a.m., indicated, .Required admission Care Plans .3. Skin Care Plan: At Risk for Impairment to Skin Integrity . A review of Resident 1's Skin Care Plan, dated February 22, 2023, indicated, . At Risk for Impairment to Skin Integrity Related To: Decreased Mobility with High Risk for Friction, Thin Fragile Skin, IBS (irritable bowel syndrome) with Diarrhea .Interventions .Monitor and Report to MD (Medical Doctor) changes in skin status: appearance, color, slow wound healing, s/sx of infection, wound size and staging . A review of admission skin Assessment, dated February 24, 2023, indicated, .Redness Sacral/Bottom recent diarrhea . A review of the Order Summary Report indicated, Order Date 3/21/2023 .Cleanse skin tear to RLE (Right Lower Extremity) with NS (Normal Saline) cover with island dressing and change PRN (as needed) for soiled/dislodge. A review of Resident 1 ' s Treatment Administration Record (TAR) for March 2023, indicated Resident 1 was receiving skin care treatments to her RLE skin tear, every other day starting on March 22, 2023. Further review of Resident 1 ' s medical records did not indicate documentation of staff monitoring the changes in skin status and the progress of the skin tear. A review of record indicated Resident 1 was transferred to the acute care hospital on April 2, 2023, for evaluation of high blood pressure (the pressure in the blood vessels is too high) and re-admitted to the facility on [DATE]. On June 6, 2023, at 12:20 p.m.; during interview with the Assistant Director of Nursing (ADON), she stated she could not find any documentation of the wound assessment prior to acute hospital transfer on April 2, 2023, and upon re-admission on [DATE]. She verified there was no skin assessments or documentation on Resident 1's skin tear on the right lower extremity. The ADON stated the nurses are responsible for assessing and documenting on their assigned residents. She added any new wounds or skin tear should be documented as a change of condition. Concurrently, the ADON and the Executive Director (ED) reviewed the facility policy and procedure and verified the policy indicated treatments and services rendered should be documented and that upon admission a skin assessment should be completed. 2. A review of Resident 2 ' s medical record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included RLE Cellulitis (bacterial skin infection) and diabetes mellitus (disease characterized by high blood sugars). A review of Resident 2's admission notes dated April 8, 2023, at 6:37 p.m.; indicated, .Desensitized and fragile (Skin) Scattered abrasions and discoloration throughout extremities; non-blanchable redness to coccyx . A review of Resident 2's Skin Care Plan, dated April 8, 2023, indicated, . At Risk for Impairment to Skin Integrity Related To: Decreased Mobility with High Risk for Friction, Thin Fragile Skin, and (Head of the Bed) elevated most of the time . A review of the Order Summary Report indicated, Order Date: 4/18/2023 .Cleanse RLE skin tear with NS cover with island dressing and change PRN (As needed) . A review of Resident 2 ' s Treatment Administration Record (TAR) for April 2023, indicated Resident 2 was receiving the treatments to his RLE skin tear, every other day, starting April 19, 2023. A review of Resident 2 ' s medical records did not indicate a change of condition assessment related to the skin tear on the right lower extremity was completed on April 18, 2023. A review of Resident 2 ' s medical records did not indicate if the facility staff assessed and investigated how the resident got a skin tear on the RLE. On June 6, 2023, at 5:05 p.m., during interviews with the Assistant Director of Nursing (ADON) and the Executive Director (ED), the ADON stated she could not find a change of condition documentation on Resident 2's skin tear. The facility ED stated if a resident has a new skin tear, it is considered a change in skin condition, and the nurse should complete the Change of Condition (COC) documentation. A review of the facility policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status, revised July 2017, indicated, . 8. The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status . A review of the facility P&P titled Wound Care, revised, October 2010, indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Documentation: The following information should be recorded in the resident ' s medical record: 1. The type of wound care given. Any changes in the resident ' s condition . 6. All assessment data (i.e., wound bed color, size, drainage, etc.) .

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to consistently assess and monitor skin condition for one...

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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 consistently assess and monitor skin condition for one of three sampled residents (Resident 1). This failure resulted in Resident 1 developing pressure injury (breakdown of skin integrity due to pressure). The resident developed a pressure injury to the right buttock while at the facility, which could negatively affect the health of the resident. Findings: 1. On April 20, 2023, at 9:55 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On April 20, 2023, a review of Resident 1 ' s medical records indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis which included muscle weakness, difficulty walking, and Intervertebral disc degeneration (decreased cushioning of the spine). A review of Resident 1's admission Evaluation dated February 21, 2023, at 11:30 a.m., indicated, .Required admission Care Plans .3. Skin Care Plan: At Risk for Impairment to Skin Integrity . A review of Resident 1's Skin Care Plan, dated February 22, 2023, indicated, . At Risk for Impairment to Skin Integrity Related To: Decreased Mobility with High Risk for Friction, Thin Fragile Skin, IBS (irritable bowel syndrome) with Diarrhea .Interventions .Monitor and Report to MD (Medical Doctor) changes in skin status: appearance, color, slow wound healing, s/sx of infection, wound size and staging . A review of Resident 1 ' s Minimum Data Set (MDS- an assessment tool), dated March 1, 2023, indicated Resident 1 was At risk for PI ' s. The document did not indicate whether the resident had pressure injury identified at the time of the assessment. The record indicated Resident 1 was transferred to the acute care hospital on April 2, 2023 and was re-admitted to the facility on [DATE]. A review of the record titled Interdisciplinary Skin/Wound Committee, dated April 6, 2023, at 3:02 p.m., by the Director of Nursing (DON), indicated . New (Right Buttocks). In-house acquired; Pressure wound; Stage 2; (Measuring) 0.2 centimeters (cm) x 0.6 cm x 0.5 cm ., and a .(SDTI) Suspected Deep tissue injury (Soft tissue damage under the skin due to pressure) Ischium . On June 6, 2023, at 12:20 p.m., during interview with the Assistant Director of Nursing (ADON), she stated she could not find any documentation of the wound assessment prior to acute hospital transfer on April 2, 2023, and upon re-admission on [DATE]. The ADON stated the nurses are responsible for assessing and documenting on their assigned residents. She added any new wounds or skin tear should be documented as a change of condition. On June 6, 2023, at 12:30 p.m.; during interview with the Executive Director (ED), she stated the admission documentation was incomplete on Resident 1's admission assessment. The ED stated a description of the skin condition should have been documented. On June 6, 2023, at 12:36 p.m., a telephone interview was conducted with the Director of Nursing (DON). The DON verified Resident 1's pressure injury on the right buttock was acquired during her stay at the facility. A nursing progress note, dated April 6, 2023, at 11:44 a.m., indicated, Resident 1 was discharged to an Acute Care Hospital (ACH) for .Emergency (evaluation) and (Treatment) for possible tube feeding placement . A review of Resident 1 ' s acute care hospital medical records dated April 7, 2023, at 6:55 a.m. indicated .Skin assessment done with multiple skin tear(s) and wound, foam (Dressing) applied and wound consult and special bed ordered . A review Resident 1's the acute care hospital notes titled, Wound Care Consult, dated April 7, 2023, indicated, .Referred to wound service regarding multiple wounds .Wound Assessment: Multiple wounds: Upper tibial: 1.5-centimeter (cm) skin tear; Right lateral lower leg: 1.5 cm shallow oval wound; Right upper thigh wound; 12-13 cm x 1.2 cm purple to pink wound with intermittent areas of open skin, similar to an abrasion caused by pulling a plastic tube across the skin . A review of the facility P&P, titled Wound Care, revised, October 2010, indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Documentation: The following information should be recorded in the resident ' s medical record: 1. The type of wound care given. Any changes in the resident ' s condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) .

May 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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure an itemized inventory list of personal belongings was completed on admission for one out of five r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure an itemized inventory list of personal belongings was completed on admission for one out of five residents reviewed (Resident 1). This failure had resulted for the resident and resident's responsible party not to have accurate details of the belongings that came with the resident on admission which increased the risk for misappropriation of property for Resident 1. Findings: On 03/20/2023 at 10:50 AM, an unannounced visit to the facility was conducted, to investigate an allegation of abuse. On 03/20/2023 at 12:59, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the staff would complete an inventory list to itemize the resident ' s belongings on admission. CNA 1 stated the inventory list would be signed by the resident and the staff who completed the inventory. On 03/20/2023 at 2:17 PM, during an interview with the Director of Nursing (DON). The DON stated the admission process included completion of an itemized inventory list of the CNA. The DON further stated the inventory list must be completed on the day of admission and not the next day. A record review of Resident 1 ' s medical record showed the resident was admitted on [DATE], with diagnoses which included Traumatic subdural hemorrhage (A bleed within the skull, which causes pressure on the brain). There was no record of a personal belongings itemized inventory list on the day of Resident 1 ' s admission. On 03/20/2023, a review of the inventory list dated 03/02/2023 (2 days after admission), indicated Resident 1 ' s personal belongings included: clothing, grooming supplies, toothbrush, cellphone, and family photos. The list did not include cash. A review of the facilities Policy and Procedure (P&P) titled, Personal Property, revised in September 2012, was reviewed. The P&P indicated, .Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits . 5. Resident ' s personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished .

Dec 2022 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 F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to arrange transportation with consideration of Resident 1's needs an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to arrange transportation with consideration of Resident 1's needs and comfort on October 15, 2022. The facility failed to specify the resident required a gurney during transport to dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) appointment. This failure resulted in Resident 1 missing dialysis treatment, when the resident refused to be transported in a wheelchair due to discomfort related to hip pain. Findings: On November 8, 2022, an unannounced visit was conducted at the faility to investigate a quality care issue. On November 8, 2022, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included fracture of unspecified part of neck of right femur (thigh bone), end stage renal disease (ESRD- the kidney cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), dependence on renal (kidney) dialysis, history of fall, and abnormalities of gait and mobility. A review of Resident 1's Hospital Referral Record dated October 12, 2022, indicated, Referral Comments: Patient goes to HD (Hemodialysis) (name of Clinic) TTHSa (Tuesday-Thursday-Saturday)—no transport set up prior. Will need gurney transport assistance and set up from SNF (Skilled Nursing Facility) .pls (please) provide transport for free or assist with family/patient transport arrangements .Need PT/OT (Physical Therapy/Occupational Therapy) S/P (status post) Fx (fracture) and surgery. A review of Resident 1's Progress Note , dated October 15, 2022, at 4:44 p.m., written by Licensed Vocational Nurse 1 (LVN) indicated, resident was not picked up for dialysis. transportation contacted, arranged for later pickup by wheelchair. Resident refused to go by wheelchair because of hip pain. Dialysis contacted. next available appt on monday at 2 PM. There was no documented evidence a request was made for a gurney for resident's comfort on October 15, 2022. On November 8, 2022, at 1:33 p.m., the Social Service Director (SSD) was interviewed. The SSD stated transportation did not come on October 15, 2022. The SSD further stated that she did not know about the admission referral arrangement indicating the resident was supposed to go for dialysis on a gurney because of hip pain. The SSD stated, I am not aware if the physician was made aware that the resident did not go for dialysis on October 15, 2022. On November 8, 2022, at 2:58 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 1 should have had her dialysis completed as scheduled on October 15, 2022. The DON stated transportation should have been arranged and a gurney requested to accommodate the resident's needs and comfort. The DON stated she was not aware of previous referral request made for gurney to be arranged for dialysis transport on admission. The DON stated if resident would miss their dialysis as scheduled, they could end up with complications such as heart failure and fluid overload. On December 19, 2022, at 11:20 a.m., the facility was visited for a follow up investigation. On December 19, 2022, at 11:40 a.m., the SSD was re-interviewed. The SSD stated she made the transportation arrangement for October 15, 2022. The SSD further stated she should have ordered a gurney transport for the resident. The SSD indicated she discusses the diagnosis with the DON and the admission Coordinator if they have a hip fracture patient, they would have to order a gurney to ensure resident's comfort, support, and to alleviate any pain. On December 19, 2022, at 1:00 p.m., the DON was re-interviewed. The DON stated that the primary issue for a hip surgery patient was pain and limited range of motion. The DON indicated a gurney would provide better support and body alignment, improve comfort and alleviate Resident 1's pain as opposed to sitting while being transported. A review of the facility policy titled, Transportation, Social Services , dated December 2008 indicated, Policy Statement. Our facility shall help arrange transportation as needed. Policy Interpretation and Implementation .2. Social services will help the residents as needed to obtain transportation .References: 483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

Dec 2022 7 deficiencies

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one resident reviewed for oxygen administration (Resident 184), when the resident received oxygen therapy without a physician's order. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and a decline in the resident's health condition. Findings: On December 5, 2022, at 10:52 a.m., Resident 184 was observed in bed with oxygen (O2) via nasal cannula (N/C - a tube used to deliver oxygen through the nose). Resident 184's oxygen administration was observed at 4.5 liters per minute (LPM). On December 7, 2022, at 12 p.m., Resident 184 was observed in his wheelchair with O2 via N/C at 4 LPM. In a concurrent interview, Resident 184 stated he was on O2 all the time since his admission to the facility, but he did not know why. Resident 184 stated he was not short of breath. Resident 184's record was reviewed. Resident 184 was admitted to the facility on [DATE], with diagnoses which included pneumonia (a lung infection). There was no physician's order for oxygen administration. On December 7, 2022, at 12:23 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 184 did not have a physician's order for O2 administration. LVN 1 confirmed Resident 184 had an O2 saturation (a measure of O2 level) of 95% (normal) on room air, on the last two saturation checks which were conducted on December 7, 2022, at 00:40 a.m. and 9:11 a.m. LVN 1 further stated Resident 184 should not have been on O2 without a physician's order. The facility policy and procedure titled, Oxygen Administration, revised October 2010, was reviewed. The policy indicated, .The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to complete a medication administration log for emergency medication kits. This failure prevented the emergency medication kits...

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Based on observation, interview, and record review, the facility failed to complete a medication administration log for emergency medication kits. This failure prevented the emergency medication kits from being tracked to prevent potential theft and diversion of medications. Findings: A concurrent observation and interview was conducted on December 6, 2022, at 3:17 p.m., with the Director of Nursing (DON), in the medication storage room. Medications had been taken from the facility emergency medication kits (E-kit) with no medication administration log available to show the documentation needed after dispensing emergency medications. The DON stated, The new pharmacy has not brought us a log for the E-kits yet. A review of the facility's policy and procedure titled, Emergency Medications, revised April 2007, indicated .The facility shall maintain a supply of medications typically used in emergencies .Any medication that is removed from the emergency kit must be documented on the emergency medication administration log .Medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order .

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess for the need of an antipsychotic medication, h...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess for the need of an antipsychotic medication, have medication evaluated by the physician, and failed to provide adequate indications for an antipsychotic medication for one of six residents reviewed for antipsychotic medication use. (Resident 335). This failure had the potential to jeopardize the health and safety of Resident 335. Findings: A review of Resident 335's face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses that included, Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, urinary tract infection (UTI) with sepsis (inflammation throughout the body). A review of Resident 335's physician's order dated November 29, 2022, indicated, SEROquel tablet (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and major depressive disorder) .12.5 mg (milligram - a unit measurement) by mouth at bedtime for antipsychotic m/b (manifested by) unable to sleep . A review of Resident 335's progress note dated December 8, 2022, indicated Resident 335's son stated the resident had been on Seroquel since the beginning of November due to an increase in confusion and agitation related to a UTI. On December 8, 2022, at 11:00 a.m., a interview was conducted with the Director of Nursing (DON). The DON stated, Resident 335 was pleasantly confused and had not exhibited agitation or aggression. The DON stated there had not been an assessment done by the physician for the need of the antipsychotic for Resident 335. On December 9, 2022, at 10:52 a.m., an interview was conducted with the Pharmacy Consultant. He stated he would not recommend using Seroquel for a resident that was unable to sleep, he would recommend discontinuing the Seroquel. A record review of the policy and procedure titled, Psychotropic Drug Use, revised 8/2017, indicated .It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record . psychotropic medications are to be administered only when required to treat the resident's medical symptoms and will be considered only after nonpharmacological interventions have been attempted and failed .The Attending Physician will review the resident's treatment plan, in collaboration with the consultant pharmacist, to re-evaluate the use of the psychotropic medication and consider whether or not medication can be reduced or discontinued upon admission or soon after admission, during initial physician admission visit .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to: 1) properly label a prescribed medication needed for safe administration, when one insulin injectable pen and one glucagon i...

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Based on observation, interview, and record review, the facility failed to: 1) properly label a prescribed medication needed for safe administration, when one insulin injectable pen and one glucagon injectable pen were found in medication cart 2 without a pharmacy label; and 2) ensure proper organization and storage of Cefazolin (antibiotic) IV (intravenous) bags, risking administration of an antibiotic beyond its use-by-date. In addition, the facility was unable to differentiate between the IV solution that were different in color. These failures had the potential for residents to receive the improper amount of insulin and for residents to receive expired IV medication. Findings: 1. On December 6, 2022, at 11:10 a.m., one Toujeo SoloStar Solution Pen Injector kit (insulin used to control blood sugar) was observed in medication cart 2, readily available for use, with a resident's name written on a sticky note. There was no pharmacy label on the kit. One glucagon emergency kit was also observed being stored in medication cart 2 readily available for use, with no label. On December 6, 2022, at 11:12 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the resident's family brought the Toujeo SoloStar insulin kit from home with the resident's belongings. LVN 2 stated, I don't know how it got into the med cart. LVN 2 stated she had no idea how long it had been in the med cart, when it had been opened, or if it needed to be in the refrigerator. LVN 2 stated the insulin kit should have been stored in the medication room. On December 6, 2022, at 11:14 a.m., LVN 2 was asked if the Glucagon injectable pen should have a label with directions for use. LVN 2 stated the Glucagon injectable pen should have a label with directions for use. On December 6, 2022, at 11:20 a.m., LVN 2 was observed giving the Toujeo SoloStar insulin injectable pen and glucagon injectable pen to LVN 1. LVN 1 stated, I suppose these should probably be in the med room, I don't know why they are in the med cart. While LVN 1 was holding the glucagon injectable pen, he stated, I will need to ask where I put this one. During an interview on December 6, 2022, at 2:44 p.m., the Director of Nursing (DON) stated the insulin injectable pen and the glucagon injectable pen should have been labeled. A review of policy and procedure titled, Labeling of Medication Containers, revised April 2019, indicated .All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .Labels for individual resident medications include all necessary information, such as .The resident's name .The prescribing physician's name .The name, address, and telephone number of the issuing pharmacy .The name, strength, and quantity of the drug .The prescription number (if applicable) .The date that the medication was dispensed .Appropriate accessory and cautionary statement .The expiration date when applicable; and .Directions for use .Labels for stock medications include all necessary information, such as .The name and strength of the drug .The lot and control number .The expiration date when applicable .Appropriate accessory and cautionary statements; and .Directions for use. A review of policy and procedure titled, Storage of Medications, revised November 2020, indicated .The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Drug containers that have missing, incomplete, improper or incorrect labels are returned to the pharmacy for proper labeling before storing, discontinued, outdated, or deteriorated drugs or biologicals are destroyed per facility protocol .then Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or other secured location . 2. On December 6, 2022, at 3:08 p.m., several small IV bags of Cefazolin were observed stored together in a larger plastic bag in the medication storage room. Each bag had three dates written on the label: 11/30/22 in the middle of the label, 11/21/22 in parenthesis to the right of the label, and next to used by: 12/19/22. There were Cefazolin IV bags that were a cloudy pale yellow and Cefazolin IV bags that were clear in color. All of the Cefazolin IV bags were labeled with the same dates. On December 6, 2022, at 3:10 p.m., the DON stated he did not know exactly what all the dates on the antibiotic IV bags meant and that he would have to contact the pharmacy. The DON could not state why some of the antibiotic IV bags were a cloudy pale yellow color and why some of the antibiotic IV bags were clear in color. On December 7, 2022, at 2:14 p.m., an interview was conducted with the Pharmacist. The Pharmacist stated the date in the middle of the label, 11/30/22, was the date the medication is processed (prepared), the date in parenthesis to the right of the label was the date the prescription was written, and the use-by-date, 12/19/22, was when the medication expires. On December 9, 2022, at 10:52 a.m., an interview was conducted with the facility's Pharmacy Consultant. He stated IV medication bags (Cefazolin) should have a label with a use-by-date when to discard. He stated any compounded (medications mixed by the pharmacist) medications were usually good for seven to fourteen days. On December 9, 2022, at 4:21 p.m., an interview was conducted with the Pharmacist. The Pharmacist stated he followed the stability table when compounding IV Cefazolin. He stated compounded medications were good for fourteen days. A record review of the facility policy and procedure titled, Pharmacy Services Overview, revised April 2019, indicated, .The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist . Medications acquired or dispensed in this facility are FDA approved for use by the residents and meet the requirements established by the Federal Food, Drug, and Cosmetic Act . Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice . According to Lexicomp (a nationally recognized pharmaceutical drug reference), .Reconstituted solutions of Cefazolin are light yellow to yellow. Reconstituted solutions are stable for 24 hours at room temperature and for 10 days under refrigeration. Cefazolin stability of intravenous admixture (a product of combining two or more substances) at refrigeration temperature .is fourteen (14) days .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the PICC (Peripherally Inserted Central Cathete...

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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 PICC (Peripherally Inserted Central Catheter - an IV [intravenous], longer than a regular IV) line dressing was changed according to the standard of practice for one of one resident reviewed (Resident 287). This failure had the potential to place Resident 287 at risk for infection and other complications. Findings: On December 6, 2022, at 9:25 a.m., Resident 287 was observed sitting in bed. Resident 287 was observed to have a PICC line in her upper right arm. The transparent dressing was labeled 11/19/22. A concurrent interview with Resident 287 was conducted. Resident 287 stated she was admitted to the facility with the PICC line in place. She stated the dressing had not been changed since admission. Resident 287's record was reviewed. Resident 287 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life-threatening complication of infection) and diabetes (increased sugar in the blood). The physician history and physical, dated November 23, 2023, indicated Resident 287 was admitted to the facility for continuation of IV antibiotics. On December 8, 2022, at 9:10 a.m., LVN 3 was interviewed. LVN 3 stated the Registered Nurse (RN) was responsible for changing the PICC line dressing. He stated the PICC line dressing should be changed every seven days. On December 8, 2022, at 9:13 a.m., the Director of Nursing (DON) was interviewed. The DON stated the RN was responsible for changing the PICC dressing. He stated the RN should assess and change the PICC line dressing upon admission, then every five to seven days and as needed. On December 8, 2022, at 9:23 a.m., a concurrent interview and record review was conducted with the Infection Preventionist (IP) nurse. The IP nurse stated the RN should assess, flush and change the PICC line dressing weekly. He stated there was no order for PICC line dressing change. The IP stated the RN should have called the physician to get an order for PICC line dressing change. On December 8, 2022, at 9:42 a.m., the Administrator (Adm) was interviewed. The Adm stated the facility did not have a specific policy and procedure for PICC line dressing change. She stated the facility had a competency assessment and the dressing change was included in the competency. According to the Center for Disease Control and Prevention, APIC (Association for Professionals in Infection Control and Epidemiology) Implementation Guide titled, Guide to Preventing Central-Line Associated Bloodstream Infections, dated 2015, the article indicated, .CVC (Central Venous Catheter/similar to PICC) Dressing Change .Assess dressing status daily .Replace dressing .every 2 days for gauze dressings .Every 7 days for transparent dressings .And whenever dressing becomes damp, loosened or soiled .

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff for four out of four residents reviewed for sufficient staffing, when staff did not respond ...

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Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff for four out of four residents reviewed for sufficient staffing, when staff did not respond timely to the call lights of Residents 9, 186, 286, and 334. This failure increased the potential for the residents to not receive timely and necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings: On December 5, 2022, at 11:31 a.m., Resident 286 was interviewed. Resident 286 was alert and oriented. Resident 286 stated the facility was shorthanded, it did not have enough staff. Resident 286 stated it took a long time for her call lights to get answered. On December 5, 2022, at 11:34 a.m., Resident 186 was interviewed. Resident 186 was alert and oriented. Resident 186 stated one night around midnight he had to wait about an hour to get help after he pressed the call light. He also stated one morning he had to wait 30-45 minutes after he pressed the call light for the nurse to come in. On December 5, 2022, at 12:47 p.m., Resident 9 was interviewed. Resident 9 was alert and oriented. Resident 9 stated one evening shift she had to wait an hour and a half for the nurse to come in, after she pressed the call light. On December 6, 2022, at 10:12 a.m., Resident 286 was interviewed again. Resident 286 stated she was very upset last night, December 5, 2022, because she pressed the call light at 9:35 pm and nobody answered. She then went out of her room at 10 p.m. to get help and saw the two Certified Nursing Assistants (CNAs) in the cafeteria area. She stated she had to wait a long time for the call light to get answered, mostly at nighttime. On December 6, 2022, at 10:30 a.m. during the resident council interview, Resident 334 stated there were times when she pushed the call light and had to wait for about 30 minutes, and sometimes about one hour, to get help. On December 7, 2022, at 3:11 p.m., an interview with Licensed Vocational Nurse (LVN) 2 was conducted. LVN 2 stated staffing was short at times on licensed nurses and CNAs on second (p.m.) shift and sometimes on third (night) shift, to the point that it was affecting patient care, specifically timely call light response. On December 7, 2022, at 3:30 p.m., Resident 9 was observed. Resident 9 was observed stating to the nurse that some afternoon and evening shifts she had to wait too long for help after pressing the call light. On December 7, 2022, at 3:34 p.m., Resident 9 was interviewed again. Resident 9 stated several times she had to wait too long after she pressed the call light for help. Resident 9 stated one time she waited over one hour, and other times more than 20 minutes to get help after she pressed the call light. Resident 9 stated the facility did not have enough staff on those shifts. She stated on one shift, a registered nurse told her they were short staffed. On December 7, 2022, at 4:21 p.m., an interview with CNA 1 was conducted. CNA 1 stated he worked p.m. shift. CNA 1 stated the facility was short staffed (licensed nurses and CNAs), especially on p.m. shift. CNA 1 stated there were shifts when he took care of 16 residents and it affected the time he responded to the call lights when the residents called. On December 8, 2022, at 2:06 p.m., an interview with CNA 2 was conducted. CNA 2 stated there were instances when the facility was short staffed on CNAs, and it affected the response time to the call lights. On December 8, 2022, at 2:28 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated he had to cover a few shifts on a few occasions when nurses called-off. A review of the facility document titled, Nursing Staffing Assignment and Sign-In Sheet, dated December 1, 2022, indicated the DON had to take a nursing assignment on the night shift of December 1, 2022. A record review of staffing data submitted via the PBJ system (Payroll Based Journal - a report specific for staffing) indicated the facility had a one-star staffing quality rating and excessively low weekend staffing.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on the observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when the inside and outside, including the...

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Based on the observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when the inside and outside, including the racks, of the double oven were observed to have dry, sticky, brown residue. This failure had the potential to result in foodborne illnesses to the vulnerable resident population. Findings: On December 5, 2022, at 9:38 a.m., during the initial tour of the kitchen with the Dietary Manager (DM), the inside and the outside area of the double oven and the oven racks were observed to have dry, sticky, brown residue. On December 5, 2022, at 9:40 a.m., the Culinary Director (CD) was interviewed. He stated, the double oven should have been cleaned once a week. A review of the maintenance log for oven cleaning was conducted. There was no documented evidence a weekly cleaning of the double oven was performed. On December 6, 2022, at 2:20 p.m., the Registered Dietician (RD) was interviewed. The RD stated the double oven should have been cleaned every week. She stated the CD was responsible in ensuring the double oven was kept and maintained clean. The facility policy and procedure, titled, OVEN - CONVECTION, GAS, dated December 19, 2019, indicated .SANITATION OF EQUIPMENT .Frequency: Immediate .Remove spills, spillovers, and burned food deposits .Frequency: Daily .Wipe cool oven's (sic) with wet cloth .Frequency: Weekly .Wipe oven exterior .Remove oven racks .Use oven cleaner and allow racks to stand according to EPA-registered label use directions .Spray side, interior, and oven doors. Use oven cleaner according to EPA-registered label use directions .Wash and rinse racks. Use detergent and hot water. Allow to air dry .Wash oven interior. Use wet cloth, sanitizing solution, and hot water .Rinse and allow to air dry .

BAYSHIRE RANCHO MIRAGE

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BAYSHIRE RANCHO MIRAGE

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