QUARTZ HILL POST ACUTE
For profit - Limited Liability company
115 Beds
WEST HARBOR HEALTHCARE
Data: November 2025
Trust Grade
68/100
#441 of 1155 in CA
Photo by Quartz Hill Post Acute
Photo by Quartz Hill Post Acute
Photo by Quartz Hill Post Acute
1 / 10 photos
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Quartz Hill Post Acute in Redding, California, has a Trust Grade of C+, indicating it is slightly above average but not quite exceptional. It ranks #441 out of 1155 nursing homes in California, placing it in the top half of facilities in the state, and #6 out of 10 in Shasta County, suggesting only one local option is better. Unfortunately, the facility's trend is worsening, with issues increasing from 4 in 2024 to 9 in 2025. Staffing is a relative strength, with a 4 out of 5-star rating and a turnover rate of 37%, which is below the state average. However, the facility has accrued $15,537 in fines, which is average but still indicates some compliance concerns. In terms of RN coverage, it is average, which means while they have a reasonable number of registered nurses, more would enhance care. Specific incidents of concern include staff not adhering to food safety protocols, such as the dietary manager failing to wear a hair net and improper food storage practices, which could expose residents to foodborne illnesses. Overall, while there are strengths in staffing, the facility must address its increasing issues and food safety practices to ensure a safe environment for residents.
- Trust Score
- C+
- In California
- #441/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near California's 48% average. Typical for the industry.
- Penalties ○ Average
- $15,537 in fines. Higher than 72% of California facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
68/100
Top 38%
No red flags
4 → 9 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 9 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below California average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
Staff Turnover: 37%
Near California avg (46%)
Typical for the industry
Federal Fines: $15,537
Below median ($33,413)
Minor penalties assessed
Chain: WEST HARBOR HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 43 deficiencies on record
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update the responsible party (RP) for one of two sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update the responsible party (RP) for one of two sample residents, (Resident 2) when Resident 2 had a fall.
This failure violated the rights of Resident 2 and the RP to for all changes to be reported immediately.
Findings:
A review of the facility ' s policy undated, titled, Acute Condition Changes-Clinical Protocol, indicated the nurse and physician will discuss and evaluate the situation. The physician should request information to clarify the situation, for an example vital signs, physical findings, a detailed sequence of events, and descriptions of symptoms. Many acute changes of condition can be managed effectively in nursing facilities with outcomes that are comparable to those of hospitalization. This discussion should consider the patient ' s overall condition, prognosis, and wishes (either direct or as conveyed by a substitute decision-maker/ RP).
Resident 2 was admitted to the facility on [DATE], for diagnoses that included neoplasm of the colon (a growth or tumor in the colon), pneumonia (lung infection causing inflammation and fluid), urinary tract infection (UTI, a bacterial infection of the urinary tract), Chronic Pulmonary Obstructive Disease (COPD, a progressive lung disease), dysphagia (difficulty swallowing), anxiety (an uncomfortable feeling of uneasiness, dread, or fear), atrial fibrillation (irregular and fast heart rate), congestive heart failure (serious disease when the heart cannot keep up with the body ' s need), Peripheral Vascular Disease (PVD, a slow and progressive blockage of the blood circulation) and presence of a heart pace maker (battery-powered, surgically placed device that helps the heart speed up and beat regularly).
A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) dated 1/9/25, indicated that Resident 2 had a Brief Interview for Mental Status, (BIMS) score of 8 out of 15 which indicated a severe cognitive (ability to think and reason) impairment. This MDS also indicated Resident 2 required maximum assistance with toileting, lower body dressing, all transfers, and bathing.
During an interview on 2/28/25 at 1:30 pm, Resident 2 stated, I remember the fall, it was last Friday evening. They did not update my family member when I fell, I did when she came in to visit. She is very involved and worries about me.
During a concurrent interview and record review on 2/28/25 at 12:45 pm. Registered Nurse (RN) A confirmed Resident 2 fell in her room on 2/21/25 and a change in condition and a physician update was documented in the medical record on 2/21/25. RN A confirmed the RP was not updated on 2/21/25 when a change in condition was identified and documented.
During a phone interview with the Director of Nursing (DON) on 2/28/25 at 12:50 pm, the DON confirmed the RP should be updated with any fall or change in condition. The DON confirmed it is the facility ' s policy to update the RP even if the resident is alert and oriented unless the resident specifically requests no updates. DON added, This update to the RP was missed for Resident 2 if it is not documented in the medical record, but I would ask the nurse who was present to be sure.
During an interview on 2/28/25 at 2:10 pm, RN B confirmed he did not update the RP or family member on 2/21/25 when Resident 2 had a fall. RN B stated, I updated the doctor but did not update the family, I will know moving forward, even if there is no apparent injury.
During an interview on 2/28/25 at 2:30 pm, the Administrator confirmed the RP was not updated for Resident 2 after a change in condition.
Feb 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was timely reported to the state survey that involved 2 (Resident #12 and Resident #...
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Based on interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was timely reported to the state survey that involved 2 (Resident #12 and Resident #58) of 4 sampled residents reviewed for abuse.
Findings included:
A facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised 04/2021, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy specified, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Per the policy, 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.
An admission Record indicated the facility admitted Resident #12 on 10/17/2023. According to the admission Record, the resident had a medical history that included diagnoses of muscle weakness, cognitive communication deficit, and arthritis.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/26/2025, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment.
An admission Record indicated the facility admitted Resident #58 on 07/19/2023. According to the admission Record, the resident had a medical history that included diagnoses of cognitive communication deficit, psychotic disorder, major depressive disorder, anxiety disorder, and cerebrovascular disease.
A quarterly MDS, with an ARD of 01/28/2025, revealed Resident #58 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment.
Resident #12's Progress Notes dated 02/03/2025 at 10:26 PM, indicated at approximately 10:00 PM, a certified nursing assistant informed a nurse that Resident #12 reported that their roommate (Resident #58) had attacked them. Per the Progress Note, Resident #12 reported their roommate came over to their side of the room and attempted to forcefully take their call light out of their hand. The Progress Note revealed Resident #12 reported that their roommate scratched their left hand near the base of their thumb and index finger. According to the Progress Note, the nurse noted discoloration in the area that was beginning to bruise. The Progress Note indicated the Administrator and Director of Nursing (DON) were notified and Resident #12 was moved to another room in the facility for their safety.
The Report of Suspected Dependent Adult/Elder Abuse, completed 02/03/2025, indicated the state survey agency received the abuse allegation on 02/04/2025 at 1:48 PM, which was greater than the two-hour time frame for reporting an allegation of abuse.
During an interview on 02/12/2025 at 1:44 PM, the Administrator and DON both stated they were notified of the allegation of abuse that involved Resident #12 and Resident #58 by way of a text message on 02/03/2025. The Administrator stated he did not report the allegation of abuse to the state survey agency within two hours because there was no injury to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed to follow the physician's order for the use of an as-needed blood pressure medication for 1 (Resident #17) of 5 sampl...
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Based on interview, record review, and facility policy review, the facility failed to follow the physician's order for the use of an as-needed blood pressure medication for 1 (Resident #17) of 5 sampled residents reviewed for unnecessary medications.
Findings included:
A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame.
An admission Record indicated the facility readmitted Resident #17 on 12/11/2024. According to the admission Record, the resident had a medical history that included a diagnosis of essential primary hypertension (high blood pressure).
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2024, revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment.
Resident #17's care plan included a focus area initiated 06/14/2022 that indicated the resident had altered cardiovascular status related to hypertension. Interventions directed staff to give medications for hypertension, document response to medication and any side effects, and monitor blood pressure and notify the physician of any abnormal readings.
Resident #17's Order Summary Report which included active orders as of 02/13/2025, revealed an order dated 12/11/2024, for clonidine hydrochloride (HCL) tablet 0.1 milligram (mg), give one table by mouth every six hours as needed for hypertension for a systolic blood pressure (SBP) greater than 150 millimeters of mercury (mmHg).
Resident #17's Medication Administration Record [MAR], for 01/2025, revealed clonidine HCL 0.1 mg was not administered to the resident when their SBP was greater than 150 mmHg on 01/09/2025 at 2:00 AM, 01/12/2025, and 01/16/2025. Per the MAR, on 01/09/2025 at 2:00 AM, the resident had a blood pressure reading of 158/98 mmHg; on 01/12/2025 at 2:00 AM, the resident had a blood pressure reading of 190/87 mmHg; and on 01/16/2025 at 8:00 AM, the resident had a blood pressure reading of 158/90 mmHg.
Resident #17's MAR for 02/2025, revealed clonidine HCL 0.1 mg was not administered to the resident when their SBP was greater than 150 mmHg on 02/07/2025. Per the MAR, on 02/07/2025 at 2:00 AM, the resident had a blood pressure reading of 154/77 mmHg.
During an interview on 02/12/2025 at 12:16 PM, Licensed Vocational Nurse (LVN) #3 stated she did not recall administering Resident #17 clonidine, but she should have if the resident's SBP was greater than 150 mmHg.
During an interview on 02/13/2025 at 11:16 AM, LVN #4 reviewed Resident #17's MAR and confirmed she should have administered clonidine to the resident on 01/16/2025 at 8:00 AM but could not remember if she did or not.
During an interview on 02/13/2025 at 11:33 AM, LVN #5 stated if a medication was supposed to be given when a resident's blood pressure was high, then it should be administered and there should be documentation of the administration.
During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development stated the nurses should follow the physician orders and give or hold medication according to the physician orders, and it should be documented.
During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated her expectation was that the nurses follow physician orders and parameters and document.
During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred all nursing concerns to the DON, but stated the staff should follow the physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure there was a physician's order for the use of non-invasive mechanical ventilator for 1 (Residen...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure there was a physician's order for the use of non-invasive mechanical ventilator for 1 (Resident #1) of 3 sampled residents reviewed for respiratory care.
Findings included:
A facility policy titled, CPAP/BiPAP [continuous positive air pressure/bilevel positive air pressure] Support, revised 03/2015, specified 3. Review the physician's order to determine the oxygen concentration and flow, and the PEEP [positive end-expiratory pressure] pressure for the machine.
An admission Record indicated the facility admitted Resident #1 on 10/21/2024. According to the admission Record, the resident had a medical history that included a diagnosis of obstructive sleep apnea.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/28/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment.
Resident #1's care plan included a focus area revised 10/29/2024 that indicated the resident required respiratory therapy/pulmonary hygiene due to obstructive sleep apnea and was at risk for impairments with full lung expansion, shortness of breath, decreased oxygen saturation, and impaired functional mobility. Interventions directed staff to provide treatments per physician orders, monitor oxygen saturation before and after treatments, and notify the physician of any shortness of breath or oxygen saturation less than 90 percent.
Resident #1's Respiratory Therapy Assessment, dated 10/30/2024, indicated the resident was educated on the use of the non-invasive mechanical ventilator, respiratory therapy, and treatment used for the maintenance of their respiratory status.
Resident #1 Respiratory Therapy Daily Note, dated 11/13/2024, indicated the resident successfully used the non-invasive mechanical ventilator.
Resident #1's Respiratory Therapy Weekly Progress Note, dated 11/15/2024, indicated the resident used a home non-invasive mechanical ventilator at night and as needed.
Resident #1's Order Summary Report which contained active orders as of 02/11/2025, revealed no order for the use of a non-invasive mechanical ventilator.
On 02/10/2025 at 10:03 AM, Resident #1 was observed lying in bed with a non-invasive mechanical ventilator on their nightstand.
During an interview on 02/11/2025 at 1:54 PM, the Registered Nurse (RN) Respiratory Therapist (RT) stated residents should have orders for the use of a non-invasive mechanical ventilator that included the settings and when it should be applied. The RN RT stated Resident #1 was not currently on her case load, but the resident did use a non-invasive mechanical ventilator and should have an order for the use of it.
During an interview on 02/12/2025 at 4:52 PM, Licensed Vocational Nurse (LVN) #3 stated residents needed to have orders to use a non-invasive mechanical ventilator that included the rate it was to be set at. LVN #3 stated Resident #1 used a non-invasive mechanical ventilator and was able to put on their own mask.
During an interview on 02/13/2025 at 11:16 AM, LVN #4 stated if a resident used a non-invasive mechanical ventilator, they should have an order that included the settings, when to use it, and when to clean it. LVN #4 stated Resident #1 did use a non-invasive mechanical ventilator.
During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development stated residents should have orders for the use of a non-invasive mechanical ventilator that included the settings, when to use, when to clean, and who to contact if it was not working to get it serviced.
During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated residents needed to have orders for the use of a non-invasive mechanical ventilator that included the application and removal, maintenance orders, and cleaning of the system.
During an interview on 02/13/2025 at 1:42 PM, the Administrator deferred all nursing concerns to the DON, but that he expected everything to be in place for the use of respiratory equipment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and changed their gloves during the provision of incontinence care for 1 (Resident #109) ...
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Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and changed their gloves during the provision of incontinence care for 1 (Resident #109) of 1 sampled resident reviewed for urinary catheter.
Findings included:
An admission Record indicated the facility admitted Resident #109 on 01/19/2025. According to the admission Record, the resident had a medical history that included a diagnosis of hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following cerebral infarction.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/26/2025, revealed Resident #109 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was dependent on staff for toileting hygiene and always incontinent of bowel.
Resident #109's care plan, included a focus area revised 02/12/2025, that indicated the resident had an alteration in elimination of bowel and bladder.
On 02/12/2025 at 11:20 AM, the surveyor observed Licensed Vocational Nurse (LVN) #7 and Certified Nursing Assistant (CNA) #23 perform incontinence care on Resident #109. Once CNA #23 cleaned bowel from Resident #109's buttocks, she did not wash her hands or change her gloves, before she applied a clean incontinence brief underneath the resident. CNA #23 was also noted to touch the bed control of Resident #109's bed while wearing gloves she used to clean bowel from the resident's buttocks.
During an interview on 02/12/2025 at 11:35 AM, CNA #23 stated she would change her gloves during incontinence care if the gloves became soiled. CNA #23 stated hand hygiene and gloves should be changed when she went from a dirty to clean task during the provision of care. CNA #23 acknowledged she did not perform hand hygiene or change her gloves when she provided care to Resident #109.
During an interview on 02/12/2025 at 12:50 PM, LVN #7 stated hand hygiene and gloves should be changed when she went from a dirty area to a clean area during incontinence care. LVN #7 stated she and CNA #23 should have changed their gloves when the resident's incontinence brief was removed and before they placed a clean incontinence brief on the resident.
During an interview on 02/13/2025 at 12:47 PM, the Infection Preventionist stated during incontinence care, staff should perform hand hygiene and change their gloves with each step.
During an interview on 02/13/2025 at 12:52 PM, the Director of Staff Development stated gloves should be changed and hand hygiene should occur in between the dirty and clean tasks.
During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated that when staff provided incontinence care, they should perform hand hygiene, put on gloves, provide the care, and after the resident was cleaned, they should change their gloves and then replace the incontinence brief and clothing, remove their gloves, and perform hand hygiene.
During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred any concerns related to incontinence care to the DON.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of five percent or less. There were three errors out ...
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Based on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of five percent or less. There were three errors out of 29 opportunities, which yielded a medication error rate of 10.34% for 2 (Resident #77 and Resident #75) of 4 residents observed for medication administration.
Findings included:
A facility policy titled, Administering Medications, revised 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame and 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
1. The KwikPen pre-filled insulin pen user manual revised 07/2020, specified, Prime before each injection. Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensure that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin.
Resident #77's Order Summary Report that contained active orders as of 02/13/2025, revealed an order dated 03/22/2023, for multivitamin oral tablet, give one tablet by mouth one time a day for supplement. There was also an order dated 03/23/2023, for Humalog (insulin lispro) KwikPen subcutaneous solution pen-injector 100 units per milliliter, inject as per sliding scale with meals for diabetes mellitus.
During medication administration observation on 02/12/2025 at 7:23 AM, Licensed Vocational Nurse (LVN) #1 administered medications to Resident #77, to include one multivitamin with mineral tablet. The surveyor noted LVN #1 did not prime the needle before he placed it on the insulin lispro kwikpen and turned the dose knob to two units.
During an interview on 02/12/2025 at 12:45 PM, LVN #1 confirmed he administered a multivitamin with mineral tablet to the resident and stated technically he did not give the right medication, but he thought the order could be interchangeable. LVN #1 stated he did not know that the insulin pen needle needed to be primed.
During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development (DSD) stated that when administering medications, the nurse should recognize the five rights, to include the right resident, route, medication, dose, and time, and should check the physician's order three times. The DSD stated the insulin pen needle should be primed with two units prior to dialing up the dose.
During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated the insulin pen needle should be primed with two units prior to use. Per the DON, the nurses should have followed the physician's orders to give the correct medication to the resident.
During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred all nursing concerns to the DON.
2. Resident #75's Order Summary Report for active orders as of 02/13/2025 included an order dated 10/14/2022, for senna-docusate sodium oral tablet 8.6-59 milligrams (mg), give two tablets by mouth one time a day for bowel care.
During medication administration observation on 02/12/2024 at 7:47 AM, Licensed Vocational Nurse (LVN) #2 administered two senna 8.6 mg tablets to Resident #75.
During an interview on 02/12/2025 at 12:43 PM, LVN #2 stated she gave plain senna tablets that did not contain docusate sodium to Resident #75. LVN #2 stated she should have checked the label of the medication with the order.
During an interview on 02/13/2025 at 12:53 PM, the Director of Staff Development stated that when administering medications, the nurse should recognize the five rights, to include the right resident, route, medication, dose, and time, and should check the physician's order three times.
During an interview on 02/13/2025 at 1:15 PM, the Director of Nursing (DON) stated that when administering medications, the nurse should review the physician's order and do the five rights with each medication three times. Per the DON, the nurses should have followed the physician's orders to give the correct medication to the resident.
During an interview on 02/13/2025 at 1:42 PM, the Administrator stated he deferred all nursing concerns to the DON.
Jan 2025
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
Deficiency F0583
(Tag F0583)
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 right to personal privacy for one of five s...
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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 right to personal privacy for one of five sampled residents (Resident 1), when patient care was provided to Resident 1 without privacy being provided.
This failure had the potential to cause distress and embarassment for Resident 1 by having other residents watching and knowing her
medical problems.
Findings:
A review of the facility's, policy titled Restorative Nursing Services, dated July 2017 indicated, 5. Restorative goals may include, but are note limited to supporting and assisting the resident in: c. Maintaining his/her dignity .
A review of Resident 1's admission Record , indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory and ability to make sound decisions), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), and diabetes (high sugar in the blood).
During an observation on 1/17/25 at 12:08 PM in the dining room, Licensed Nurse A (LN A) entered the resident's dining room and checked Resident 1 ' s blood sugar by pricking her finger and using a glucometer (a devise used to measure blood sugar level) at the dining table, while other residents were at the table.
During an observation on 1/17/25 at 12:13 PM in the dining room, LN A entered the dining room and gave Resident 1 an insulin (a biological product to treat blood sugar disease) shot at the dining table, with other residents at the table.
During an interview on 1/23/25 at 11:32 AM, with the Infection Control Nurse (IP), the IP confirmed that checking blood sugar and giving insulin in the dining room did not meet the facility ' s standard practices for ensuring patient privacy and dignity.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 infection control measures were adhered to whe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control measures were adhered to when Licensed Nurse A (LN A) provided patient care in the dining room without following infection control policy and procedures. These failures had the potential to cause the spread of infection and disease to other residents in the dining room.
Findings:
A review of the facility's, policy titled, Infection Prevention and Control Program dated August 2016 indicated a. Important facets of infection prevention include: (2) instituting measures to avoid complications or dissemination (spread) and .adhere to proper techniques and procedures.
A review of Resident 1's admission Record , indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (loss of memory and ability to make sound decisions), cognitive communication deficit (an impairment in thought organization, attention, memory, problem solving, and safety awareness), diabetes (high sugar in the blood).
During an observation on 1/17/25 at 12:08 PM, in the dining room, LN A entered the dining room and checked Resident 1 ' s blood sugar by pricking her finger with a lancet (a small, sharp needle used to prick the skin to obtain a blood sample) and using a glucometer (a devise used to measure blood sugar level) at the table.
During an observation on 1/17/25 at 12:13 PM, in the dining room, LN A entered the dining room and gave Resident 1 insulin (a biological product to treat blood sugar disease) using an insulin syringe (a short thin needle used to inject insulin into the body) at the table.
During an interview on 1/23/25 at 11:32 AM, with the Infection Control Nurse (IP), the IP confirmed that checking blood sugar and giving insulin in the dining room did not meet the facility ' s infection control policy or standard practices.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety whe...
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Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when:
1. Dietary Manager (DM) was not wearing a hair net in the kitchen.
2. Food was not properly covered, labeled and dated.
These failures created a potential risk for exposure to foodborne illnesses in a medically vulnerable population of 110 residents who received food prepared in the kitchen.
Findings:
1. During review of facility Policy & Procedure (P&P) titled Kitchen Cleaning Policy and Procedures, 4/20/23, the P&P indicated food employees shall wear hair restraints such has hair nets.
During concurrent observation and interview with the DM on 1/16/25 at 10:20 AM, the DM was not wearing a hair net in the kitchen. The DM confirmed that she should be wearing a hair net while in the kitchen.
2. During review of facility Policy & Procedure (P&P) titled, Procedure for Refrigerated Storage, no date, the P&P indicated food items will be covered, labeled, and dated.
During concurrent observation and interview with DM on 1/16/25 at 10:23 AM, in the walk-in refrigerator the DM confirmed that there were two pans containing cranberry bars which were not covered, labeled, and dated.
Jun 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 that one of five sampled residents (Resident 2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of five sampled residents (Resident 2), received assistance with activities of daily living (ADLs) to attain or maintain their independence when routine and scheduled showers and bathing were not completed.
This failure had the potential to result in Resident 2 feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.
Findings:
A review of the facility's policy revised 2/2018, titled, Bath, Shower/Tub, indicated the purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. This facility's policy also indicated to Notify the supervisor if the resident refuses the shower/tub bath.
A review of the facility's policy revised 2/2021, titled, Dignity, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. This facility's policy also indicated residents are treated with respect and dignity at all times, and individual needs and preferences of the resident are identified through the assessment process.
During a review of Resident 2's medical record, the admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur (broken thigh bone), diabetes (a disease when too much sugar is in the blood), high blood pressure, heart disease, acquired absence of kidney, and dependence on renal (kidney) dialysis (removes toxins from the blood).
During a review of Resident 2's care plan, a focus dated 4/2/24 indicated Resident 2 had a potential/actual impairment to skin integrity, and this care plan indicated an intervention for staff to Keep skin clean and dry, use lotion on dry skin to maintain or develop clean and intact skin by 6/14/24/24. This care plan dated 4/2/24 also indicated, Resident 2 has an ADL (activities of daily living are hygiene, toileting, grooming, bathing, and eating) deficit, and needs assistance.
A Review of Resident 2's Minimum Data Set (MDS, a resident tool assessment) dated 4/8/24, indicated Resident 2 required maximal assistance assist during activities of daily living such as transfers in and out of bed and bathing. Resident 2 had a BIMS (brief interview for mental status) score of 8, indicating Resident 2 with a severe impairment and was not competent to make his own decisions.
During a review of Resident 2's medical record dated 4/2024 and 5/2024, a document titled, Documentation Survey Report v2, indicated indicated Resident 2 had one shower from 4/1/24 through 5/29/24, and this shower was completed and documented on 5/9/24. This document also indicated no refusals of baths or showers were documented.
During an interview on 6/21/24 at 4:10 pm, the Director of Nursing (DON) confirmed Resident 2 only had one shower for the entire months of April 2024, and May 2024. DON stated, This resident is fragile, and the showers help with skin assessments needed. I confirm the showers should have been completed, even if we had to change days to accommodate dialysis schedule.
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 F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and the facility's policy, the facility failed to complete assessments and add pertinent inte...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and the facility's policy, the facility failed to complete assessments and add pertinent interventions on the care plan developed for one of three residents, (Resident 2) requiring renal (kidney) dialysis.
This failure had the potential for re-hospitalization, and a negative clinical outcome.
Findings:
A review of the facility's policy revised 9/2010, titled, End-Stage Renal Disease, Care of the Resident with, indicated residents with end-stage renal (ESRD, kidney disease) will be cared for according to currently recognized standards of care. This policy also indicated staff caring for residents with ESRD, including residents receiving dialysis (removing toxins from the body) care outside the facility, shall be trained in the care and special needs of these residents. Number five of this policy indicated the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.
A review of Resident 2's medical record, the admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur (broken thigh bone), diabetes (a disease when too much sugar is in the blood), high blood pressure, heart disease, acquired absence of kidney, and dependence on renal (kidney) dialysis (removes toxins from the blood).
A Review of Resident 2's Minimum Data Set (MDS, a resident tool assessment) dated 4/8/24, indicated Resident 2 required maximal assistance assist during activities of daily living such as transfers in and out of bed and bathing. Resident 2 had a BIMS (brief interview for mental status) score of 8, indicated Resident 2 had a severe impairment and was not competent to make his own decisions.
A review of Resident 2's care plan, a focus dated 4/2/24 indicated Resident 2 had a problem listed for dialysis, and this care plan did not include post dialysis assessments, to include assessment of Resident 2's left arm fistula (a surgical procedure that creates a connection between an artery and vein for dialysis access) for bleeding, and for all staff to not obtain a blood pressure in the Left arm.
A review of Resident 2's Active Orders dated 5/28/24, indicated to remove pressure dressing to dialysis fistula site fours hours post treatment one time a day on every Monday, Wednesday, and Friday. These Active Orders, also indicated Resident 2 goes to a local dialysis center every Tuesday, Thursday, and Saturday which would indicate this dialysis order for dressing removal was prescribed for the wrong days for dressing removal.
During an interview on 6/24/24 at 12:30 pm, the Director of Nursing (DON) confirmed the facility did not follow their policy and procedure for dialysis care for Resident 2 and post dialysis assessments were not completed for Resident 2.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, and interview, the facility failed to clean the assistive devices used to transfer residents for five out of six mechanical lifts.
This failed action had the potential for the sp...
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Based on observation, and interview, the facility failed to clean the assistive devices used to transfer residents for five out of six mechanical lifts.
This failed action had the potential for the spread of infection to clients, staff, and visitors.
Findings:
A review of the facility's policy revised 7/2017, titled, Lifting Machine, Using a Mechanical, indicated the purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. This policy also indicated to wash and sanitize lift according to manufacturer's instructions, disinfect lift surfaces, wipe with a clean towel until dry.
During concurrent observations and interviews on 6/21/24 at 12:09 through 12:24 pm with Licensed Nurse (LN) 1, five out of six mechanical lifts were soiled with cumulative dust, sticky yellow and brown colored substances, dried food particles, and grime. LN 1 confirmed these lifts were not clean and could cause the spread of infection to other residents, staff, and visitors and needed to be cleaned as soon as possible.
During an interview on 6/21/24 at 12:30 pm, the Administrator (Admin) confirmed that five mechanical lifts were not clean. Admin stated, We use a contract outside agency for cleaning equipment, I will call the agency and get these lifts cleaned immediately. We take pride in our facility being clean, we may need to increase the days the lifts are cleaned to keep in order for use.
Jun 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
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to ensure professional staff were licensed in accordance with California state laws, when registered nurse (RN) 1 was employed from 11/2/23 t...
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Based on interview, and record review, the facility failed to ensure professional staff were licensed in accordance with California state laws, when registered nurse (RN) 1 was employed from 11/2/23 through 1/4/2024 without a valid registered nursing license issued by the Board of Registered Nursing
This failure had the potential to result in substandard quality of care to all the residents in the facility and negatively impact their quality of life and ability to attain or maintain their highest practicable level of physical, emotional, and psychosocial well-being.
Findings:
A review of the Employee Information Form, dated 11/2/23, indicated that RN 1 was hired full-time on the day shift with a date of hire of 10/30/23.
A review of the facility ' s job description titled RN-Charge Nurse, dated 11/2/23, indicated the position Must possess a current, unencumbered, active license to practice as an RN in this state. The primary purpose of the position was to provide direct nursing care to residents and to supervise day-to-day nursing activities, and to ensure that the highest degree of quality care is maintained at all times.
A review of the Application for Employment, dated 10/30/23, indicated that RN 1 presented a valid registered nursing license number.
A review of the California Board of Registered Nursing-Licensing Details indicated the license number provided by RN 1 was verified by the facility on 11/21/23.
A review of RN 1 ' s Employment Eligibility Verification Form, indicated that the documents provide by RN 1, to verify her identity, did not match the information on the Registered Nursing-Licensing Details. The RN license was registered to an individual with a similar name; however, the first name was spelled differently, and the middle name was not the same.
During an interview on 6/14/24 at 12:40 pm, with the Director of Nursing (DON), the DON confirmed that RN 1 was not licensed, and she had missed this verification upon hire. DON confirmed the error of the spelling of RN 1's first name, and confirmed she did not check the middle name for validity. DON stated, I will never let this happen again, I will triple check to make sure the license verification is accurate.
A review of the Change in Relationship Form, dated 1/5/24, indicated that RN 1 ' s employment was terminated with the facility.
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
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 observation, interview and record review, the facility failed to follow the skin assessment care plan and monitor the s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the skin assessment care plan and monitor the skin condition for one of 3 sample Residents (Resident 1). This failure resulted in Resident 1 did not have skin assessment and wound care treatment until 2 days after his re-admission and had the potential to contribute to wound infection.
Findings:
A review of Resident 1's admission record, indicated he was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a problem in the brain. It is caused by a chemical imbalance in the blood), Alcoholic Cirrhosis (Cirrhosis is scarring of the liver caused by long-term liver damage after many years of heavy drinking. The scar tissue prevents the liver working properly) of Liver with ascites (the build-up of fluid in the space between the lining of the abdomen and abdominal organs), diabetes (elevated blood sugar), and difficulty in walking. Resident 1 was transferred to the local hospital on 7/31/2023 for vomiting blood, he was readmitted to the facility on [DATE] with diagnoses which included esophagitis (Inflammation that damages the tube running from the throat to the stomach) with bleeding, and abdominal pain. He was his own health care decision maker.
A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered , revised 3/2022, indicated that The comprehensive, person-centered care plan reflects currently recognized standards of practice for problem areas and conditions , and Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .
A review of Resident 1's care plan, initiated on 5/26/2023, revised on 8/4/2023, indicated that the skin plan was to anticipate skin breakdown secondary to: generalized weakness, liver cirrhosis, diabetes . , and the interventions/tasks included Daily skin inspection during care: Notify Licensed Nurse (LN) of skin integrity impairments .
A review of Resident 1's progress note, dated 8/2/2023 at 4:20 pm, indicated that Resident 1 was readmitted to the facility at 3:30 pm from the hospital. There's no note indicated that Resident 1 had skin issue on his left big toe.
A review of Resident 1's Weekly Skin Alteration Report , dated 8/4/2023 at 12:16 pm, indicated that Resident 1 had a new Non-pressure area on the left great toe with discoloration , and the Date of First Observance was on 8/4/2023. The size of wound was 1 centimeter x 1.2 centimeter . The Assessment/Care plan Summary indicated that Patient returned from hospital and was noted to have a new area of concern on the left great toe that was no noted prior. The tip of the left great toe is black in color with surrounding erythema noted. MD notified and ordered bilateral lower leg arterial dopplers (an imaging test to check the blood flow in the arteries in the legs) .
A review of Resident 1's Skin/Wound progress note, dated 8/4/2023 at 12:20 pm, indicated that Resident 1 was noted to have a new area of concern on the left great toe that is black in color with surrounding area blanching erythema . there's no Skin/wound assessment on the day, 8/2/2023, Resident 1 was readmitted back to the facility.
A review of Resident 1's physician order, Left great toe: Paint with betadine every day on every dayshift , dated 8/4/2023, started on 8/5/2023, 3 days after the resident was readmitted .
During a concurrent observation and interview on 8/9/2023, at 3:03 pm, Resident 1's left great toe appeared to be swollen with redness, and a 1 cm x 1 cm black area presented at the tip of the toe. Resident 1 stated that he bumped himself but could not recall where and when it happened.
During a concurrent interview with the Administrator (ADMIN) and Assistant of Director of Nursing (ADON) and record review on 8/9/2023 at 3:27 pm, ADMIN stated that Resident 1 was re-admitted with a skin abrasion on his left big toe. ADON admitted that there's no skin assessment record could be located on the day Resident 1 was readmitted and she stated that The admitting nurse should do the entire assessment, including skin assessment . It should be done on 8/2/2023 .
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the most recent care plan for one of two 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 follow the most recent care plan for one of two residents (Resident 1) to provide one on one checks per physician orders for safety after a recent suicide attempt.
This failure had the potential to cause Resident 1 physical and psychosocial harm.
Findings:
A review of the facility's policy titled Depression-Clinical Protocol revised 11/2018, indicated number 2, The nurse shall assess and document/report the following: Vital signs, description of affect, level of activity and responsiveness, whether mood decline is associated with anorexia, (not eating), crying and sleeplessness; pain assessment, suicidal ideation, (If present, follow facility policy/protocol for suicide threats).
A review of the facility's policy titled Suicide Threats dated 12/2007, indicated resident suicide threats shall be taken seriously and addressed appropriately. Number seven stated, If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present.
A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised 3/2022, indicated Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation including the right to receive the services and/or items included in the care plan.
During a record review of a document titled, Care Plan revised [DATE], indicated new interventions for new problem, Resident 1 had mood problem and verbalized want to self-harm, as well as engaged in actual self-harm, cutting behavior. One on one supervision to be provided for increased visual accountability of safety and wellness of patient. Every fifteen-minute checks for safety, daily visits daily with DSS for 72 hours, and longer if indicated.
A review of a document titled Individual Progress Note dated [DATE] from a local hospital for Crisis evaluation indicated Resident 1 was being evaluated for danger to self, following [Resident 1] engaging in cutting behavior, he has a superficial cut to the left wrist.
Resident 1 was admitted to the facility on [DATE] for diagnoses that included repeated falls, injury of the head, and major depressive disorder (a persistently low or depressed mood that causes a sense of loss and sadness, and anxiety (feeling of uneasiness, worry and fear of everyday life).
During a record review for Resident 1, a document titled Minimum Data Set (MDS, a resident assessment), dated [DATE] indicated Resident 1 had a slight cognitive impairment, (ability to think, reason, and recall) with a Brief Interview Mental Status score of 10.
During a record review for Resident 1, a document titled Social Service Note dated [DATE], indicated Follow up to recent event: Resident 1 self-harming by cutting wrist causing a superficial laceration.
During an interview on [DATE] at 7:30 am, Licensed Nurse (LN) A stated, Yes, Resident 1 is still on every fifteen-minute checks related to a suicide attempt.
During an observation on [DATE] at 7:45 am through 8:45 am, no fifteen minutes were completed for Resident 1 from any staff members, which was in the updated care plan for safety.
During an observation on [DATE] at 7:35 am, Resident 1 was eating breakfast while sitting on the side of the bed. Left wrist had a Band-Aid with dried, dark red colored substance.
During an interview on [DATE] at 7:50 am, Resident 1 (tearful) stated, Yes, I am sad. My wife died a couple of months ago; she was my wife for over 60 years. I feel so lost without her, just lost. I miss her, I met my wife in grade school. I was supposed to go home after rehab. I tried to cut my wrist, but all I had was a butter knife. Resident 1 confirmed left wrist Band-Aid had dried blood from cutting his wrist.
During an interview with the physician on [DATE] at 8:20 am, the physician confirmed every fifteen-minute checks should be completed on Resident 1 for safety related to recent self-harm attempt on [DATE], and recent hospitalization for suicide attempt.
During a follow up interview on [DATE] at 8:30 am, Resident 1 stated, I am so sad, I miss my wife, tearful at intervals. No one understands, my wife was my best friend, I was supposed to go home and not live here. I don't want to hurt my son, but I am just lost. I can't stop feeling this way.
A document titled Safety Check log for Resident 1, undated indicated no fifteen-minute checks were completed for 8:00 am, 8:15 am, 8:30 am and 8:45 am on [DATE]. These time periods were blank and no initials.
During an interview on [DATE] at 9:10 am, Director of Nursing (DON) stated, Yes, I was called about Resident 1 and came in on a Holiday and updated the care plan to complete every fifteen-minute checks. The staff should be doing every fifteen-minute checks, the Certified Nursing Assistants, (CNA) should be getting verbal reports from the nurses.
During a record review of Resident 1's medical record a document titled Physician Verbal Order , dated [DATE] at 9:21 am, indicated One on one for resident, 24 hours a day, every shift, for observation for three days, 24 hours a day for 72 hours.
During an interview on [DATE] at 9:56 am, the Director of Social Services stated, I knew Resident 1 had not been paid by the Veteran's Administration (VA) for 90 days and he was upset his money was late. I did not know his wife had passed. I will call the VA back to find out if they are working on it.
During an interview on [DATE] at 10:35 am, CNA B stated, From my understanding, I thought it was me and the nurse doing the checks on Resident 1, not just me. I did not get report from the nurse this morning, I was running late.
During an interview on [DATE] at 11:30 am, the Administrator confirmed Resident 1 had 24-hour supervision effective 10:00 am [DATE] for three days per physician order and a new appointment was made for the VA to evaluate depression.
During an interview on [DATE] at 11:35 am, the Director of Nursing (DON) confirmed Resident 1's care plan was revised, but not followed by staff. DON also confirmed the fifteen-minute checks were not completed on [DATE] from 8:00 am to 8:45 am, and the recording log was blank for those time frames. DON confirmed the nurse did not give report or communicate to the CNAs on [DATE] on the hall for safety, supervision of Resident 1.
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
Report Alleged Abuse
(Tag F0609)
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 direct care and administrative staff reported a...
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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 direct care and administrative staff reported allegations of staff to resident abuse to the mandated agencies for one of two sampled residents (Resident 1).
This had the potential to put all residents at risk for abuse from staff at the facility.
Findings:
A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Identify and assess incidents of abuse. Investigate and report any allegations for abuse within the timeframes as required by federal requirements. Protect residents during the abuse investigations.
A review of facility policy revised April 2012, titled, Recognizing Signs and Symptoms of Abuse/Neglect indicated abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish. Signs of actual physical abuse are welts and bruises, abrasions or lacerations, and black eyes.
Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling.
A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss.
A review of Resident 1's medical record a document dated 6/3/23 titled Progress Note, indicated Certified Nursing assistant reported a bruise to coccyx for Resident 1, MD notified and monitor until resolved.
A review of Resident 1's medical record a document dated 6/4/23 titled Change in Condition Progress Note, indicated Resident 1 up in wheelchair and noticed a dark bluish bruise around Resident 1's right eye, Also bluish bruise on Resident 1's left wrist, updated MD and Responsible party.
A review of Resident 1's medical record, a document dated 6/8/23, titled Interdisciplinary Team (IDT) Review of Skin alteration, indicated Resident 1 was found on 6/4/23 by the am staff to have a purple discoloration to her medial eye socket of the right eye. There is also a purple discoloration on the left dorsal wrist. IDT met and determined that the cause for the bruise could be anti-coagulant therapy, (use of blood thinners for heart disease). Also, Resident 1 is noted to prefer to sleep on her right side, often holding onto the quarter rail and leaning her head on the rail.
A review of Resident 1's medical chart indicated no mandatory reporting or investigation documentation of new blue discolorations for Resident 1's right eye, left wrist and coccyx area through 6/13/23.
During an interview on 6/13/23 at 11:50 am, the administrator (Admin) confirmed the allegation of abuse to Resident 1 from an employee was not reported to CDPH and stated, I was here on Monday 6/5/23 and saw the bruising to Resident 1's eye but thought since we removed the bedrail I did not have to report. Admin confirmed etiology, (cause) of bruises are still unknown and the facility staff was not sent home for an investigation to be completed for allegations of abuse to Resident 1.
During an interview with the Director of Nursing (DON) on 6/13/23 at 12:10 pm. DON stated, We did not send a report to California Department of Public Health (CDPH) for Resident 1's bruising of Right eye and left wrist. The staff accused of alleged abuse to Resident 1 was not in the building on 6/4/23. I think the bruising was from the bed rail. No, I cannot say for certain.
During an interview on 6/13/23 at 12:50 pm, the DON and Admin confirmed they were aware of the allegations of Employee to Resident abuse because the California Board of Registered Nursing (BRN) had emailed and called the DON to obtain information and update the facility an allegation had been filed against an employee. DON stated, BRN would inform me how to proceed with options to protect the staff and residents. We were emailing back and forth and talking on the phone.
During an observation on 6/13/23 at 3:10 pm, Resident 1 was lying in bed, severe bruising noted to right periorbital (around the eye) area, three small bruises on the left wrist, no bruising area noted to the coccyx. Resident 1 also had two new bruises, dark purple areas, not documented to the right top of forehand, and upper right arm.
During an interview on 6/13/23 at 3:20 pm, Registered Nurse (RN) B stated, I could not determine what could have happened to Resident 1, that is why I was calling the staff, no one reported the bruising to me. I did not report or fax CDPH, when I called the DON and she said they would follow up on it.
During a follow up interview on 6/13/23 at 3:25 pm, RN B also confirmed two new dark purple bruises on Resident 1, one large purple area covering the top of right hand, the other dark purple bruise on the upper right arm. RN B stated, No I did not see those new bruises, I will go tell the Admin now.
During an interview on 6/13/23 at 3:45 pm, RN A stated, I thought Resident 1's bruising was going to be reported or I would have. There are fax forms at all the nurses' stations. I do not think this bruising was handled right, they should have reported it, we are all mandatory reporters.
During an interview on 6/13/23 at 4:02 pm, the ADON stated, I had no idea I was being accused of abuse, I just found out today. I did bring up the bruising of Resident 1 to her right eye, left wrist, and coccyx at Interdisciplinary Team (IDT) meeting, and there was no known cause at the time it was reported by RN B.
During an interview on 6/13/23 at 4:32 pm, the Director of Staff Development stated, I heard about the bruising to Resident 1 from the Admin. Should I have reported it? I teach the staff to report, without the Admin if needed.
During a follow up interview on 7/12/23 at 3:40 pm, the Admin and DON confirmed the alleged abuse should have been reported to CDPH and all entities per abuse policy, and the resident should have been protected while this allegation was investigated. The DON stated, I will make sure moving forward all this is completed as well as the five day follow up report. I will work together with the Admin to meet the time frame per policy.
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 ensure allegations of staff to resident abuse were investigated and ...
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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 allegations of staff to resident abuse were investigated and residents were protected during this process for one of two residents (Resident 1).
This put all residents at risk for staff to resident abuse.
Findings:
A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Protect residents during the allegation of abuse investigations.
A review of facility policy revised April 2012, titled, Recognizing Signs and Symptoms of Abuse/Neglect indicated abuse is defined as willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish. Signs of actual physical abuse are welts and bruises, abrasions or lacerations, and black eyes.
Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling.
A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss.
A review of Resident 1's medical record a document dated 6/3/23 titled Progress Note, indicated Certified Nursing assistant reported a bruise to coccyx for Resident 1, MD notified and monitor until resolved.
A review of Resident 1's medical record a document dated 6/4/23 titled Change in Condition Progress Note, indicated Resident 1 up in wheelchair and noticed a dark bluish bruise around Resident 1's right eye, Also bluish bruise on Resident 1's left wrist, updated MD and Responsible party.
A review of Resident 1's medical record, a document dated 6/8/23, titled Interdisciplinary Team (IDT) Review of Skin alteration, indicated Resident 1 was found on 6/4/23 by the am staff to have a purple discoloration to her medial eye socket of the right eye. There is also a purple discoloration on the left dorsal wrist. IDT met and determined that the cause for the bruise could be anti-coagulant therapy, (use of blood thinners for heart disease). Also, Resident 1 is noted to prefer to sleep on her right side, often holding onto the quarter rail and leaning her head on the rail.
A review of Resident 1's medical chart indicated no mandatory reporting or investigation documentation of new blue discolorations for Resident 1's right eye, left wrist and coccyx area through 6/13/23.
During an interview on 6/13/23 at 11:50 am, the administrator (Admin) confirmed the allegation of abuse to Resident 1 from facility staff was not reported to CDPH and stated, I was here on Monday 6/5/23 and saw the bruising to Resident 1's eye but thought since we removed the bedrail I did not have to report. Admin confirmed etiology of bruises are still unknown and the alleged staff member was not sent home for an investigation to be completed for allegations of abuse to Resident 1.
During an interview on 6/13/23 at 12:50 pm, the DON and Admin confirmed they were aware of the allegations of facility staff member to Resident abuse because the California Board of Registered Nursing (BRN) had emailed and called the DON to obtain information and update the facility an allegation had been filed against an employee. DON stated, BRN would inform me how to proceed with options to protect the staff and residents. We were emailing back and forth and talking on the phone.
During an observation on 6/13/23 at 3:10 pm, Resident 1 was lying in bed, severe bruising noted to right periorbital (around the eye) area, three small bruises on the left wrist, no bruising area noted to the coccyx. Resident 1 also had two new bruises, dark purple areas, not documented to the right top of forehand, and upper right arm.
During an interview on 6/13/23 at 4:02 pm, the ADON stated, I had no idea I was being accused of abuse, I just found out today. I did bring up the bruising of Resident 1 to her right eye, left wrist, and coccyx at Interdisciplinary Team (IDT) meeting, and there was no known cause at the time it was reported by Registered Nurse (RN) B.
During a follow up interview on 7/12/23 at 3:40 pm, the Admin and DON confirmed any employee will be sent home to protect all residents until a thorough investigation has been completed to rule out any type of alleged abuse per facility abuse policy.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transfer one of two sampled residents, (Resident 1) safely using a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transfer one of two sampled residents, (Resident 1) safely using a Hoyer lift (a mechanical lift used to transfer residents) when one Certified Nursing Assistant left Resident 1 without a mat in place beside the bed while leaving the room.
This failure resulted in an avoidable accident when Resident 1 sustained a fall hitting her head, right shoulder, and right elbow.
Findings:
During a review of a policy revised March 2018, titled Falls, and Fall Risk, Managing, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.
During a review of a policy revised July 2017, titled Safe Lifting and Movement of Residents, indicated in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. This policy also indicated resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.
During a review of a policy revised July 2017, titled Accidents and Incidents, indicated incident and accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility, and to analyze any individual resident vulnerabilities.
Resident 1 was admitted to the facility on [DATE] for diagnoses that included dementia, heart disease, pain, and a history of falling.
A review of the Minimum Data Set (MDS, a resident assessment) dated 5/17/23, indicated for functional ability Resident 1 was totally dependent on staff for transfers and needed two assistants. Resident 1 had a severe cognitive impairment (unable to think and reason), unable to verbalize needs, and unable to recall events due to severe memory loss.
During a record review of Resident 1's medical record, a review of a care plan revised on 5/23/23 indicated Resident 1 is at risk for falls related to dementia, non-ambulatory, chronic pain and history of falls. This care plan also indicated Resident 1 is at risk for injury from falls related to anti-coagulant therapy (blood thinners) required for heart disease.
During a record review of Resident 1's medical record, a document dated 7/3/23 at 3:00 pm, titled Interdisciplinary Team Fall (IDT) Review, indicated Resident 1 had an unwitnessed fall out of bed in resident's room. Root cause indicated Certified Nursing Assistant (CNA) had removed mattress on floor beside bed and went to get the Hoyer lift for a transfer, when CNA returned with the Hoyer lift, the resident was found on the floor beside the bed.
During a record review of Resident 1's medical record, a document dated 7/3/23 titled Progress Notes, indicated CNA found Resident 1 at bedside on her right side, as Resident 1 was calling out.
During a record review of Resident 1's medical record, a document dated 7/4/23 at 9:50 pm, titled Progress Notes, indicated Resident 1 is on alert monitoring for a recent fall. Resident had a bluish bruise to the right temple area, also bruising noted to right shoulder and right elbow areas.
During a record review of Resident 1's medical record, a document dated 7/4/23 at 1:52 pm, titled Progress Notes, indicated Resident 1 had periorbital bruising and hematoma. Resident was found on night shift out of bed with bruising which later developed to hematoma above right eye.
During a record review of Resident 1's medical record, a document dated 7/5/23 indicated resident has bruising to right forehead, right shoulder, and right elbow related to a recent fall.
During an interview on 7/12/23 at 12:30 pm, the Director of Nursing confirmed Resident 1's fall was preventable and was due to the CNA not placing the mat beside the bed when he stepped out of Resident 1's room.
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with dignity and respe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 put her hand towards her face. This had the potential to result in a decline in her physical, emotional and psychosocial well being.
Findings:
On 3/10/23 at 3:40 pm, the California Department of Public Health received a report (via phone) that Resident 1 alleged CNA 1 called her disrespectful and put her hand up to her face. A follow up written report was faxed on 3/10/23 at 5:06 pm.
A review of Resident 1's record indicated she was admitted on [DATE], with diagnoses that included a stroke, morbid (severe) obesity, hemiplegia (inability to move one side of the body), diabetes, and anxiety disorder.
During an interview on 3/16/23 at 11:20 am, Resident 1 stated CNA 1 was across the hall helping another resident and she waved at her to get her attention because she needed to go to the bathroom. She said when CNA 1 came in the room she told me not to disrespect her that way then she waved her hand in my face. She said CNA 1 did not touch her face but her hand was right up in her face and she told CNA 1 to stop and started yelling for the nurse.
Further review of the record included an Interdisciplinary Team (IDT-group of healthcare disciplines that meet to discuss resident care needs) note, dated 3/14/23, which indicated on 3/10/23, Resident 1 reported a verbal altercation with CNA 1. The night shift nurse had over heard the altercation and removed CNA 1 from the room. Per policy, CNA 1 would receive appropriate disciplinary action and re-training.
During an interview on 4/27/23 at 12:45 pm, CNA 1 confirmed she wrote a statement on 3/9/23 at 11:48 pm. She said she asked Resident 1 to try not to wave and holler. CNA 1 said she stuck her hand out and said stop and did not realize her hand was in Resident 1's face who then swatted her hand away.
During an interview on 3/20/23 at 1:15 pm, Licensed Nurse (LN) 1 said she heard Resident 1 yelling so she went into the resident's room. Resident 1 said CNA 1 pulled on her and put her hand toward her face. LN 1 said she asked CNA 1 to leave the room and had another CNA take over that room.
The investigative report report provided by the adminstrator concluded there was not abuse but CNA 1 was unprofessional.
A review of the facility's policy, Resident Rights, dated 2/2021, indicated, Employees shall treat all residents with kindness, respect and dignity.
Mar 2023
20 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 issue complete and timely Beneficiary (a person who received Medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue complete and timely Beneficiary (a person who received Medicare insurance benefits) Notifications to three of 18 sampled residents (Residents 48, 50, and 77). This failure had the potential to prevent the residents from making informed decisions about their care which could have threatened their health and well-being.
Findings:
A review of Resident 48's record showed an original admission date of 8/7/21. Resident 48's diagnoses included cerebral infarction (a stroke), osteomyelitis left femur (infection of the left thigh bone), and chronic pain. Resident 48's representative assisting with healthcare decisions was Family Member (FAM) D.
Record review of Resident 48's Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) indicated, The Effective Date Coverage of Your Current MEDICARE A Services Will End: 2/2/23.
Record review of Resident 48's CMS Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) indicated, Beginning on 2/3/23, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. Care listed was, Skilled Nursing Room & Board. Reason Medicare May Not Pay was blank. Estimated Cost was blank. Information on the form directed the resident or RP to choose one of three options and check only one box; all boxes were unchecked. The line at the bottom of the page for Signature of Patient or Authorized Representative was blank.
A copy of a United States Postal Service (USPS) Certified Mail Receipt, undated, was reviewed. The receipt indicated an unspecified item had been sent to FAM D. A Postal Service Form 3811, Domestic Return Receipt, indicated the item had been delivered to FAM D on 2/11/23.
A review of Resident 48's record showed a General Note, dated 3/9/23, at 2:14 PM, by the Minimum Data Set Assistant (MDSA). MDSA wrote, Licensed Nurse (LN) spoke with resident wife (FAM D) regarding Resident 48 coming off Medicare. (FAM D) expressed that she would like to speak to the business office as she is confused on how the process works. This communication occurred five weeks after Resident 48's Medicare A coverage ended.
A review of Resident 50's record showed admission to the facility on 8/13/21. Resident 50's diagnoses included diabetes mellitus (a disorder of blood sugar regulation), myocardial infarction (heart attack), and pulmonary fibrosis (scarred lung tissue). Resident 50's RP assisting with healthcare decisions was FAM B.
Record review of Resident 50's CMS NOMNC indicated, The Effective Date Coverage of Your Current Medicare A Services Will End: 12/9/22.
Record review of Resident 50's CMS SNFABN indicated, Beginning on 12/10/22, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. Care listed was, Skilled Nursing & Therapy Services. Reason Medicare May Not Pay, indicated that Resident 50 had met all goals and no longer required nursing services. None of the three options were checked and the signature line was blank.
A copy of a USPS Certified Mail Receipt, undated, was reviewed. The receipt indicated an unspecified item had been sent to FAM B.
A review of Resident 50's record showed a General Note, dated 3/9/23, at 2:16 PM, by MDSA. MDSA wrote, LN spoke with Resident 50 son (FAM B) regarding his mother coming off Medicare in November. Resident [sic] stated 'he will take care of it, have a nice day.' He then hung up. This communication occurred three months after Resident 50's Medicare A coverage ended.
A review of Resident 77's record indicated they were originally admitted to the facility on [DATE]. Resident 77's diagnoses included Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought and mood), repeated falls, and dementia (a mental disorder that caused memory loss and confusion).
Resident 77's RP assisting with healthcare decisions was FAM C.
Record review of Resident 77's CMS NOMNC indicated, The Effective Date Coverage of Your Current MEDICARE A services will end: 12/24/22.
Record review of Resident 77's CMS SNFABN indicated, Beginning on 12/23/22 (one day prior to the date indicated on the NOMNC form), you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. Care listed was, Skilled Nursing Room & Board. Reason Medicare May Not Pay was blank. Estimated Cost was blank. None of the three option boxes were checked. The signature line was blank, but there was a handwritten date of 12/21/22.
A copy of a USPS Certified Mail Receipt, dated 3/9/23, was reviewed. The receipt indicated an unspecified item had been sent to FAM C.
A review of Resident 77's record showed a General Note, dated 3/9/23, at 2:19 PM, by MDSA. MDSA wrote, Spoke with Resident 77 RP (FAM C) regarding (Resident 77) coming off Medicare in December. RP thanked me for the call. This communication occurred two and one-half months after Resident 77's Medicare A coverage ended.
During a concurrent interview and record review, on 3/9/23, at 2:45 PM, the Business Office Manager (BOM) responded to a request for documentation and/or progress notes about the Beneficiary Notifications given to Residents 48, 50 and 77. BOM stated there were no progress notes available and the residents and their RPs hadn't been notified until today. BOM provided progress notes about telephone calls made to the RPs today by MDSA.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an accurate and complete assessment for one of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an accurate and complete assessment for one of five sampled residents (Resident 68) when an assessment dated [DATE] documented that vision was adequate and no activity assessment after admission.
These failures had the potential for staff to not be fully informed of his health status, to determine the need for further assessment and interventions that could result in delays in care and decline in resident's condition.
Findings:
The facility policy and procedure titled, Comprehensive Assessments, revised 3/2022 indicated that comprehensive assessments are conducted to assist in developing person-centered care plans and also in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) manual.
a. Resident 68 was originally admitted to the facility on [DATE] and re-admitted on [DATE]/23 with diagnoses that included dementia with behavioral disturbances and with repeated falls. Resident 68 was alert, able to verbalize self but with confusion and had no capacity to make health care decisions.
A review of the most recent Minimum Data Set (MDS-a resident assessment), dated 2/8/23 indicated, Resident 68 had adequate vision and no corrective lenses such as glasses.
A review of the Social Service assessment dated [DATE] indicated that Resident 68 marked as having eye glasses.
During an interview with Resident 68 on 03/9/23 @ 8:40 AM, stated he had macular degeneration (eye disease that causes vision loss). Resident 68 stated he was unable to see people's face but only color of the clothes. Resident 68 stated wearing eye glasses helped a little bit.
During a concurrent interview and record review with the MDS Nurse Assistant (MDSA) 1 on 3/9/23 at 10:25 AM, she was not made aware that Resident 68 used corrective lenses such as eye glasses. MDSA 1 confirmed that the MDS assessment was not accurate.
During an interview with the Resident Representative (RR) on 3/9/23 at 4:10 PM, stated that Resident 68 was legally blind and that he had worn glasses. RR further stated that a care conference was held a month ago with RR being present and that the facility should made aware of the situation. RR further stated that wearing eye glasses helped a bit.
The facility's policy and procedure titled, Electronic Transmission of the MDS, revised 9/2010, directed the MDS Coordinator to ensure that appropriate edits are made prior to transmitting MDS data.
b. The facility policy and procedure titled, Comprehensive Assessment, revised 3/2022, directed facility staff that for admission assessment, is a comprehensive assessment for a new resident and, under some circumstances, a returning resident must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: the resident has been admitted to the facility and was discharged return not anticipated or the resident has been admitted and was discharged return anticipated and did not return within 30 days of discharge.
During a concurrent interview and record review with the Activities Director (AD) on 3/9/23 at 9:45 AM, she discussed about her job duties. Part of it was to ensure activity assessment should be done every new admission, quarterly, change of condition and annually. AD confirmed there was no activity assessment done since Resident 68 was re-admitted on [DATE]. The last assessment done was on 8/21/22.
During a concurrent interview and record review with the MDS Coordinator on 3/9/23 at 2:15 PM, stated that assessments should be done during new admission, quarterly, change of condition and annually. She confirmed that there was no record indicated that activity assessment was done after Resident's admission on [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure accurate documentation with specific psychiatric (mental health illness) diagnosis for the use of mind-altering drug ca...
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Based on observation, interview and record review, the facility failed to ensure accurate documentation with specific psychiatric (mental health illness) diagnosis for the use of mind-altering drug called quetiapine (also known as Seroquel, a medication used to treat mental illness) in one out of 18 sampled residents (Resident 40).
This failure may pose unsafe medications use in the facility with inconsistent diagnosis.
Findings:
During a concurrent interview and observation of Resident 40, in her room, at [NAME] station, on 3/9/23, at 10:30 AM, accompanied with Certified Nurse Assistant (CNA) C, Resident 40 was in bed, eyes closed and then opened her eyes starring randomly with face in distress, she held her hands to the face and kept moving in her bed. CNA C stated Resident 40 needed total assistance for daily care, and she was in bed most of the time. CNA C stated Resident 40's verbal response was mostly Yes or No, Stop that or Don't do that.
During an interview with Licensed Nurse (LN) B, who was Resident 40's nurse, at [NAME] station, on 3/9/23, at 11:02 AM, LN B stated Resident 40 was a total care, not ambulating (not walking) and vocalizing mostly stop it as if someone hurting her. LN B stated Resident 40 had PTSD (or Post-traumatic stress disorder, a mental health problem after experiencing traumatic events) and dementia. LN B confirmed that PTSD diagnosis was not in the electronic medical record. LN B stated he didn't think Resident 40 had schizophrenia (type of mental illness with hearing voices or seeing unreal things) and she was no danger to anyone.
During a review of Resident 40's medical record titled, Medication Administration Record ( MAR, document listed doctor's orders and documented medication use and monitoring), with date range of 3/1/23 to 3/30/23, the MAR indicated a doctor's order for a mind-altering drug as follow:
Quetiapine (or Seroquel) .Tablet: Give 125 mg (mg is unit of measure) by mouth in the evening related to UNSPECIFIED PSYCHOSIS . AEB (As Exhibited By) hitting herself and pulling out her hair. Give with dinner. -Order Date- 7/5/19.
Review of Resident 40's medical record under Care Plan (Plan of care for nursing care), with revision date of 10/14/20, the care plan for use of mind-altering medication indicated Resident 40 [redacted] uses ANTIPSYCHOTIC medications (Seroquel) r/t (related to): Dementia with psychosis. Resident 40 pinches herself and pulls her hair out. She yells out non-stop . Reorient and redirect Resident 40 with gentle touch when she is reliving being sexually and physically abused by .
Review of the Resident 40's medical record under MDS Records (Minimum Data Set- resident assessment), dated 2/9/23, the MDS report on section I, under active diagnosis for Neurological (nerve related) diseases was not marked for dementia (forgetfulness with or without behavior issues) type diagnosis. Further review of the MDS report on Section I, under active diagnoses for psychiatric/mood disease, the record indicated Anxiety Disorder, Depression, Psychotic Disorder, Schizophrenia (e.g., schizoaffective . disorders) . as active diagnosis.
Review of Resident 40's medical record on past hospitalization for psychiatric condition titled, Discharge Summary, dated 7/5/2019, the record from Mental Hospital (MH) A, indicated a discharge diagnosis of: Dementia, probable Alzheimer's type (a type of profound forgetfulness), early onset, with behavioral disturbance.
Review of Resident 40's electronic medical record titled, Diagnosis Report, dated 3/8/23, the record listed resident's diagnosis and the onset. The report indicated Primary Diagnosis (main diagnosis number 1) as unspecified Psychosis . with onset date of 2/20/19, and diagnosis number 9 as schizoaffective disorder . with onset date of 4/29/20. The record did not include any dementia diagnosis.
During a telephone interview with Resident 40's family member as Resident's Representative (RR) 1, on 3/9/23, at 12:30 PM, the RR 1 stated Resident 40 was diagnosed with dementia after hospitalization at a mental hospital. RR 1 stated she was never told if Resident 40 had a schizophrenia diagnosis.
During a telephone interview with Medical Doctor (MD) 1on 3/9/23 at 1:49 PM, MD 1 stated Resident 40's diagnosis was listed in her face sheet (referring to the medical record information sheet) and the schizoaffective disorder was diagnosed in an out of state hospital. MD 1 stated nothing had changed in terms of diagnosis for a long time. MD 1 stated he could not recall when she was diagnosed, and the resident had no memory of past trauma.
During an interview with facility's MDS Coordinator (ADON/MDS) on 3/9/23 at 2:15 PM, ADON/MDS stated for all new admissions to the facility, the doctor's notes, history and discharge summary were reviewed for accurate diagnosis documentation. ADON/MDS stated the top 10 diagnostic codes were entered in the MDS data. ADON/MDS stated her team also reviewed the doctor's notes for current residents for quarterly MDS update.
Review of the MD 1's note in paper format titled, History & Physical, dated 2/10/23, the note indicated a history of . Dementia, psychosis, anxiety .
Review of the MD 1's note in paper format titled, History & Physical, dated 3/8/23, the note indicated a history of . Dementia, psychosis, anxiety .
Review of the facility policy titled, Antipsychotic Medication Use, last revised in 7/2022, indicated, Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. The policy on section 9 indicated, Residents diagnosis is based on a comprehensive assessment and evidence-based criteria and is consistent with professional standards, such as the Diagnostic and Statistical Manual of Mental Disorder (current edition) [or DMS-5, published in March 2022; a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria].
Review of the facility's policy titled, Care Planning- Interdisciplinary Team, (team meeting with all health care providers and resident/resident's representative on how to plan an individualized care), last revised on 9/2013, the policy on section 3 indicated, The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revision to resident's care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
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 complete Discharge Plan for one of 18 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 complete Discharge Plan for one of 18 sampled residents (Resident 77). This failure had the potential to prevent a smooth and safe transition for Resident 77 from the facility to the community.
Findings:
A facility policy titled, Discharge Summary and Plan, revised 12/1/16, was reviewed. The policy indicated that when a resident's discharge was anticipated, a post-discharge plan would have been developed to assist the resident to adjust to their new living environment. Every resident would have been evaluated for their discharge needs and would have an individualized post-discharge plan. The post-discharge plan would have been developed by the care planning/interdisciplinary team (IDT-a group of professionals from different disciplines that met to discuss the residents' care) with the assistance of the resident and their family and would have included: where the individual planned to reside; arrangements that had been made for follow-up care and services; a description of the resident's stated discharge goals; the degree of caregiver/support person availability, capacity and capability to perform required care; how the IDT would have supported the resident or representative in the transition to post-discharge care; what factors may have made the resident vulnerable to preventable readmission; and how those factors would have been addressed. The discharge plan would have been re-evaluated based on changes in the resident's condition or needs prior to discharge. A member of the IDT would have reviewed the final post-discharge plan with the resident and family at least 24 hours before the discharge was to take place. A copy of the post-discharge plan would have been provided to the resident and receiving facility and a copy would have been filed in the resident's medical record.
A job description, titled, Director of Social Services, revised 11/1/10, was reviewed. Among the responsibilities of the Social Services Director (SSD) listed was to develop preliminary and comprehensive assessments of the social service needs of each resident. Additionally, the SSD was to develop a written plan of care for each resident that identified the social problems/needs of the resident and goals to accomplish for each problem identified, and to develop and maintain a community and social services referral file of agencies and organizations that provided assistance to residents.
A review of Resident 77's record indicated they were originally admitted to the facility on [DATE]. Resident 77's diagnoses included Parkinson's disease (a chronic disease of the central nervous system that affected movement, thought and mood), repeated falls, and dementia (a mental disorder that caused memory loss and confusion).
A review of a Multidisciplinary Care Conference note from Resident 77's record, dated 12/19/22, indicated the time stamp read, 01:30, with no AM or PM noted. Per the 24-hour (military time) clock, 01:30 without any other notation would have been the equivalent of 1:30 AM. To demonstrate a pattern of how these times were recorded in the electronic health record (EHR), another Multidisciplinary Care Conference note from Resident 77's EHR displayed the date and time, 2/21/23 at 14:05, which was the equivalent of 2:05 PM (not written as 02:05). Under the, Attendance at Meeting section were boxes checked for Social Worker, Activation [sic], and Nursing Administration. No names accompanied the titles. Under the, Nursing Summary section was a note that indicated Resident 77, expressed some concerns related to her D/C (discharge) plan. SS intervened and was able to offer suggestions. Under the Social Work Summary section was the note, Patient voiced concerns about D/C plan counseled by SSD. The note was electronically signed by the Social Services Assistant (SSA).
During a concurrent interview and record review, on 3/9/23, at 1:20 PM, SSD confirmed the Multidisciplinary Care Conference note from 12/19/22 at 1:30 AM was created by the SSA. Two Social Service Bundle assessments-WH-Copy, notes, dated 12/23/22 at 9:36 AM, one for D/C Planning and one for Psychosocial assessment, were also done by the SSA. There were no names of any other participants documented. There were no notes detailing what concerns Resident 77 expressed and what suggestions were offered by SSA. SSD stated the time of 1:30 AM on the document was not accurate.
During a concurrent interview and record review, on 3/10/23, at 10:50 AM, SSD answered questions about the discharge process. SSD stated that when a resident was admitted , they did customer rounds at the bedside for the first five days to determine where they lived, what kind of services they needed, etc. The rounds were just verbal and they did not document them or what was discussed. SSD used a sheet of paper titled, Discharge Cover Worksheet for the Care Conference information. The Care Conference was done in the resident's room with the resident or family. SSD was not familiar with the term Post-Discharge Plan, and stated that was what they referred to as the Care Conference. SSD stated that they did not meet with the resident/RP 24 hours before discharge to review the plan. SSD stated they gave suggestions for finding facilities, and sometimes offered a Senior Resource Book or website address, but didn't always document what material had been given. When asked for a copy of the complete Discharge Care Plan for Resident 77, SSD stated that they kept most of the notes on the Discharge Cover Sheet, or in their head. SSD confirmed that they had not updated Resident 77's Discharge Care Plan that was initiated on 9/16/22 and cancelled on 12/29/22 (after discharge).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accommodate one out of one resident (Resident 85) with preferred fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accommodate one out of one resident (Resident 85) with preferred food preferences that met cultural needs when dietary staff did not update Resident 85's medical record with preferences.
This failure created the potential for a lack of the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss.
Findings:
A review of Resident 85's records indicated admission to the facility on [DATE] with the diagnoses that included unspecified dementia (memory loss) and unspecified protein-calorie malnutrition (a lack of proper nutrition or inability to absorb nutrients from food). Resident 85's cognition (ability to reason, think and make decisions) was intact and he was able to make his own decisions. Resident 85 did not speak English, was a vegetarian and required the assistance of one person and supervision during all meals.
A review of the record titled, Weight Note, dated 11/30/22, indicated Registered Dietician (RD) would look into adding hummus onto Resident 85's meal trays.
A review of the record titled, Weight Note, dated 12/21/22, indicated RD and Medical Doctor (MD) discussed Resident 85's food preferences. The Weight Note indicated Resident 85 wanted room temperature milk on trays and beans with meals. The Weight Note indicated the preferences would be added to the tray card (dietary meal ticket).
A review of the record titled, Care Plan (CP), with various dates, did not reflect Resident's preference for cultural Indian food. The CP indicated Resident 85 liked room temperature milk, beans, lentils, hummus, and was open to other plant-based foods.
During an interview on 3/8/23 at 2:10 PM, RD stated some residents have no food preferences so there are no preferences listed on their tray tickets. RD stated Resident 85 didn't eat much meat and liked lentils, chickpeas, and hummus. RD stated dietary staff had given Resident 85 they give him beans, hummus, and lentils. RD stated it was unknown how often or when those preferred foods had been last provided. RD stated RD was primarily responsible for obtaining resident food preferences, sometimes the DM would get them, and sometimes nursing would communicate resident food preferences.
During an interview on 3/10/23, at 8:13 AM, Resident 85's family member E (FAM E) stated he came in every morning to translate for Resident 85. FAM E stated Resident 85's primary diet prior to admission to the facility was Indian food, he was a vegetarian, and had not consumed any meat, eggs, or fish in over 30 years. FAM E stated some things Resident 85 liked included cow's milk in the morning, fruit, macaroni and cheese and faux (artificial) vegetarian meats. FAM E stated Resident 85 preferred softer foods because he has missing teeth.
A review of the undated, dietary tray card did not include Resident 85's preferences for cultural Indian food, room temperature milk, beans, lentils, hummus, or other plant-based foods and was provided a regular texture diet.
A review of the record titled Job Duties, with the handwritten date of 4/23/22, indicated the DMA was responsible to participate in the maintenance of records that included the resident's food likes and dislikes.
A review of the record titled Job Duties, with the handwritten date of 9/16/21, indicated DM was responsible to participate in the maintenance of records that included the resident's food likes and dislikes.
A review of the record titled Job Duties, with the handwritten date of 5/16/22, indicated the RD was responsible in obtaining the history of resident's food likes and dislikes
A review of the P&P titled Nutritional Assessment, revised 10/1/17, indicated nutritional data such as food preferences, dislikes, including texture and forms, food restrictions, and cultural or religious practices affecting food choice would be collected upon admission to the facility and as indicated by changes in condition.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
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 individualized needs were met for two of 18 res...
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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 individualized needs were met for two of 18 residents when:
1. Resident 70's call light device was not within his reach or his line of sight.
This failure had the potential for the resident's needs not being met promptly and an increase in accidents and injury.
2. Resident 85 was not provided a trained and competent language translator for his communication with facility staff.
This failure had the potential for the resident's needs not being met and psychosocial harm.
Findings:
1. Review of Resident 70's record noted that he was admitted on [DATE] withdiagnoses that included stroke, repeated falls, communication problems and muscle weakness. Resident 70 had 8 falls since June of 2022 which made him a high fall risk.
Review of Resident 70's Minimum Data Set (MDS- a resident assessment) indicated Resident 70 needed extensive assistance for transfers and walking.
A review of policy and procedure titled, Answering the Call Light,revised March 2021, under the heading of, General Guidelines, indicated:
1. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
A review of the Certified Nursing Assistant(CNA) job functions dated 2003, under the heading, Safety and Sanitation, indicated:
1. Keep the nurses' call system with easy reach of the resident.
2. Answer resident's call light as promptly as feasible.
During a concurrent observation and interview on 3/7/2023 at 3:57 PM, observed Resident 70 sitting in a wheelchair by the foot of his bed facing the head of the bed. Observed Resident 70's call light chord wrapped around the bed rail at the head of the bed. This distance was approximately 3.5 to 4 feet from Resident 70 and out of his reach. Resident 70 stated he would push the button if he needed a nurse. Resident 70 looked around and could not find the call light.
During a concurrent observation and interview on 3/8/2023 at 2:53 PM, observed Resident 70 in a chair located to the side of his bed facing the foot of his bed. Observed the call light to the left and behind Resident 70 out of his line of sight between the mattress and the bedrail. Certified Nurse Assistant (CNA) E was in the room and agreed Resident 70 could not find his call light.
During a concurrent observation and interview on 3/9/2023 at 3:30 PM, Resident 70 was observed sitting in a chair by his bed with his wheelchair approximately 1.5 feet in front of him. Residents 70's urinary catheter bag (bag that holds urine) hooked to the underside of the wheelchair and Resident 70 was scooting forward in his chair. The call light was hanging on a transfer pole which was to the left and slightly behind him. Resident 70 stated he was getting up because it was close to dinner time and he should call the nurse before getting up. Resident 70 looked around but could not find the call light.
2. A review of the records indicated Resident 85 had been admitted to the facility on [DATE] with diagnoses that included unspecified dementia (memory loss), psychotic disturbance (loss of contact with reality and can experience delusions (believe things that are not real), mood disturbance (could include feelings of sadness), and anxiety (feelings of nervousness or worry). Resident 85 had good cognition (memory, ability to reason), was able to make his own decisions, and had a communication barrier.
During a concurrent observation, record review, and attempted interview, on 3/8/23 at 9:01 AM, Resident 85 was sitting in his room in a wheelchair watching the television. Resident 85 nodded his head up and down in a yes motion to interview questions and began speaking in a language that was not English. On Resident 85's bedside table were communication papers that included the alphabet in English and pictures of items. Underneath each item was a word that described the picture. For example, one picture was a comb and underneath the picture was the word comb written in English.
During an interview on 3/8/23 at 9:05 AM, Social Services Assistant (SSA) confirmed Resident 85 did not speak English. SSA stated staff would call Resident 85's son to translate and there was two facility staff members who would translate when needed. SSA stated there was a communication board and cue papers (communication papers) in Resident 85's room, did not know what language Resident 85 spoke and Resident 85's language was not in the facility's translation service. SSA stated need to follow up with surveyor at a later time.
During an interview on 3/8/23 at 9:15 AM, Licensed Nurse (LN) B stated Resident 85 did not speak English. LN B stated Resident 85 spoke [NAME] and there were two facility staff members who assisted with translation along with Resident 85's family. LN B stated if Resident 85's family were here they would communicate to staff the things Resident 85 wanted or needed. LN B was not aware if the facility had a translation service. LN B was asked how staff would communicate with Resident 85 when family members or the two staff members who spoke [NAME] were not available. LN B replied, that's a tough one. LN B stated Resident 85 did not ask for much and was unsure if the reason was due to a communication barrier. LN B stated if Resident 85 wanted to personally tell LN B something, we would have a barrier there. During the interview with LN B, SSA returned and stated the facility used Microsoft [NAME] (an app that could be downloaded onto a cell phone) for translation with Resident 85.
During a concurrent interview and record review on 3/9/23 at 1:30 PM, Human Resources (HR) returned surveyors written request for documentation that would support the facility's two staff members had been trained and competent in interpreting. The written response from HR on the paper indicated the facility did not have any special tests for staff. HR confirmed the written reply stating ADMIN confirmed there was no test available to measure staff translation for competency or qualifications.
During an interview on 3/10/23, at 8:13 AM Resident 85's family member (FM) stated coming into the facility every morning to inquire about Resident 85's care. FM stated after speaking with Resident 85, FM would translate any care needs or requests, made by Resident 85, to nursing staff. FM stated Resident 85 did not always understand what staff tried to communicate and that staff used gestures, such as pointing. FM stated unawareness if the facility had a translation service available or if translation services had ever been used.
During a concurrent interview and record review on 3/10/23 at 8:57 AM, Restorative Nursing Assistant (RNA) stated family would come in daily to translate for Resident 85. RNA stated RNA would use gestures to communicate what RNA wanted to do while providing care for Resident 85 and had used Google Translation (an app that could be downloaded to a cell phone) a few times on his personal cell phone to communicate. RNA stated, I think Resident 85 understood enough when care was being provided. RNA stated having tried to use the communication papers in Resident 85's room in the past and that Resident 85 would not use them. RNA reviewed and acknowledged the communication forms provided to Resident 85 were written in English and that might be a reason Resident 85 did not use the communication papers.
During an interview on 3/10/23 at 9:20 AM, Director of Staff Development (DSD) stated when communicating with Resident 85, the use of gestures or Microsoft [NAME] could be used. DSD confirmed the communication papers provided to Resident 85 were not appropriate for communication and stated there were no specific in services provided to staff regarding cultural competencies or use of translation services. DSD stated when a resident was admitted to the facility with specific cultural needs or did not speak English, DSD would verbally educate staff that was responsible for that resident's care. DSD stated unawareness if the two facility staff members that assisted Resident 85 with translation had been trained or competent in the skill of translating. DSD acknowledged inability to know whether information had been translated correctly. DSD acknowledged inability to know if information had been understood by family members or residents when using family members to translate.
During a concurrent interview and record review of the facility policy and procedure (P&P) titled, Translation and or Interpretation of Facility Services, on 3/10/23 at 10:42 AM, the facility's Administrator (ADMIN) confirmed the facility utilized Resident 85's family and two facility staff members to translate. ADMIN confirmed not following the facility's P&P facility translation services, the facility did not have a translation service available for residents that included translators who were trained and competent in the skill of interpreting.
A review of the facility's P&P titled, Translation and or Interpretation of Facility Services, revised 4/1/12, indicated family members would not be relied upon to provide translation. The P&P indicated a staff member that was a contracted interpreter service, or a telephone interpreter service would be used for translation. The P&P indicated translators were to be trained in medical terminology and ethical issues that might arise when communicating health-related information. Staff would be trained upon hire and yearly on how to provide language access services to residents who have limited English proficiency.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
5. During a confidential interviews on 3/8/2023 at 10:00 AM, five of six residents stated they had lost clothing in the last six months. They stated they had notified the laundry manager and she did n...
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5. During a confidential interviews on 3/8/2023 at 10:00 AM, five of six residents stated they had lost clothing in the last six months. They stated they had notified the laundry manager and she did not know anything about missing clothes and the clothes were not returned. Six of six confidentially-interviewed residents stated the staff does not bring lost clothing around for resident's to view.
During a concurrent observation and interview on 3/9/2023 at 3:20 PM, observed in the laundry room a rack of clothes on the wall with pants and shirts hanging. Observed a sign above the rack that indicated, No name clothes on this rack only. Directly in front of the clothing on the rack was a rolling laundry cart with large amounts of clothing hanging and piled on top of each other with a white sheet covering them. Closer to the dryer was another rolling cart with clothes and shoes. Environmental Services (ENV) B, stated if clothing has no name or room number on them, they are placed in the laundry cart closer to the dryers. ENV B stated the rack along the wall is for donated items and used for residents that need clothing. ENV B stated the Certified Nursing Assistant (CNA) can come in and look for lost clothing. If they can't find the item, they fill out a paper with the resident's name and description of the lost clothing for the laundry staff. ENV B stated he did not know what the clothes were that were located in the cart in front of the rack.
During an interview on 3/9/2023 at 3:47 PM with CNA G, stated that if a resident complains of lost clothing there is a rack of clothes on the wall in the laundry department that the staff can look through to locate the item. CNA G stated they can fill a form out for the laundry service with resident's name and description of clothing that was lost. CNA G did not know what the other laundry cart of clothes were next to the rack and does not go through them when looking for lost items.
During an interview on 3/9/2023 at 3:55 with CNA H, stated they would look in the lost and found which are the clothes hanging on the rack in the laundry department. If they can't locate the item, they fill out a form for the laundry staff with the resident's name and description of the item.
During an interview on 3/10/2023 with Environmental Manager (ENV A), stated there is no specific lost and found area but they have a binder with forms that should be filled out by staff when residents report lost clothing. ENV A stated the rack of clothes on the wall are donated clothing and clothes with no names. ENV A stated the rolling laundry cart full of clothes in front of the rack were unmarked clothing that had been there for months. ENV A stated the recent unmarked clothing was in the laundry cart closest to the dryer. ENV A stated that they have not taken the unmarked items out for the residents to look through in a long time.
During an interview on 3/10/2023 with Director of Staff Development (DSD), stated her expectations are the CNA will go down to the laundry and look for the lost clothing. If they cannot locate the clothing, they can fill out a form for social services to try and resolve the issue. DSD 1 stated the clothes on the rack against the wall are donated items and available to all the residents.
Based on observation, interview and record review the facility failed to ensure four of four sampled residents (Resident 50, 7, 25 and 16), and five of six confidential resident interviewed, were not protected from loss when the facility had no system to return lost clothing items to residents.
This failure resulted in residents feeling angry and frustrated because they did not have their own clothes to wear.
Findings:
Review of the facility's policy titled, Personal Property dated March 2021 indicated that Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of others. The policy states further that resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary, and that the facility promptly investigates any complaints of misappropriation or mistreatment of resident property.
1. In an interview on 3/07/23 at 4:11 PM, FAM A, Resident 50's son, stated that the facility has repeatedly lost his father's clothing. They keep losing her pants and clothes. We put his name in them and they keep disappearing. We buy new ones for him.
2. In an interview on 3/7/23 at 4:13 PM, Resident 7 stated that the facility had done her laundry and she was missing yellow tops that she loved.
3. In an interview on 3/7/23, at 2:47 PM, Resident 25 stated her socks and grey flannel leggings were missing.
4. In an interview on 3/7/23 at 4:10 PM, Resident 16 stated that she was missing pants and blouses.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 38 indicated he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnose...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 38 indicated he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including embolism of iliac artery ( a blood clot in the artery to the kidneys) with post procedure acute kidney failure requiring dependence on renal dialysis (procedure to artificially replace kidney function), muscle weakness and diabetes mellitus.
A review of the MDS dated [DATE], indicated Resident 38 scored 21 out of 27 on a mood behavior screen (PHQ9,Scoring between 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, and 20 or more severe depression), which indicated a major depressive disorder (a mental health disorder characterized by persistent mood of sadness or loss in interest in activities, causing significant impairment in daily life).
During record review of Care Plans dated 1/20/23, 1/21/23, 2/2/23 and 2/7/23, for Resident 38, no care plans were found addressing Resident 38's severe depression.
During record review of an admission assessment dated [DATE], there were no boxes checked in section J.b. for behavior/mood. A readmission assessment dated [DATE], there were no boxes checked in section J.b. for behavior/mood.
During record review of Interdisciplinary Team (IDT team members from different disciplines meet to share information, set goals and make decisions) meetings dated 1/23/23, 1/24/23 and 2/6/23, no discussion was noted regarding Resident 38's severe depression.
During record review of progress notes dated 1/23/23, Social Services Assistant (SSA) documented, During MDS PHQ9 assessment Resident 38 scored a 21, severe depression. Resident 38 was not currently taking any psychotropic medication for depression. MD notified. SS to assist as needed.
During record review of Resident 38's monthly History and Physical dated 1/26/23 and 2/6/23, the physician documented no reference to severe depression.
During record review of Order Summary report for Resident 38 with order dates from 1/30/23 to 3/7/23, there were no orders for a mental health evaluation or antidepressant medication noted.
During an interview on 3/09/23 2:35 PM, CNA H reported Resident 38 was the main caregiver for his wife who passed away due to Alzheimer's disease.
During an interview on 3/9/23 at 2:45 PM, LN 1 stated Resident 38 was usually friendly, but subdued, quiet, and was used to being caregiver for wife who passed away from Alzheimers disease. LN 1 stated Resident 38 had two wound appliances to assist healing that make mobility difficult. LN 1 confirmed in the medication record that there was no antidepressant (medication for mood/depression) ordered.
During a concurrent interview and record review on 03/09/23 3:33 PM, SSA stated anything over an MDS score of 7/27 on PHQ9, she sends a physician notification sheet and puts in physician's box to be faxed to him to review/act on. SSA and Social Services Director could not find any new physician orders in the record in regards to Resident 38's severe depression.
5. The facility policy, titled, Assistive Devices and Equipment, revised 1/1/20, was reviewed. It indicated that recommendations for the use of devices and equipment were based on the comprehensive assessment and documented in the resident's Care Plan.
A review of Resident 72's clinical record showed they were originally admitted to the facility on [DATE]. Resident 72's diagnoses included a fall, fracture of the right humerus (a broken upper arm bone), and dementia (a mental disorder that caused memory loss and confusion).
During an observation, on 3/7/23, at 3:26 PM, Resident 72 wore an arm brace on their right arm.
During an interview, on 3/9/23, at 11:06 AM, CNA D was not aware of any special written instructions for Resident 72's arm brace. CNA D stated the Physical Therapist (PT) showed them how to put the brace on Resident 72's arm the week before. The staff member instructed by P.T. then passed on the instructions verbally to other staff.
A review of Resident 72's Care Plan indicated there were no entries about the arm brace.
During a concurrent interview and record review, on 3/9/23, at 4:51 PM, the Registered Nurse Consultant (RNC) confirmed there was nothing in Resident 72's Care Plan about an arm brace.
4. A review of Resident 73's record indicated he was admitted to the facility on [DATE] with diagnoses which included repeated falls, difficulty walking, and history of stroke.
A review of an admission assessment dated [DATE] at 2:49 PM, indicated under wander/elopement (behavior of exit seeking to leave building) section, that Resident 73 was a risk, due to being disoriented, does not understand surroundings, and early dementia. The wandering risk score was blank. The area for assessing elopement risk was blank, no responses. A quarterly bundle assessment dated [DATE] at 2:13 PM, indicated Resident 73 was a wandering risk due to being disoriented, independent with walking, and had a known history of wandering.
A review of Resident 73's Health Status Notes indicated:
On 9/14/22 at 9:23 PM, indicated resident at risk for wandering and falls, very forgetful and walking into other resident rooms.
On 9/15/22 at 12:23 PM, indicated resident did well this AM shift, only wandered one time out of room.
On 9/16/22 at 10:36 AM and 9/17/22 at 1:32 PM, indicated resident wanders into the hall and tries to get into other resident rooms throughout the day.
On 9/18/22 at 12:29 PM, indicated resident wanders into other resident rooms.
On 9/20/22 2:48 PM, indicated resident was ambulatory and likes to wander into resident rooms.
On 9/21/22 at 2:55 PM and 9/22/22 at 5:08 PM, resident likes to wander.
During confidential resident interviews on 3/08/23 at 11:28 AM, three of six residents stated Resident 73 wanders into their rooms, all hours of the day sometimes twice a day which made them frustrated.
During an interview on 3/9/23 at 9 AM, LN D stated Resident 73 wandered often, and went in and out of residents rooms.
During a concurrent interview and record review on 3/9/23 at 10 AM, DON and Assistant Director of Nursing (ADON/MDS) confirmed the wandering/elopement assessments upon admission were not complete and there were no care plans about wandering for Resident 73. DON did not find any behavior monitoring for wandering in the record.
During a concurrent interview and record review on 3/10/23 at 9:21 AM, MDSA 2 was interviewed about Resident 73 and 38. MDSA 2 confirmed that there was no care plan generated for Resident 38 even though in a care area for behavior mood was triggered by the MDS assessment entry. MDSA 2 was unsure why the care plan was not generated other than that it was not completed correctly. MDSA 2 stated that anyone on the IDT created a care plan. MDSA 2 stated when the social worker identified the severe depression, a care plan could have been generated. MDSA 2 stated nursing staff could have also created a care plan at the time of admission for larger concerning issues such as wandering or severe depression. MDSA 2 stated there was no MDS assessment area that addressed elopement/wandering to trigger a care area for plan of care.
Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans for five of 18 sampled residents (Resident 2, 38, 68, 72, and 73) when:
1. Resident 2 for potential risk of choking hazards during mealtimes (Refer F689);
2. Resident 68 for impaired visual function ;
3. Resident 38 for severe depression;
4. Resident 73 wandering around the facility and;
5. Resident 72 the use of arm brace.
These failures had the potential for care plans to inaccurately reflect the care needed, being provided, or resident care needs to go unmet or the conditions to worsen.
Findings:
A review of a facility policy titled, Comprehensive Assessments, revised March 2022, indicated comprehensive assessments are conducted to assist in developing person centered care plans.
1. Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia, history of falling and dysphagia ( difficulty swallowing).
The most recent Minimum Data Set (MDS-a resident assessment) dated 2/14/23, indicated Resident 2 was alert, with confusion, had cognition deficits (unable to think and reason) and needed extensive assistance with Activities of Daily Living (ADL) such as bed mobility and eating.
A review of the physician's orders, dated 3/21/21 indicated, Regular diet, mechanical soft texture, thin liquids consistency, fortified diet (added fat). Certified Nursing Assistants (CNAs) to supply and assist resident with the application of meal condiments.
A review of all the care plans did not indicate the potential risk of choking hazards during mealtimes and what interventions the facility need to do.
During a concurrent meal observation and a review of the diet card on 3/9/23 at 8 AM, CNA C took the tray out of the cart and taken to Resident 2's room. CNA C took the cover out and served the food to Resident 2. She was sitting in a wheelchair waiting for her food tray to be served. The breakfast tray included scrambled egg, toast, raisin bran, milk, juice, with condiments added such as two unopened small plastic butter pack, salt and pepper packets and utensils. CNA C left the room and the condiments were left unopened on the meal tray.
During an observation on 3/9/23 at 8:40 AM, Resident 2 placed the one unopened small plastic butter pack in her mouth, attempted to chew it, but having difficulty. Resident 2 also had difficulty taking the unopened small plastic butter pack out from her mouth. CNA A who passed by the hallway while helping other residents got notified. By then, Resident 2 was eventually able to take it out of her mouth and placed the unopened small plastic butter pack on top of the raisin bran bowl. CNA A immediately removed all the unopened condiments and stated, She should not have these unopened condiments in her tray.
During a concurrent observation and interview with CNA C on 3/9/23 at 9 AM, stated that she was assigned to Resident 2 but not too often. CNA C stated that Resident 2 needed set up meals only without utensils and condiments. CNA confirmed that it was overlooked this morning when the tray was given to Resident 2.
During an interview with CNA A on 3/9/23 at 9:10 AM, stated this incident happened three times already a month ago with the unopened small plastic butter pack in her mouth. CNA A stated that this was communicated by Licensed Nurse (LN) A because of what happened in the past. CNA A stated that there should have been a note sent to the kitchen not to have any condiments on the tray.
During a concurrent interview and record review on 3/9/23 at 9:35 AM, LN B explained that before the tray was passed to the residents that it should be checked first before CNA gave it to a resident. This included checking the diet as ordered and texture to ensure residents getting the right diet. LN B further explained to call the kitchen, put in the computer under communication log for everyone to see. LN B was unable to find in the communication section that it was communicated to the kitchen. LN B stated that the tray was checked this morning before it was passed but just overlooked the condiments.
During a concurrent interview and record review with the MDS Assistant (MDSA) 1 on 3/9/23 at 10:25 AM, confirmed that there was no care plan developed for Resident 2's potential risk of choking hazard during mealtimes.
During a concurrent interview and record review with the Director of Nursing (DON) on 3/9/23 at 11:30 AM, stated that she was not made aware of the incident in the past as it was not documented anywhere in the record. DON further discussed the facility process that licensed nurses should have communicated to the dietary services and then the diet card should have been updated. DON confirmed there was no plan of care addressed in Resident 2's record.
During an interview with the Registered Dietician (RD) on 3/9/23 at 11:45 Am, stated that this was not communicated before and that she was made aware of the incident since this morning.
2. Resident 68 was originally admitted to the facility on [DATE] and re-admitted on [DATE]/23 with diagnoses that included dementia with behavioral disturbances and with repeated falls. Resident 68 was alert, able to verbalize self but with confusion and had no capacity to make health care decisions.
A review of the most recent MDS, dated [DATE] indicated, Resident 68 had adequate vision and no corrective lenses such as glasses.
A review of the Social Service assessment dated [DATE] indicated that Resident 68 marked as having eye glasses.
During an observation on 3/7/23 at 4:17 PM, Resident 68 did not wear corrective lenses such as eye glasses.
During an observation on 3/9/23 at 8:30 AM, Resident 68 was up in wheel chair in room eating breakfast, and fed self. No eye glasses observed.
During a concurrent observation and interview on 3/9/23 at 8:35 AM with CNA A, confirmed Resident 68 did not wear eye glasses. CNA A looked in the drawer and found to be uncleaned. CNA A cleaned the eye glasses and gave to Resident 68. CNA A was asked about when was the last time Resident 68 have them. CNA A stated she can't recall.
During an interview with Resident 68 on 03/9/23 at 8:40 AM, stated he had macular degeneration (eye disease that causes vision loss). Resident 68 stated he was unable to see people's face but only color of the clothes. Resident 68 stated wearing eye glasses helped a little bit.
During a concurrent interview and record review with the MDS Nurse Assistant (MDSA) 1 on 3/9/23 at 10:25 AM, she was not made aware that Resident 68 used corrective lenses such as eye glasses. MDSA 1 confirmed that there was no care plan developed to address Resident 68's impaired visual function.
During an interview with the Social Service Director (SSD) on 3/9/23 at 10:55 AM, explained about her role. SSD stated that she participated during care conference and also making referrals for residents who needed to be seen by an optometrist (detect defects in vision)usually every six months to one year. SSD confirmed that she was not made aware that Resident 68 had not been wearing his glasses.
During an interview with the Resident Representative (RR) on 3/9/23 at 4:10 PM, stated that Resident 68 was legally blind and that he had worn glasses. RR further stated that a care conference was held a month ago with RR being present and that the facility should made aware of the situation. RR further stated that wearing eye glasses helped a bit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 38 medical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 38 medical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included diabetes, heart failure, muscle weakness and bilateral (both sides) groin wounds.
During a review of the the facility's policy and procedure titled, Activities of Daily Living (ADL), revised March 2018, indicated that a resident's ability to perform ADLs will be measured using clinical tools, including the MDS.
During record review of Resident 38's MDS dated [DATE], indicated he required staff assistance with all ADLs.
During record review of shower/bath schedule dated 2/8/23-3/8/23, Resident 38 was scheduled for baths on Sundays and Wednesdays. He missed 4 out of 10 bed baths scheduled. No record of nail care performed was found.
During concurrent interview and record review on 3/10/23 at 8:50 AM with DSD, confirmed that Resident 38 was on the shower schedule for twice weekly bed baths on Sundays and Wednesdays and did not receive 4 of 10 baths scheduled. She confirmed that when a bath was documented as refused, there was no process for documentation by CNA to chart that it was offered again after a refusal or offered on a different day or time.
During a concurrent observation and interview on 3/08/23 at 8:36 AM, Resident 38, stated he only recently received a haircut and shave, and was frustrated due to wanting more frequent baths. Resident 38 stated his toenails needed trimming and were uncomfortable. He has asked to have them trimmed on several occasions without response. Resident 38 was observed to have a face with several days growth. Resident 38 reported rare bed baths.
During interview on 3/8/23 at 9 AM, Social Services Assistant (SSA) stated Resident 38 was scheduled to see a podiatrist (foot physician) on 2/6/23 and was not seen.
A review of a Health Status Note dated 3/8/2023 at 8:49 PM, LN documented Resident 38's toe nails appeared to be slightly uncomfortable. His toe nails were trimmed and Resident 38 stated they feel much better.
During record review, no documentation noted for resident requesting toenails trimmed or CNA noting that toenails needed trimming.
During an interview on 3/10/2023 at 8:52 AM with DSD, stated her expectations were the CNA was responsible to check the resident's finger/toenails with each shower/bedbath and should have reported to LN and Registered Nurse if nails needed trimming. DSD stated there was form the CNA can fill out for social services if the resident needed a podiatry appointment.
Based on observation, interview and record review, the facility failed to ensure direct care staff provided necessary grooming, nail care and bed bath services for three of seven dependent residents (Residents 8, 38 and 70).
This failure had the potential to cause injury or pain for Residents 8 and 70, and Resident 38 having long uncomfortable toenails and missing 4/10 bed baths.
Findings:
A review of the policy and procedure titled, Activities of Daily Living (ADL) Supporting, revised March 2018 indicated, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
A review of the Certified Nursing Assistant,,(CNA) job functions dated 2003, indicated under the heading, Personal Nursing Care Functions,:
1. Assist residents with bathing functions (i.e , bed-bath, or shower bath etc.) as directed
2. Assist residents with nail care (i.e , clipping, trimming, and cleaning the finger/toenails). (Note: Does not include diabetic residents).
1. Review of Resident 70's record indicated he was admitted to the facility on [DATE] with diagnoses that included stroke, repeated falls, communication problems and muscle weakness.
Review of Resident 70's Minimum Data Set (MDS, resident assessment) dated 2/10/23, indicated Resident 70 needed assistance with bathing and one person assist with personal hygiene.
During a concurrent observation and interview on 3/7/2023 at 3:45 PM with Resident 70, observed his fingernails to be long. Resident 70 stated his nails were too long and needed them cut.
During an interview on 3/8/2023 at 2:58 PM, CNA E confirmed that Resident 70's fingernails were long and needed to be trimmed. She stated the CNA should notify the nurse when the nails were long.
2. Review of Resident 8's record indicated that he was admitted to the facility on [DATE] with diagnoses that included long term pain, fatigue and lung disease.
Review of Resident 8's MDS dated [DATE], indicated that Resident 8 was unable to bathe himself and needed one person physical assist with personal hygiene.
During a concurrent observation and interview on 3/7/2023 at 3:38 PM, observed Resident 8's fingernails to be long, sharp on the edges and one fingernail was torn right below the nail bed. Resident 8 stated his fingernails needed to be cut because they were sharp especially on the edges and getting caught on his blankets.
During an interview on 3/8/2023 at 2:53 PM with CNA F, stated the CNA was supposed to notify the nurse when a resident's fingernails needed to be cut. CNA F stated she would use an emery board to file down the sharp edges if she could not locate nail clippers.
During a concurrent observation and interview on 3/8/2023 at 3:06 PM with Resident 8, observed his fingernails to be nicely trimmed and clean. Resident 8 stated his granddaughter came in today and trimmed his fingernails for him.
During an interview on 3/8/2023 at 4:17 PM, Licensed Nurse (LN) E stated the CNA should checked the finger/ toenails of the resident on resident shower days and trimmed them unless the resident was a diabetic.
During a record review of Shower/Skin Assessment Sheet, of Resident 8 and 20 dated from January 2023 to March 6, 2023, 0 out of 25 shower sheets had a record of the finger or toenails being assessed or trimmed.
During a record review of Complaints/Grievances Follow-up, from the Social Service department indicated the following:
1/10/2023 Issues: During a care conference the same issues were brought to attention; call light times, teeth brushing and shaving for all shifts.
1/15/2023 Issues: Always having to ask to have nails cut and cleaned after eating.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of a policy titled, Wandering, Unsafe Resident revised August 2014, indicated the facility will strive to prevent un...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of a policy titled, Wandering, Unsafe Resident revised August 2014, indicated the facility will strive to prevent unsafe wandering. The staff will identify residents who are at risk for harm because of unsafe wandering. The staff will assess at risk individuals for potentially corrective risk factors related to unsafe wandering, and the care plan will indicate safety issues, interventions to maintain safety such as a detailed monitoring plan will be included.
A review of Resident 73's record indicated he was admitted to the facility on [DATE] with diagnoses which included repeated falls, difficulty walking, and history of stroke.
A review of an admission assessment dated [DATE] at 2:49 PM, indicated under wander/elopement (behavior of exit seeking to leave building) section, that Resident 73 was a risk, due to being disoriented, does not understand surroundings, and early dementia. The wandering risk score was blank. The area for assessing elopement risk was blank, no responses. A quarterly bundle assessment dated [DATE] at 2:13 PM, indicated Resident 73 was a wandering risk due to being disoriented, independent with walking, and had a known history of wandering.
A review of Resident 73's Health Status Notes indicated:
On 9/14/22 at 9:23 PM, indicated resident at risk for wandering and falls, very forgetful and walking into other resident rooms.
On 9/15/22 at 12:23 PM, indicated resident did well this AM shift, only wandered one time out of room.
On 9/16/22 at 10:36 AM and 9/17/22 at 1:32 PM, indicated resident wanders into the hall and tries to get into other resident rooms throughout the day.
On 9/18/22 at 12:29 PM, indicated resident wanders into other resident rooms.
On 9/20/22 2:48 PM, indicated resident was ambulatory and likes to wander into resident rooms.
On 9/21/22 at 2:55 PM and 9/22/22 at 5:08 PM, resident likes to wander.
During confidential resident interviews on 3/08/23 at 11:28 AM, three of six residents stated Resident 73 wanders into their rooms, all hours of the day sometimes twice a day which made them frustrated.
During an interview on 3/9/23 at 9 AM, LN D stated Resident 73 wandered often, and went in and out of residents rooms.
During a concurrent interview and record review on 3/9/23 10 AM, DON and Assistant Director of Nursing (ADON/MDS) confirmed the wandering/elopement nursing assessments upon admission were not complete and there were no care plans about wandering risks and interventions for Resident 73. DON did not find any behavior monitoring for wandering in the record. DON stated nursing assessments were to be complete and accurate.
During a concurrent interview and record review on 3/10/23 9:21 AM, MDSA 2 nursing staff could have also created a care plan at the time of the nursing admission assessment for larger concerning issues such as wandering for Resident 73. MDSA 2 stated there was no MDS assessment area that addressed elopement/wandering to trigger a care area for plan of care.
Based on observation, interview and record review, the facility failed to ensure a plan of care to address the safety of two of 18 residents when:
1. Resident 2 did not have assistance during meals.
2. Resident 73 was wandering into other resident rooms frequently without supervision.
This resulted a choking hazard and had the potential to put all residents at risk for falls and resident to resident altercations.
Findings:
The facility's policy and procedure titled, Safety and Supervision of Residents, revised 7/2017, indicated that the facility strives to make an environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Also, resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.
1. Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia, history of falling and dysphagia (difficulty swallowing).
The most recent Minimum Data Set (MDS-a resident assessment) dated 2/14/23, indicated Resident was alert, with confusion, had cognition deficits (unable to think and reason) and needed extensive assistance with Activities of Daily Living (ADL) such
as bed mobility and eating.
A review of the physician's orders, dated 3/21/21 indicated, Regular diet, mechanical soft texture, thin liquids consistency, fortified diet (added fat). CNAs (Certified Nursing Assistants) to supply and assist resident with the application of meal condiments.
A review of all the care plans did not indicate the potential risk of choking hazards during mealtimes and what interventions the facility needed to do.
During a concurrent meal observation and a review of the diet card on 3/9/23 at 8 AM, CNA C took the tray out of the cart and taken to Resident 2's room. CNA C took the cover out and served the food to Resident 2. She was sitting in a wheelchair waiting for the breakfast tray to be served. The breakfast tray included scrambled egg, toast, raisin bran, milk, juice, with condiments added such as two unopened small plastic butter pack, salt and pepper packets and utensils. CNA C left the room and the condiments were left unopened on the meal tray.
During an observation on 3/9/23 at 8:40 AM, Resident 2 placed the one unopened small plastic butter pack in her mouth, attempted to chew it, but having difficulty. Resident 2 also had difficulty taking the unopened small plastic butter pack out from her mouth. CNA A who passed by the hallway while helping other residents got notified. By then, Resident 2 was eventually able to take it out of her mouth and placed the unopened small plastic butter pack on top of the raisin bran bowl. CNA A immediately removed all the unopened condiments and stated, She should not have these unopened condiments in her tray.
During a concurrent observation and interview with CNA C on 3/9/23 at 9 AM, stated that she was assigned to Resident 2 but not too often. CNA C stated that Resident 2 needed set up meals only without utensils and condiments. CNA confirmed that it was overlooked this morning when the tray was given to Resident 2.
During an interview with CNA A on 3/9/23 at 9:10 AM, stated this incident happened three times already a month ago with the unopened small plastic butter pack in her mouth. CNA A stated that this was communicated by Licensed Nurse (LN) A because of what happened in the past. CNA A stated that there should have been a note sent to the kitchen not to have any condiments on the tray.
During a concurrent interview and record review on 3/9/23 at 9:35 AM, LN B explained that before the tray was passed to the residents that it should be checked first before CNA gave it to a resident. This included checking the diet as ordered and texture to ensure residents getting the right diet. LN B further explained to call the kitchen, put in the computer under communication log for everyone to see. LN B was unable to find in the communication section that it was communicated to the kitchen. LN B stated that the tray was checked this morning before it was passed but just overlooked the condiments.
During a concurrent interview and record review with the MDS Assistant (MDSA) 1 on 3/9/23 at 10:25 AM, confirmed that there was no care plan developed for Resident 2's potential risk of choking hazard during mealtimes.
During a concurrent interview and record review with the Director of Nursing (DON) on 3/9/23 at 11:30 AM, stated that she was not made aware of the incident in the past as it was not documented anywhere in the record. DON further discussed the facility process that licensed nurses should have communicated to the dietary services and then the diet card should have been updated. DON confirmed there was no plan of care addressed in Resident 2's record.
During an interview with the Registered Dietician (RD) on 3/9/23 at 11:45 Am, stated that this was not communicated before and that she was made aware of the incident since this morning.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a record review of shower/bath schedule dated 2/8/23-3/8/23, Resident 38 was scheduled for baths on Sundays and Wednesday...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a record review of shower/bath schedule dated 2/8/23-3/8/23, Resident 38 was scheduled for baths on Sundays and Wednesdays. He missed 4/10 bed baths scheduled. No record of nail care performed was found.
During a concurrent interview and record review on 3/10/23 at 8:50 AM with DSD, confirmed that Resident 38 was on the shower schedule for twice weekly bed baths on Sundays and Wednesdays and did not receive 4 of 10 baths scheduled. 3/9/23. During review of Activities of Daily Living (ADL) policy indicated that a resident's ability to perform ADLs will be measured using clinical tools, including the MDS.
During a review of Certified Nursing Assistant job description dated 2003, included assisting residents with bath functions, nail care, hair care, answer call lights as promptly as feasible, make residents comfortable, inventory and mark resident's personal possessions and report all complaints and grievances made by the resident.
During a concurrent observation and interview on 3/08/23 at 8:36 AM, with Resident 38, stated he only recently received a haircut and shave, and he was frustrated due to wanting more frequent baths. Resident 38 stated his toenails needed trimming and were uncomfortable. He has asked to have them trimmed on several occasions without response. Resident 38 was observed to have a face with several days growth. Resident 38 reported rare bed baths.
A review of a Health Status Note dated 3/8/2023 at 8:49 PM, LN documented Resident 38's toe nails appeared to be slightly uncomfortable. His toe nails were trimmed and Resident 38 stated they feel much better.
During an interview on 3/10/2023 at 8:52 AM with DSD stated her expectations are the CNA was responsible to check the resident's finger/toenails with each shower/bedbath and and report to LN and Registered Nurse if nails needed trimming. DSD stated there was form the CNA can fill out for social services if the resident needs a podiatry (foot physician) appointment.
During a concurrent interview and record review on 3/10/23 10:14 AM with DSD, reported that CNAs were expected to evaluate residents fingernails/toenails every shower/bedbath. There was no documentation noted for resident requesting toenails trimmed or CNA noting that toenails needed trimming.
4. A review of the MDS dated [DATE], indicated Resident 38 scored 21 out of 27 on a mood behavior screen (PHQ9,Scoring between 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, and 20 or more severe depression), which indicated a major depressive disorder (a mental health disorder characterized by persistent mood of sadness or loss in interest in activities, causing significant impairment in daily life).
During a concurrent observation and interview on 3/08/23 8:31 AM, Resident 38 was seen laying in bed with beard stubble present, tired, and not making eye contact. Resident 38 stated he was frustrated that he rarely got bed baths and that his toenails needed to be trimmed. He stated he has requested for nail trimming for several weeks with no response.
During record review of Care Plans dated 1/20/23, 1/21/23, 2/2/23 and 2/7/23, for Resident 38, no care plans were found addressing Resident 38's severe depression.
During record review of an admission assessment dated [DATE], there were no boxes checked in section J.b. for behavior/mood. A readmission assessment dated [DATE], there were no boxes checked in section J.b. for behavior/mood.
During record review of Interdisciplinary Team (IDT team members from different disciplines meet to share information, set goals and make decisions) meetings dated 1/23/23, 1/24/23 and 2/6/23, no discussion was noted regarding Resident 38's severe depression.
3. A review of the policy and procedure titled, Activities of Daily Living (ADL) Supporting, revised March 2018 indicated, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
A review of the Certified Nursing Assistant, (CNA) job functions dated 2003, indicated under the heading, Personal Nursing Care Functions,:
1. Assist residents with bathing functions (i.e , bed-bath, or shower bath etc.) as directed
2. Assist residents with nail care (i.e , clipping, trimming, and cleaning the finger/toenails). (Note: Does not include diabetic residents).
During an interview on 3/8/2023 at 2:58 PM, CNA E agreed that Resident 70's fingernails were long and needed to be trimmed. She stated the CNA should notify the nurse when the nails were long.
During an interview on 3/8/2023 at 2:53 PM with CNA F, stated the CNA was supposed to notify the nurse when a resident's fingernails needed to be cut. CNA F stated she would use an emery board to file down the sharp edges if she could not locate nail clippers.
During a record review of Shower/Skin Assessment Sheet, of Resident 8 and 70 dated from January 2023 to March 6, 2023, 0 out of 25 shower sheets had a record of the finger or toenails being assessed or trimmed.
During a record review of Complaints/Grievances Follow-up, from the Social Service department indicated:
1/10/2023 Issues: During a care conference the same issues were brought to attention; call light times, teeth brushing and shaving for all shifts.
1/15/2023 Issues: Always having to ask to have nails cut and cleaned after eating.
During and interview on 3/10/2023 at 8:52 AM with Director of Staff Development (DSD), stated her expectations were the CNA was responsible to check the resident's finger/toenails with each shower/bedbath and trimmed the nails if needed. DSD stated the CNA should note on the shower sheet any concerns and notify the nurse. DSD stated there is a form the CNA can fill out for social services if the resident needs a Podiatry appointment.
5. A review of an admission assessment dated [DATE] at 2:49 PM, indicated under wander/elopement (behavior of exit seeking to leave building) section, that Resident 73 was a risk, due to being disoriented, does not understand surroundings, and early dementia. The wandering risk score was blank. The area for assessing elopement risk was blank, no responses. A quarterly bundle assessment dated [DATE] at 2:13 PM, indicated Resident 73 was a wandering risk due to being disoriented, independent with walking, and had a known history of wandering.
A review of Resident 73's Health Status Notes indicated:
On 9/14/22 at 9:23 PM, indicated resident at risk for wandering and falls, very forgetful and walking into other resident rooms.
On 9/15/22 at 12:23 PM, indicated resident did well this AM shift, only wandered one time out of room.
On 9/16/22 at 10:36 AM and 9/17/22 at 1:32 PM, indicated resident wanders into the hall and tries to get into other resident rooms throughout the day.
On 9/18/22 at 12:29 PM, indicated resident wanders into other resident rooms.
On 9/20/22 2:48 PM, indicated resident was ambulatory and likes to wander into resident rooms.
On 9/21/22 at 2:55 PM and 9/22/22 at 5:08 PM, resident likes to wander.
During a concurrent interview and record review on 3/9/23 10 AM, DON and Assistant Director of Nursing (ADON/MDS) confirmed the wandering/elopement nursing assessments upon admission were not complete and there were no care plans about wandering risks and interventions for Resident 73. DON did not find any behavior monitoring for wandering in the record. DON stated nursing assessments were to be completed and accurate.
During a concurrent interview and record review on 3/10/23 9:21 AM, Minimum Data Set Assistant (MDSA) 2 stated that anyone on the Interdisciplinary team (group of disciplines who develop resident plan of care) can create a care plan. MDSA 2 stated when the social worker identified the severe depression a care plan could have been generated. MDSA 2 stated nursing staff could have also created a care plan at the time of admission for larger concerning issues such as wandering or severe depression.
Based on observation, interview, and record review the facility failed to ensure nursing staff had appropriate competencies and skills sets for developing and implementing plan of care for 18 sampled residents when:
1. Resident 2 did not have the direct care staff supervision for safety during meals.
2. Direct care staff did not ensure Resident 68 had eye glasses available for use.
3. Direct care staff did not provide necessary grooming, nail care, and bed bath services for three of seven dependent residents (Residents 8, 38 and 70).
4. Nursing staff did not develop and implement a plan of care for severe depression for Resident 38.
5. Resident 73 had no interventions in place to mitigate his wandering behavior.
This had the potential to put all residents at risk for accidents and hazards and decreased quality of care and life.
Findings:
1. During a concurrent observation and interview with CNA C on 3/9/23 at 9 AM, stated that she was assigned to Resident 2 but not too often. CNA C stated that Resident 2 needed set up meals only without utensils and condiments. CNA confirmed that it was overlooked this morning when the tray was given to Resident 2.
During an interview with CNA A on 3/9/23 at 9:10 AM, stated this incident happened three times already a month ago with the unopened small plastic butter pack in her mouth. CNA A stated that this was communicated by Licensed Nurse (LN) A because of what happened in the past. CNA A stated that there should have been a note sent to the kitchen not to have any condiments on the tray.
During a concurrent interview and record review on 3/9/23 at 9:35 AM, LN B explained that before the tray was passed to the residents that it should be checked first before CNA gave it to resident. Check diet, thickness, to ensure residents getting the right diet. LN B further explained to call the kitchen, put in the computer under communication log for everyone to see. LN B was unable to find in the communication section that it was communicated to the kitchen. LN B stated that the tray was checked this morning before it was passed but just overlooked the condiments.
During a concurrent interview and record review with the MDS Assistant (MDSA) 1 on 3/9/23 at 10:25 AM, confirmed that there was no care plan developed for Resident 2's potential risk of choking hazard during mealtimes.
During a concurrent interview and record review with the Director of Nursing (DON) on 3/9/23 at 11:30 AM, stated that she was not made aware of the incident in the past as it was not documented anywhere in the record. DON further discussed the facility process that licensed nurses should have communicated to the dietary services and then the diet card should have been updated. DON confirmed there was no plan of care addressed in Resident 2's record.
2. A review of the Social Service assessment dated [DATE] indicated that Resident 68 marked as having eye glasses.
During an observation on 3/7/23 at 4:17 PM, Resident 68 had no corrective lenses such as eye glasses.
During an observation on 3/9/23 at 8:30 AM, Resident 68 was up in wheel chair in room eating breakfast, and fed self. No eye glasses observed.
During a concurrent observation and interview on 3/9/23 at 8:35 AM with CNA A, confirmed Resident 68 did not wear eye glasses. CNA A looked in the drawer and found to be uncleaned. CNA A cleaned the eye glasses and gave to Resident 68. CNA A was asked about when was the last time Resident 68 have them. CNA A stated she can't recall.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on interview, observation and record review, the facility failed to ensure safe medication storage in two out of three medication rooms (a locked room storing the drugs and supplies) and three o...
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Based on interview, observation and record review, the facility failed to ensure safe medication storage in two out of three medication rooms (a locked room storing the drugs and supplies) and three out of six medication carts (a secure mobile cart storing resident's medications) when:
1. Medication refrigerators (a locked temperature-controlled unit for medication storage) were frosted where vaccines, and insulin (Medicine for blood sugar or diabetic disease) products were stored.
2. Multi dose containers (a bulk container that can be used more than once) of medication and supplies were not dated when first opened and not stored per manufacturer labeling (the drug maker's label on how to store or use the product).
3. Medication refrigerator and emergency kit for narcotic medications (or Ekit contained supply of narcotics or controlled drugs with abuse potential) were not secured with a lock in the medication room.
These failures could contribute to unsafe or ineffective medications use in the facility.
Findings:
1A. During a concurrent observations and inspection of the facility's [NAME] unit (a unit within the facility) medication room, on 3/7/23, at 10:45 AM, accompanied by Licensed Nurse D (LN D), the medication refrigerator back wall on the middle shelf was frosted and medication boxes contained flu vaccine (flu or influenza vaccine; brand name Flucelvax, the flu shot for year 2022- 2023) and insulin products were in contact with the white frost. LN D confirmed the finding.
1B. During a concurrent observations and inspection of the facility's East unit medication room, on 3/7/23, at 11:01 AM, accompanied by Licensed Nurse E (LN E), the medication refrigerator's back wall on second and third shelves were frosted. More than 8 medication boxes for flu vaccine were attached and stuck to the frost and could not be removed by hand. The facility's refrigerator kit (or Emergency kit (Ekit) for insulin and refrigerated medications) was stored on the top shelf with frosted wall. LN E acknowledged the finding and stated she was not sure why it was not noticed since they checked the temperature twice daily.
2A. During a concurrent observation and inspection of medication room in the [NAME] unit station, on 3/7/23, at 10:48 AM, accompanied by LN D, the unlocked medication refrigerator stored an undated, opened vial of testing agent called Aplisol (used to test for TB or tuberculosis, a serious lung infection) when the label on the box indicated once entered, vial should be discarded after 30 days. LN D acknowledged the findings.
2B. During a concurrent observation and inspection of medication cart #1, in the [NAME] unit station, on 3/7/23, at 2:31 PM, accompanied by Licensed Nurse H (LN H), the following multi dose containers stored in the medication cart:
i. One opened bottle of probiotic called Acidophilus (a brand name probiotics which contained a mixture of live bacteria and/or yeast used as supplement) stored in the medication cart #1 for daily use. The product label on the bottle indicated Store unopened container at room temperature; REFRIGERATE AFTER OPENING. LN H acknowledged the finding.
ii. One Opened vial of injectable (into the vein or muscle or skin) numbing medicine called lidocaine (or Xylocaine, used to numb the skin and reduce pain during injection) was not dated when first opened. The label on the bottle noted as Sterile . Multiple Dose Vial. LN H acknowledged the finding.
iii. Opened purple color foiled pouch, for inhalation (breathing) medicine called Budesonide inhalation Suspension (medicine used with a machine to improve breathing) was not dated when first opened. The manufacturer label on the pouch indicated Once the foil envelope is opened, use the vials within 2 weeks. LN H acknowledged the finding.
iv. Multiple opened foiled pouches, for an inhalation medication called Ipratropium . and Albuterol . (or DuoNeb, combination of two medicines used to treat the shortness of breath), were not marked with date that it was opened. The manufacturer label on the pouch indicated Once removed from the foil pouch, the individual vials should be used within one week. LN H acknowledged the finding.
2C. During a concurrent observation and inspection of medication cart #3, in the East unit station, on 3/7/23, at 3: 08 PM, accompanied by Licensed Nurse I (LN I), the following multi dose containers stored in the medication cart:
i. Two opened bottles of probiotic called Acidophilus (a brand name probiotics which contained a mixture of live bacteria and/or yeast used as supplement) stored in the medication cart #3 for daily use. The product label on the bottle indicated Store unopened container at room temperature; REFRIGERATE AFTER OPENING. LN I acknowledged the finding.
ii. One opened container of a medicine called INCRUSE Ellipta (an inhalation medication used to help with chronic breathing disease of the lung) was not marked with the date that it was first opened. The manufacturer label on the container indicated Discard the inhaler 6 weeks after opening the moisture-protective foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. LN I acknowledged the finding.
iii. One opened foiled pouch, for an inhalation medication called Ipratropium . and Albuterol . (or DuoNeb, combination of two medicines used to treat the shortness of breath), stored in medication cart #3, was not marked with the date that it was opened. The manufacturer label on the pouch indicated Once removed from the foil pouch, the individual vials should be used within one week. LN I acknowledged the finding.
3A. During a concurrent observation and inspection of medication room in the [NAME] unit station, on 3/7/23, at 10:48 AM, accompanied by LN D, the unlocked medication refrigerator stored two controlled medications called dronabinol (or Marinol, a controlled medication for appetite). LN D acknowledged the finding and stated that someone must have forgotten to lock the refrigerator.
3B. During a concurrent observation and inspection of medication room in the East unit station, on 3/7/23, at 10:59 AM, accompanied by LN E, the medication refrigerator was unlocked. LN E stated the refrigerator should have been locked after each use.
3C. During a concurrent observation and inspection of medication room in the East unit station, on 3/7/23, at 11:10 AM, accompanied by LN E, the cabinet that stored narcotic Ekit was unlocked. LN E stated that the cabinet was supposed to be locked when not in use.
In an interview with Director of Nursing (DON), in her office, on 3/8/23, at 10:31 AM, the DON stated the refrigerator temperature were assessed and documented twice a day and the licensed staff should have had a critical eye and alert the maintenance for any issues. DON stated the refrigerator should have remained locked when not in use and the keys were held only by the medication nurse and the charge nurse. The DON stated the licensed staff should follow the manufacturer mandate and/or the facility's policy for medications with short dating once opened. DON stated she expected the staff to lock the cabinet door where the narcotic Ekit stored.
Review of the facility's policy, titled Refrigerators and Freezers, with revision date of 12/2014, the policy on section 9 indicated Supervisors will inspect refrigerators and freezers monthly for . fan condition, presence of rust, excess condensation and any other . maintenance needs.
Review of the facility's policy, titled Administering Medications, last revised on 4/2019, the policy on section 12 indicated The expiration/beyond use date on the medication label is checked . When opening a multi-dose container, the date opened is recorded on the container.
Review of the facility's policy, titled Storage of Medications, last revised on 11/2020, the policy on section 6 indicated Compartments (including . refrigerators .) containing drugs . are locked when not in use .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
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 qualifications, competencies, and skill sets of the Regi...
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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 qualifications, competencies, and skill sets of the Registered Dietitian (RD) and the Dietary Manager (DM) were in place and supported to carry out the functions of the food and nutrition service when:
1. A qualified dietician or other clinically qualified nutrition professional was not employed at the facility full time.
2a. The RD did not monitor or implement weekly weights for three out of three residents: Resident 4
2b. Resident 59
2c. Resident 85
3. The DM did not meet the minimum qualifications.
4. The DM did not evaluate new staff for competencies. (Refer to F802)
These failures had the potential to result in foodborne illness, compromise nutritional status, weight loss, ineffective resident care interventions and decreased quality of life impacting 89 residents who lived in the facility.
Findings:
1. During an interview on 3/8/23, at 2:10 PM, RD stated hours worked at this facility were approximately 24-25 hours a week and divided RD's time between two facilities. RD stated it would be difficult to quantify how many hours were spent working in the dietary department (kitchen) versus the hours worked out on the floor with residents. RD confirmed the majority of hours worked at this facility had been spent out on the floor performing nutrition assessments.
A review of the record titled, Dietician, with a handwritten date of 5/16/22, indicated specific requirements for the RD was to be knowledgeable of law, regulations, and guidelines governing dietary functions in the nursing facility.
2a. A review of Resident 4's records indicated admission to the facility on 3/22/17 with the diagnoses that included type 2 diabetes and adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition). Resident 4 had good cognition (ability to think, reason, and remember), and was able to make his own decisions.
During an interview on 3/9/23 at 3:08 PM, RD stated if a resident triggered for severe weight loss (significant weight loss was 5% or more in total body weight, severe weight loss was 10% or more in total body weight), RD would request weekly weights to be implemented if the weight loss was due to a nutritional reason.
During a concurrent interview and record review on 3/10/23 at 11:33 PM, RD reviewed the record titled, Weights for Residents 4. RD acknowledged Resident 4 triggered for a severe weight loss on 12/5/22 and the next weight obtained was on 12/26/22. RD acknowledged Resident 4 triggered for a significant weight loss on 2/2/23 and the next weight obtained was on 3/2/23.
A review of Resident 4's record titled, Weight Note, Interdisciplinary meeting note (IDT-group of health care disciplines that meet to discuss resident care needs), dated 12/7/22 and 2/8/23, did not reflect weekly weights discussed as an intervention during the IDT weight meeting.
A review of Resident 4's record titled, Order Details, dated 4/7/22 indicated the physician had ordered Resident 4 to be weighed weekly.
2b. A review of Resident 59's records indicated admission to the facility on 6/8/22, with the diagnoses that included lung disease and dysphagia oropharyngeal (difficulty swallowing). Resident 59 had good cognition (able to think and reason) and made her own decisions.
During a concurrent interview and record review on 3/10/23 at 11:33 AM, RD reviewed the record titled, Weights for Residents 59. RD acknowledged Resident 59 triggered for severe weight loss on 12/20/22 and the next weight obtained was on 1/4/23. RD acknowledged Resident 59 triggered for severe weight loss on 3/2/23 and no weight had been entered for 3/9/23, one week after triggered weight loss.
A request had been made for Resident 59's Weight Notes. No weight notes that discussed triggered weight loss or weekly weight interventions were included for dates: 12/20/22 and 3/2/23. Weight Notes provided were dated 11/23/22, 11/30/22, 12/7/22, and 12/14/22.
A review of Resident 59's record titled, Order Details, dated 11/18/22, indicated Resident 59 was to be weighed on admission and weekly for three weeks. No other weight orders had been noted.
2c. A review of Resident 85's records indicated admission to the facility on [DATE] with diagnoses that included lung disease and unspecified severe protein-calorie malnutrition (if resident had two or more of the following: muscle wasting, loss of subcutaneous fat, poor national intake, bedridden, significant reduced functional capacity). Resident 85 had good cognition and made his own decisions.
A review of Resident 85's record titled, Weight Note, dated 11/30/22, 12/7/22, 12/14/22, and 12/29/22 did not reflect weekly weights discussed as an intervention during the IDT weight meeting.
A review of Resident 85's record titled, Order Details, dated, 1/11/23, indicated Resident 85 was to be weighed upon admission and weekly for three weeks.
During an interview on 3/9/23 at 3:08 PM, RD stated if a resident triggered for severe weight loss RD would request weekly weights to be implemented if the weight loss was due to a nutritional reason.
During a concurrent interview and record review on 3/10/23 at 11:33 AM, RD reviewed the record titled, Weights for Residents 85. RD acknowledged Resident 85 triggered for severe weight loss on 11/28/22 and the next weight obtained was on 12/5/22. RD confirmed Resident 85 triggered for severe weight loss on 12/20/22 and the next weight was obtained on 3/2/23, almost two months later. RD confirmed inconsistent weight monitoring could potentially contribute to weight loss and weights were not being done the day after the weight trigger alert or weekly for Resident 4, 59, and 85. RD stated during IDT meetings, she would alert nursing if there was a need for weekly weights and the nursing staff would obtain the weights. RD confirmed IDT meeting notes did not reflect weekly weights to be implemented.
During a concurrent interview and record review and on 3/10/23 at 12:44 PM, Director of Nursing (DON) stated weight loss was not divided up between nutritional weight loss or weight loss caused by a medical reason. DON stated if a resident had a weight loss or gain that was significant or greater, the RD was responsible for contacting the physician for weekly weights and nursing was responsible for entering the weekly weight order. DON reviewed weights for Residents 4, 59, and 85 and confirmed weekly weights had not been obtained. DON stated weight loss was discussed collectively during IDT meetings and weight loss interventions would be developed.
A review of the record titled, Dietician, with the handwritten date of 5/16/22, indicated RD job duties and responsibilities included ensuring food service notes were informative, descriptive, and the resident's response to service. It included developing a written dietary plan of care that identified the dietary problems or needs when identified and to review goals for modification as necessary.
A review of the facility's policies and procedures (P&P) titled, Weight Assessments and Interventions, revised 9/1/08, indicated any weight loss of 5% or more would be retaken the next day for confirmation.
A review of the P&P titled, Nutritional Assessment, revised 10/1/17, indicated the nutritional assessment will be a systematic, multidisciplinary process that included gathering and interpreting. The P&P indicated collected data would be used to help define meaningful interventions for residents at risk for or with impaired nutrition.
3. During an interview on 3/7/23, at 9:35 AM, DM stated being the manager of the dietary department for one year.
During an interview on 3/9/23 at 1:50 PM, DM stated the facility provided the materials needed for obtaining required Certified Dietary Manager (CDM) title and had not filed to take the test.
During an interview on 3/10/23, at 10:42 AM, Administrator (ADMIN) confirmed DM had not completed CDM requirements.
A review of the record titled, Dietary Supervisor Food Services, with the handwritten date of 6/16/21, indicated specific requirements for DM's role. The specific requirements listed must be registered as a Food Service Director in this state.
4. During an interview on 3/9/23, at 1:50 PM, DM described the training protocol for new dietary staff. DM stated new staff received a tour of the kitchen, were oriented to locations of equipment, new staff reviewed their job descriptions and utilized other staff members to provide one on one training. DM stated new staff had a competency checklist and performed their own self-evaluation. DM stated if the staff felt they required more training in certain areas, DM would provide additional training.
A review of the record titled, Dietary Supervisor Food Services, with a handwritten date of 9/16/21, indicated DM job duties and responsibilities included performing administrative duties such as evaluations. The record indicated the DM was responsible to review and check competence of food services personnel and make necessary adjustments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure staff were competent to perform food safety processes according to professional standards when:
1. Equipment was not cl...
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Based on observation, interview and record review, the facility failed to ensure staff were competent to perform food safety processes according to professional standards when:
1. Equipment was not cleaned according to professional standards of practice. (Refer to F812)
2. Four out of four chicken breasts were thawing at room temperature. (Refer to F812)
3. Staff used the wrong test strips and documented incorrect results when testing the dishwasher's chlorine level. (Refer to F812)
4. Dietary Manager (DM) did not evaluate new staff for competencies.
Failure to ensure staff were competent in food safety processes had the potential to result in foodborne illness for 89 residents consuming food from the facility.
Findings:
1. During a concurrent observation and interview on 3/7/23 at 9:35 AM, in the kitchen's dry storage area, the lid that covered the brown rice was upside down and was covered in gray substance buildup. In the food prep area, two drawers containing food prep items were soiled. The wall mounted fan located in the food prep area pointed towards the tray line had thick gray substance and debris on the fan blades. The walk-in refrigerator had thick gray substance build up on the fans. DM and DMA confirmed findings.
During an observation and interview on 3/7/23 at 10:02 AM, 10 out of 10 sheet pans, the oven, stove, tray line steam table, and stationary can opener were observed to have a heavy buildup of grime. DMA confirmed findings.
During a concurrent observation and interview on 3/8/23 at 10:02 AM, a large fan sitting on the floor, facing four carts of clean dishes, was forcefully blowing across the dirty floor toward the drying dishes. The fan had a thick build up of gray substance and black string like material hanging off the metal fan frame. DA 3 confirmed the fan was being used to dry the clean dishes.
During a concurrent observation and interview on 3/9/23 at 9:46 AM, DA 3 had been asked to describe the cleaning and sanitization process for surfaces and equipment that was non removable (cannot go through the dishwasher). DA 3 pointed to a spray bottle filled with sanitizer and stated DA 3 would spray the equipment down then wipe dry. Spilled milk was observed on a dietary cart. DA 3 was asked about process for cleaning and sanitizing the cart. DA 3 stated a peroxide sanitizer would be used. DA 3 stated the cart would not be cleaned prior to sanitizing.
During an interview on 3/9/23 at 1:50 PM, DM and DMA confirmed a large fan was being used to dry clean dishes, the fan was dirty, and should be cleaned weekly or as needed.
2022 FDA Food Code Annex 3, 4-602.13, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
2022 FDA Food Code 4-204.11 Ventilation Hood Systems, Drip Prevention. Exhaust ventilation hood systems in FOOD preparation and WAREWASHING areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES.
2. During a concurrent observation and interview on 3/7/23 at 9:29 AM, four uncovered, partially frozen chicken breasts were observed on a sheet pan located in a rack of clean sheet pans. Dietary [NAME] (DC) confirmed four chicken breasts were on the sheet pan that was in the sheet pan rack and stated the chicken had been prepped on the pan. DC stated DC got sidetracked, and forgot the chicken breasts were there. CD confirmed frozen meat should not be thawed at room temperature.
2022 FDA Food Code 3-501.13 Thawing.
Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed:
(A) Under refrigeration that maintains the FOOD temperature at 5oC (41°F) or less Pf; or
(B) Completely submerged under running water:
(1) At a water temperature of 21 C (70°F) or below Pf,
(2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and
(3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41°F) Pf, or
(4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41°F), for more than 4 hours including:
(a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or
(b) The time it takes under refrigeration to lower the FOOD temperature to 5oC (41°F) Pf;
3. During a concurrent observation and interview on 3/7/23 at 12:43 PM, DA 2 demonstrated the chlorine (sanitizer used in dish machine) testing procedure of the dish washer water. DA 2 used a QT-40 Hydrion test strip to test the water. DA 2 stated and demonstrated dipping the test strip into the pool of water in the bottom of the dish machine for 30 seconds, then matched the colors with the test strip. The test strip became a pale cream color, most closely matching 150 parts per million (ppm) on the test strip container. Observed poster on wall, next to where DA 2 performed chlorine test, indicated Chlorine testing procedure, color match, instructions to dip, remove immediately, and read sample within 5-10 seconds. DA 2 was observed entering data onto the record titled, Dishwasher Temperature Log and Chlorine Test Log for Low Temperature Machines. The numbers entered did not reflect the results of the test strip used. DA 2 entered 75 under the chlorine ppm section and the test strip used showed a result of 200 ppm.
During a concurrent observation and interview on 3/7/23 at 3:45 PM, the QT-40 Hydrion test strip package and instructions previously used by DA 2 to test the chlorine in the dish machine had been reviewed. The package indicated the test strip had been for use with Quat sanitizer. Directions indicated to dip for 10 seconds, compare colors at once. Dietary Manager Assistant (DMA) provided the QT-40 Hydrion test strip and stated they should be dipped in the pool of water in the bottom of the dish machine at the end of the cycle.
During a concurrent observation and interview on 3/7/23 at 4 PM, an External Technician (ET, outsourced technician with knowledge of kitchen equipment and testing) confirmed the QT-40 Hydrion test strips were for quat sanitizer not for the chlorine used in the dish machine. DMA arrived and produced another test strip. ET confirmed that test strip was incorrect. DMA produced a third test strip; ET confirmed the test strip was correct and stated the chlorine test strips should be touched to the rack or a plate immediately after the last cycle ends. ET stated the test strip should not be dipped in the pool of water in the bottom of the dish machine. DMA stated education and training provided to DMA was to dip the test strip in water.
During a concurrent interview and record review on 3/9/23, at 4 PM, DM stated in February, the chlorine test strips were expired, thrown away, and the chlorine test strips had not been replaced. A review of the record titled, Dishwasher Temperature Log and Chlorine Test Log, for Low Temperature Machines had 20 entries for the month of March that were all identical. DMA and ET confirmed the test strip results entered on the log did not match the results from the QT-40 Hydrion test strips that were used.
2022 FDA Food Code 4-302.14 Sanitizing Solutions, Testing Devices.
A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided.
4. During an interview on 3/9/23 at 1:50 PM, DM described the training protocol for new dietary staff. DM stated new staff received a tour of the kitchen, were oriented to locations of equipment, new staff reviewed their job descriptions and utilized other staff members to provide one on one training. DM stated new staff had a competency checklist and performed their own self-evaluation. DM stated if the staff felt they required more training in certain areas, DM would provide additional training.
A review of the record titled, Dietary Supervisor Food Services, with a handwritten date of 9/16/21, indicated DM job duties and responsibilities included performing administrative duties such as evaluations. The record indicated the DM was responsible to review and check competence of food services personnel and make necessary adjustments.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
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 provide two out of two residents (Residents 85 and 4) ...
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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 two out of two residents (Residents 85 and 4) with plant-based (vegetarian) meals that met the nutritive needs of the residents when:
1. Planned vegetarian menus, prepared in advance, that included a nutrient analysis and alternates (a meal substitute provided when the served menu item was not wanted by the resident) for Resident 85 and Resident 4, were not followed, and were not available for residents or staff.
2. Alternate menu food items did not have a recipe.
These failures created the potential for vegetarian residents to receive food that did not meet their nutrient needs and or provide the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss.
Findings:
1. A review of Resident 85's records indicated admission to the facility on [DATE] with the diagnoses that included unspecified dementia (memory loss) and unspecified protein-calorie malnutrition (a lack of proper nutrition or inability to absorb nutrients from food). Resident 85's cognition (ability to reason, think and make decisions) was intact and he was able to make his own decisions. Resident 85 did not speak English, was a vegetarian and required the assistance of one person and supervision during all meals.
A review Resident 4's records indicated admission to the facility on 3/22/17 with diagnoses that included type two diabetes, unspecified dementia, and adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition). Resident 4's cognition was intact and was able to make his own decisions. Resident 4 was a vegetarian and required the assistance of one person to set up meal trays and provide supervision during meals.
During an interview on 3/7/23 at 12:30 PM, Dietary [NAME] (DC) stated there was no spreadsheet for the vegetarian diets, DC tried to match the vegetarian meals to the regular meals by substituting with vegetarian meat. DC was asked how to know what to serve the vegetarian residents and give them variety when there was no guide or spreadsheet, and no record of what the previous cooks had chosen to serve. DC stated to ask the night cook what they served.
During a concurrent interview and record review on 3/8/23 at 2:10 PM, Registered Dietician (RD), Dietary Manager (DM) and Dietary Manager Assistant (DMA) confirmed there was not a readily available spreadsheet or menu for vegetarian diets. RD, DM, and DMA stated their menu company had a vegetarian menu with a nutrient analysis. DMA printed out menu with vegetarian alternatives and analysis. The record titled Good for Your Health Menus, dated 3/6/23 through 6/4/23 had been reviewed. DM and DMA confirmed the vegetarian meals that had been served to Resident 85 and Resident 4 this week did not match the Good for Your Health Menu.
2. During a concurrent interview and record review on 3/8/23, at 1:04 PM, DC provided the record titled Good for Your Health Spring Recipe Book for review. DC confirmed there were no recipes directed for tray line alternative protein and vegetables and stated the cook chose how to prepare it. For example, DC was preparing chicken breasts as an alternate food item, and DC stated not using a recipe when preparing the chicken breasts.
During a concurrent interview and record review on 3/8/23, at 1:10 PM, DM stated the main alternate menu choices had recipes. DC confirmed the choice for alternate for tray line and how they are prepared was per cook Preference.
A review of the record titled, Spring Cycle Menus Spreadsheet, dated 3/8/23 did not include alternate food items.
A review of the record titled, Good for Your Health Menus, dated 3/6/23 through 6/4/23 did not include alternate food items the residents could request.
A request for the diet manual that discussed vegetarian diets had been made. Documents were not provided.
A review of the Spring 2023 Meal Service Alternatives, flyer that had been provided, indicated residents had the choice of a chef's salad, chicken quesadilla, or a grilled cheese sandwich as an alternative in place of the regular menu being served.
A review of the record titled, Job Duties, with the handwritten date of 4/23/22, indicated the DMA was responsible to ensure that menus were maintained and filed in accordance with established policies and procedures.
A review of the record titled, Job Duties, with the handwritten date of 9/16/21, indicated DM was responsible to ensure that menus were maintained and filed in accordance with established policies and procedures.
A review of the record titled, Job Duties, with the handwritten date of 5/16/22, indicated the RD was responsible to ensure that menus were maintained and filed in accordance with established policies and procedures, assist the DM in planning menus, and assure substitute foods of similar nutritive value are provided to residents.
A review of the facility's policy and procedure (P&P) titled, Standardized Recipes, revised 4/1/07, indicated only standardized would be used to prepare foods. The P&P indicated the Food Service Manager would maintain the recipes and make them available to Food Service staff as necessary.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure food was served at an appetizing temperature when four out of four residents (Resident 4, 19, 38, and 59) stated the food was cold.
T...
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Based on observation and interview, the facility failed to ensure food was served at an appetizing temperature when four out of four residents (Resident 4, 19, 38, and 59) stated the food was cold.
This failure had the potential for a decrease in meal intake and could contribute to weight loss resulting in compromised nutritional status.
Findings:
During an interview on 3/8/23 at 1:05 PM, Resident 19 and Resident 59, both stated when meals got delivered to them, their food was cold.
During an interview on 3/8/23 at 1:06 PM, Resident 38 stated the eggs served were always cold.
During an observation on 3/8/23 at 11:37 AM, the dining cart that contained lunch trays for the residents who ate meals in the assisted dining room (dining area for residents who needed assistance to eat) was placed in the independent dining room (where residents eat meals who do not require assistance). An overhead page on the facility intercom system had been made stating that the dining cart was ready for staff pickup.
During an observation on 3/8/23 at 11:43 AM, the Social Services Assistant arrived and took the dining cart to the assisted dining hall.
During an observation on 3/8/23 at 11:44 AM, the dining cart was delivered to the assisted dining room.
During an observation on 3/8/23 at 11:45 AM, Licensed Nurse (LN) A began passing out trays to the residents.
During an observation on 3/8/23 at 12:03 PM, the last lunch tray had been delivered and the last resident began eating her meal at 12:05 PM.
During an observation and interview on 3/8/23 at 12:06 PM, the Dietary Manager (DM) obtained a temperature of the food on the test trays with a facility dial thermometer (thermometer with a red pointer that moved in a circular motion that indicated a temperature).
The DM, facility's Administrator (Admin), and Registered Dietician (RD), were present during test tray food temperatures and tasted each food item along with surveyors. The regular test tray (containing food for a resident with no dietary restrictions) temperatures were: turkey 80 degrees Fahrenheit (°F), sweet potato 90°F, peas and cauliflower 82°F, and the salad was 70°F. The pureed (food that was blended and a smooth texture like mashed potatoes) test tray temperatures were: turkey 80°F, sweet potato 70°F, peas and cauliflower 76 °F, and the salad was 68°F. Admin, RD, DM confirmed pureed peas and sweet potatoes were lukewarm (not hot). Admin, RD, and DM confirmed regular peas and cauliflower were cold. Staff did not acknowledge surveyor's statement regarding regular and pureed turkey being cold.
During an interview on 3/9/23 at 4:21 PM, Resident 4 stated that sometimes the food was cold.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed...
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Based on observation, interview and record review, the facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of services the facility provided when:
1. A qualified Registered Dietician (RD) or other clinically qualified nutritional professional were not employed at the facility full time who was responsible to carry out the functions of the food and nutrition service and that their Dietary Manager (DM) did not meet the minimum qualifications.
2. Licensed Nursing staff did not develop and implement a plan of care for five of 18 sampled residents (Resident 2, 38, 68, 72, and 73).
3. Certified Nursing Assistants (CNA)s had the skills and competencies to assist dependent residents with their Activities of Daily Living (ADL).
This failure had the potential for all residents to be at risk for decreased quality of care and quality of life.
Findings:
A facility policy and procedured titled, QAPI Program, revised 2/1/20, was reviewed. The policy indicated the facility should have developed, implemented and maintained an ongoing, facility-wide, data-driven (based on analyzed information) QAPI program that was focused on indicators (signs) of the outcomes (measurable results) of care and quality of life for the residents. Among the objectives (goals) of the QAPI program was to provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. The owner and/or governing board (body) of the facility was ultimately responsible for the QAPI program. The QAPI committee reported directly to the administrator (ADMIN). The QAPI plan described the process for identifying and correcting quality deficiencies (failures). Key components of the process included: a) tracking and measuring performance; b) establishing goals and thresholds (targets) for performance measurement; c) identifying and prioritizing quality deficiencies; d) systematically analyzing underlying causes of systemic quality deficiencies; e) developing and implementing corrective action or performance improvement activities; and f) monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising them as needed.
1 A. RD did not monitor or implement weekly weights for three out of three residents (Residents 4, 59 and 85).
B. DM and RD did not ensure professional food safety and sanitation practices were in place and did not evaluate new staff for competencies to perform food safety processes according to professional standards when:
C. Equipment was not cleaned according to professional standards of practice.
D. Four out of Four chicken breasts were thawing at room temperature.
E. Staff used the wrong test strips and documented incorrect results when testing the dishwasher's chlorine level.
F. Dietary staff were not cleaning equipment prior to sanitizing.
G. Inappropriate use of hats and hairnets were observed for three dietary staff members.
H. Four out of four chicken breasts were not stored and handled according to professional standards of practice.
I. Chlorine test strips were not available to all staff, two out of two staff used the wrong test strip, and chlorine test strip results were incorrectly.
J. The walk-in freezer floor, dry storage rice bin, prep area drawers, stationary and non-stationary fans, reach-in refrigerator, and the ice machine were not clean.
K. The stove, oven, tray line, stationary can opener, and sheet pans were non cleanable due to a black residue build up and grime.
L. The tray line cutting board was severely scored with non-cleanable blacked surfaces that appeared to be melted.
2. Licensed Nurses did not create and implement resident comprehensive care plans to address their needs when:
A. Resident 2 for potential risk of choking hazards during mealtimes (Refer F689);
B. Resident 68 for impaired visual function ;
C. Resident 38 for severe depression;
D. Resident 73 wandering around the facility and;
E. Resident 72 the use of arm brace.
3. CNAs did not demonstrate competencies to assist residents in their ADLs when:
A. Direct care staff did not provide necessary grooming, nail care, and bed bath/shower services for three of seven dependent residents (Residents 8, 38 and 70).
B. Resident 2 did not have the direct care staff supervision for safety during meals.
C. Direct care staff did not ensure Resident 68 had eye glasses available for use.
During an interview on 3/10/23, at 9:34 am, ADMIN shared their QAPI topics for the last year. These included resident falls, issues with pharmacy and psychotropic medication documentation, lithium (a psychiatric medication) monitoring and management, narcotic medication destruction, and Clinical Risk Assessments. ADMIN could not recall any issues identified with the dietary department or direct care staff competencies that had been part of the QAPI plan for the last year.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe infection control practices when:
1. Licen...
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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 safe infection control practices when:
1. Licensed nurses (LNs) did not sanitize their hands upon entering or exiting five resident's rooms when direct care was provided.
2. Licensed nurse did not sanitize the shared glucometer (a device used to measure blood sugar) in between resident care for Resident 80, Resident 19, and Resident 7.
3. Licensed nurse did not sanitize the shared blood pressure device (or BP device that measured the pressure of blood pushing against the walls of the arteries) in between resident care provided for Resident 80 and Resident 19.
These failed practices may result in spread of infection in the facility.
Findings:
1A. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated [DATE], indicated, This facility considers hand hygiene the primary means to prevent the spread of infection, and, .7. Use an alcohol-based hand rub containing at least 62% alcohol .for the following situations: f. Before donning sterile gloves.
During an observation on [DATE] at 8:50 AM, LN A entered the room of a resident with transmission based precautions and donned surgical gloves without re-washing her hands after touching multiple items. In a concurrent interview, LN A acknowledged that her hands should be sanitized prior to donning gloves.
1B. During a medication pass observation with LN F, in facility's [NAME] Station, on [DATE] at 9:28 AM, LN F entered Resident 24's room to administer the morning medications. LN F did not sanitize her hands before going into the room or after exiting the room.
1C. During a medication pass observation with LN F, in [NAME] Station, on [DATE] at 9:35 AM, LN F entered Resident 74's room which had a yellow color sign posted on the door, indicating Contact Precautions, (required hand washing or gloves after direct care of the patient). LN F administered medications and to answer resident's question, she re-entered the room with her portable laptop computer briefly. LN F did not sanitize hand with alcohol-based sanitizing gel before and after entering the room. LN F then proceeded to administer medications to Resident 51 (roommate of the Resident 74) which was mixed in an apple sauce for administration. LN F did not sanitize hand before entering the room and after exiting the room.
1C. During medication pass observation with LN F, on [DATE] at 10:19 AM, in the [NAME] station, LN F prepared medications for Resident 8. LN F mixed the pills in apple sauce and poured a topical drug called Diclofenac (applied to skin to help with pain relief) into a cup, then went inside Resident 8's room for administration. LN F entered the room without hand sanitization, administered the pills first, then put on glove in one hand (the right hand) and applied the cream to the resident's leg/knee area. LN F then removed the glove, did not sanitize her hands, and proceeded to the next resident. LN F moved on to administer medications to Resident 52 (which was roommate to Resident 8) including an eye drop called Refresh Plus (lubricating eye drop). LN F did not use gloves or tissues to administer the eye drop in both eyes.
During an interview with LN F on [DATE] at 2:25 PM, in the West's nursing station, LN F stated she was running behind on her medication administration during observation and probably didn't do hand sanitization. LN F stated the hand gel bottle on her medication cart was discarded that morning because it was expired (or no longer good to use).
1E. During a concurrent observation and interview on [DATE] at 8:50 AM, LN A entered the room of a resident with transmission-based precautions and donned (put on) gloves without re-washing her hands after touching multiple items. LN A stated that there had been extensive hand hygiene training at the facility and acknowledged that hands should be sanitized prior to donning gloves.
During an interview with Director of Nursing (DON) on [DATE] at 10:15 AM, the DON stated the clinical staff and nurses should use hand sanitization upon entering and exiting a resident's room and if any resident care involved touching the skin, they should wear gloves and sanitize hand before and after putting or removing the gloves.
During an interview with facility's Infection Preventionist (IP, staff member with expertise in helping facility follow rules in preventing spread of contagious disease) on [DATE] at 11:23 AM, the IP stated she expected the nursing staff to either use alcohol-based sanitizing gel or wash hands upon entering or exiting a resident's room. The IP stated the hands should be washed if heavily soiled or after each patient care or therapy that involved with touch of the skin or body. The IP stated if a resident had an isolation precaution warning, the staff should use gloves or gown for cares such as wound care, incontinent care (means bowel accidents), foley care (means the bag that collected the urine) or changing the linen.
Review of the facility's policy titled, Handwashing/Hand Hygiene, last revised on 8/2019, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy instructed facility staff to use an alcohol-based hand rub or soap and water for the following situations; before preparing or handling medications, after contact with resident's skin, after removing gloves and before and after entering isolation precaution setting.
2A. During a medication administration observation with LN F, in the facility's [NAME] unit, on [DATE] at 9:56 AM, LN F grabbed the glucometer, a test strip (a testing strip inserted in glucose machine to help measure the sugar in the blood), lancet (a sharp device used to prick the finger to get drops of blood for testing blood sugar) and alcohol pads into Resident 80's room to measure the blood sugar. LN F did not perform hand sanitization and did not use gloves when using the lancet to get blood from the finger or performing the blood sugar check by glucometer. Once the blood sugar measured, LN F did not sanitize hand, discarded the used test strip, lancet and alcohol pad in the disposal containers. LN F then proceeded to her cart where she used one alcohol pad to quickly wipe the outer surface of glucometer and placed it in the drawer.
During an interview with LN F on [DATE] at 2:25 PM, in the West's nursing station, LN F stated she did not believe she used gloves during her blood sugar check. LN F stated she cleaned the glucometer with an alcohol wipe because that was all she had available at her cart.
2B. During a medication administration observation with LN G in [NAME] unit, on [DATE] at 4 PM, LN G gathered glucometer, test trip, lancet and alcohol pad and put on gloves entered the Resident 19's room to measure blood sugar. LN G measured the blood sugar and exited the room. LN G removed gloves and rubbed hand with sanitizing hand gel. LN G was observed further with no gloves on, used one sanitizing wipe labeled Disposable Germicidal Surface Wipes, and quickly wiped the outer surface of the glucometer for less than 10 seconds. LN G then proceeded to next room to measure Resident 7's blood sugar using the same glucometer. LN G administered the medication to the Resident 7 and then put on gloves and measured the blood sugar via glucometer. LN G removed gloves and sanitized hands upon exiting the room and used one sanitizing wipe to quickly wipe the outer surface of glucometer for less than 10 seconds.
Review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, last revised on 10/2011, directed facility staff to always ensure that blood glucose (or sugar) meters intended to reuse are cleaned and disinfected between resident uses. It further indicated to clean and disinfect reusable equipment between uses according to the manufacturer's instruction and current infection control standards of practice.
Review of the glucometer manufacturer's, with brand name Assure Platinum Blood Glucose Monitoring System, with revision date of 9/2019, under the section on Cleaning and Disinfecting, indicated that the meter should be cleaned and disinfected after use on each patient. The cleaning procedure was needed to clean dirt, blood, and other body fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure was needed to prevent the transmission of blood-borne pathogens (means germs in the blood).
Review of the facility's germicidal (germ killer) wipes, brand name, McKesson Disposable Germicidal Surface Wipe, indicated to pre-clean all surfaces to be treated with product. Apply this product by wiping to thoroughly wet hard, non-porous surfaces. And that this producr kills bacteria in 2 minutes on pre-cleaned hard, non-porous surfaces.The label on the product further indicated, blood and other body fluids must be thoroughly cleaned from surfaces/objects before disinfection. Contact time to allow surfaces to remain wet for 2 minutes to kill viruses.
3A. During a concurrent medication administration observation and interview with LN F, on [DATE] at 9:56 AM, in the [NAME] unit hallway, LN F used a wrist size automatic blood pressure device (a small device that once placed on the wrist could measure the BP) to Resident 80's room to measure the BP. LN F was unable to get the blood pressure after two attempts. LN F was observed to put the BP device on top of the cart without cleaning it. LN F stated she wanted to measure the blood pressures before giving medications just in case, but the BP taken by certified nursing assistants earlier that morning was also available to her. LN F further stated automatic wrist size blood pressure devices had been used for years.
3B. During a concurrent observation and interview with LN G, on [DATE] at 3:45 PM, in the [NAME] station hallway, LN G used a wrist size automatic blood pressure device to Resident 19's room to measure the BP. LN G was unable to get an accurate BP and stated, It's a little low, I might take it manually. LN G then proceeded to use another BP device that measured the blood pressure manually. LN G did not clean the manual BP device outer surfaces that touched the resident after use. LN G cleaned the automatic wrist BP device with germicidal wipes without gloves for less than 10 seconds after use. LN G stated that automatic BP device were not provided by the facility.
During an interview with DON on [DATE] at 9:40 AM, the DON stated the manual BP devices were preferred due to its accuracy and the wrist size automatic BP device were not provided by the facility. DON stated the BP devices that touched a resident should have been cleaned thoroughly with germicidal wipes after each use.
During a review of facility's policy titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, with a revised date of 6/2011, indicated, non-critical resident care items included the blood pressure devices. It further indicated that non-critical reusable items can be decontaminated where they are used. Reusable items were to be cleaned and disinfected between residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure professional food safety and sanitation practices were in place when:
1. Inappropriate use of hats and hairnets were ob...
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Based on observation, interview and record review, the facility failed to ensure professional food safety and sanitation practices were in place when:
1. Inappropriate use of hats and hairnets were observed for three dietary staff members.
2. Four out of four chicken breasts were not stored and handled according to professional standards of practice.
3. Chlorine test strips were not available to all staff, two out of two staff used the wrong test strip, and chlorine test strip results were incorrectly.
4a.The walk-in freezer floor, dry storage rice bin, prep area drawers, stationary and non-stationary fans, reach-in refrigerator, and the ice machine were not clean.
b. The stove, oven, tray line, stationary can opener, and sheet pans were non cleanable due to a black residue build up and grime.
c. The tray line cutting board was severely scored with non-cleanable blacked surfaces that appeared to be melted.
5. Dietary staff were not cleaning equipment prior to sanitizing.
These failures had the potential to result in foodborne illness for a facility with a census of 89 residents who consumed food prepared in the facility.
Findings:
1. During an observation of the facility's kitchen on 3/7/23 at 9:35 AM, Dietary Manager (DM) was observed wearing a hat without a hair net. DM had exposed hair hanging out from under the hat.
During an observation of the facility's kitchen on 3/7/23 at 3:54 PM, DM was observed wearing a hat without a hair net DM had hair hang out from under the hat.
During an observation on 3/8/23 at 11:08 AM, Dietary Aide (DA) 1 and Registered Dietician (RD) were observed in the food prep area while lunch trays were being assembled. DA 1's hairnet was about two inches above the ears with exposed hair sticking out around the face. RD's hairnet was just below the ears with approximately three inches of exposed hair that hung out of the bottom of the hair net.
2022 FDA Food Code 2-402.11(A) showed, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.
2. During a concurrent observation and interview on 3/7/23 at 9:29 AM, four uncovered, partially frozen chicken breasts were observed on a sheet pan located in a rack of clean sheet pans. Dietary [NAME] (DC) confirmed four chicken breasts on the sheet pan, located in the sheet pan rack and stated the chicken had been prepped on the pan, DC got sidetracked, and forgot the chicken breasts were there. DC confirmed raw meat should not be thawed at room temperature.
2022 FDA Food Code 3-501.13 Thawing.
Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed:
(A) Under refrigeration that maintains the FOOD temperature at 5oC (41°F) or less Pf; or
(B) Completely submerged under running water:
(1) At a water temperature of 21oC (70°F) or below Pf,
(2) With sufficient water velocity to agitate and float off loose particles in an overflow Pf, and
(3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41°F) Pf, or
(4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41°F), for more than 4 hours including:
(a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking Pf, or
(b) The time it takes under refrigeration to lower the FOOD temperature to 5oC (41°F) Pf;
3. During a concurrent observation and interview on 3/7/23 at 12:43 PM, DA 2 demonstrated the chlorine (sanitizer used in dish machine) testing procedure of the dish washer water. DA 2 used a QT-40 Hydrion test strip to test the water. DA 2 stated and demonstrated dipping the test strip into the pool of water in the bottom of the dish machine for 30 seconds, then matched the colors with the test strip. The test strip became a pale cream color, most closely matching 150 parts per million (ppm) on the test strip container. Observed poster on wall, next to where DA 2 performed chlorine test indicated Chlorine testing procedure, color match, instructions to dip, remove immediately, and read sample within 5-10 seconds. DA 2 was observed entering data onto the record titled Dishwasher Temperature Log and Chlorine Test Log for Low Temperature Machines. The numbers entered did not reflect the results of the test strip used. DA 2 entered 75 under the chlorine ppm section and the test strip used showed a result of 200 ppm.
During a concurrent observation and interview on 3/7/23 at 3:45 PM, the QT-40 Hydrion test strip package and instructions previously used by DA 2 to test the chlorine in the dish machine had been reviewed. The package indicated the test strip had been for use with Quat sanitizer. Directions indicated to dip for 10 seconds, compare colors at once. Dietary Manager Assistant (DMA) provided the QT-40 Hydrion test strip and stated they should be dipped in the pool of water in the bottom of the dish machine at the end of the cycle.
During a concurrent observation and interview on 3/7/23 at 4 PM, an External Technician (ET, outsourced technician with knowledge of kitchen equipment and testing) confirmed the QT-40 Hydrion test strips were for quat sanitizer and not for the chlorine used in the dish machine. DMA arrived and produced another test strip. ET confirmed that test strip was incorrect. DMA produced a third test strip; ET confirmed the test strip was correct and stated the chlorine test strips should be touched to the rack or a plate immediately after the last cycle ends. Chlorine forms a gas that dissipates quickly, so it must be tested and read immediately. The test strip should not be dipped in the pool of water in the bottom of the dish machine. DMA stated education and training provided to DMA was to dip the test strip in water.
During a concurrent interview and record review on 3/9/23 at 4 PM, DM stated prior to this month (March) the chlorine test strips had been expired, they were thrown away, and the chlorine test strips had not been replaced. A review of the record titled, Dishwasher Temperature Log and Chlorine Test Log for Low Temperature Machines had 20 entries for the month of March that were all identical.
DMA and ET confirmed the test strip results entered on the log did not match the results from the QT-40 Hydrion test strips that were used.
2022 FDA Food Code 4-302.14 Sanitizing Solutions, Testing Devices.
A test kit or other device that accurately measures the concentration in MG/L of SANITIZING solutions shall be provided.Pf
4a. During a concurrent observation and interview on 3/7/23 at 9:35 AM, staff had been observed rolling up a black floor mat in the walk-in freezer that was covered in a thick layer of ice. The walk-in freezer floor was soiled, and severe ice build up covered the condenser fans, ceiling, walls, and shelving units. In the dry storage area, the lid that covered the brown rice was upside down and was covered in dust buildup. In the food prep area, two drawers containing food prep items were soiled. The wall mounted fan located in the food prep area pointed towards the tray line had thick dust and debris on the fan blades. The walk-in refrigerator had thick gray substance build up on the fans. DM and DMA confirmed findings.
During a concurrent observation and interview on 3/8/23 at 10:02 AM, a large fan sitting on the floor, facing four carts of clean dishes, was forcefully blowing across the dirty floor toward the drying dishes. The fan had a thick build of dust and black string like material hanging off the metal fan frame. DA 3 confirmed the fan was being used to dry the clean dishes.
During a concurrent observation, interview and record review on 3/8/23 at 3:08 PM, Maintenance Director (MND) demonstrated the process for cleaning the ice machine located in the kitchen. A white paper towel test used in ice machine showed black residue along deflector in ice bin and along lip near lid hinge. MND confirmed finding. A review of ice machine cleaning log located on side of ice machine indicated it was last cleaned 11/16/22. MND stated the ice machine had been cleaned monthly per protocol. MND was not able to produce a 2023 cleaning log for the months January-March.
2022 FDA Food Code Annex 3, 4-602.13 The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
2022 FDA Food Code 4-204.11 Ventilation Hood Systems, Drip Prevention.
Exhaust ventilation hood systems in FOOD preparation and WAREWASHING areas including components such as hoods, fans, guards, and ducting shall be designed to prevent grease or condensation from draining or dripping onto FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES.
4b. During an observation and interview on 3/7/23 at 10:02 AM, 10 out of 10 sheet pans, the oven, stove, tray line steam table, and stationary can opener were observed to have a heavy buildup of grime. DMA confirmed findings.
2022 FDA Food Code Annex 3, 4-602.13 The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
4c. During a concurrent observation and interview on 3/7/23 at 10:17 AM, the tray line cutting board had deep cut marks (potential for cross contamination) with blacked areas that looked melted and could not be scrapped off. DMA confirmed findings.
2022 FDA Food Code 4-501.12 Cutting Surfaces.
Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced.
2022 FDA Food Code 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils -
(A)
Equipment food-contact surfaces and utensils shall be clean to sight and touch.
(B)
The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations.
(C)
Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris.
5. During a concurrent observation and interview on 3/9/23 at 9:46 AM, DA 3 had been asked to describe the cleaning and sanitization process for surfaces and equipment that was non removable (cannot go through the dishwasher). DA 3 pointed to a spray bottle filled with sanitizer and stated DA 3 would spray the equipment down then wipe dry. Spilled milk was observed on a dietary cart. DA 3 was asked about process for cleaning and sanitizing the cart. DA 3 stated a peroxide sanitizer would be used. DA 3 stated the cart would not be cleaned prior to sanitizing.
2022 FDA Food Code Annex 3, 4-602.13 The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.
4-701.10 Food-Contact Surfaces and Utensils. EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED.
4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning.
4-603.14 Wet Cleaning.
(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be effectively washed to remove or completely loosen soils by using the manual or mechanical means necessary such as the application of detergents containing wetting agents and emulsifiers; acid, alkaline, or abrasive cleaners; hot water; brushes; scouring pads; high-pressure sprays; or ultrasonic devices.
(B) The washing procedures selected shall be based on the type and purpose of the EQUIPMENT or UTENSIL, and on the type of soil to be removed.
During an interview on 3/9/23 at 1:50 PM, DM stated staff were expected to wear hair coverings while in the kitchen. Staff needed to wear a hair net, beards were to be covered with a beard guard, and hairnets should be worn under hats. DM and DMA confirmed a large fan was being used to dry clean dishes, the fan was dirty, and stated should be clean and cleaned weekly or as needed DM and DMA stated soapy water was not used to clean surfaces or fixed non-removable equipment. DM stated cleaning was sanitizing, fixed non movable equipment would be sprayed with sanitizer, wiped down with a rag, and then air dried. DM stated nonfood prep area surfaces and equipment was sprayed down with a peroxide solution, the solution sat for 60 seconds, then followed up with sanitizer.
A review of the facility's policies and procedures (P&P) titled, Cleaning and Sanitizing Food Service Equipment and Work Surfaces, revised 6/1/16, indicated proper cleaning and sanitizing minimized growth of microorganisms that could cause food contamination. The P&P indicated food contact surfaces were to be cleaned with use of approved detergent, rinsed with clean water, sanitized, and air dried.
A review of the facility's P&P titled, Thawing, dated 2/28/14, indicated frozen food items could be thawed in the refrigerator, part of the cooking process, submerging under 70-degree water that was running, or in the microwave if the item will be cooked immediately.
A review of the facility's P&P titled, Ice Production and Handling, dated 2/28/14, indicated ice required proper production and handling to minimize the risk of contamination that could result in food-borne illness. The P&P indicated the equipment was to be kept clean according to manufacture's recommendations and cleaning schedules.
A review of the facility's P&P titled, Monitoring Dish Machine Temperatures and Sanitizers, revised 5/28/15, indicated sanitizer levels are monitored to verify proper functioning and sanitizer levels that are below the minimum concentrations would not effectively sanitize dishware or contact surfaces.
A review of the facility's P&P titled, Dishwashing Dish Machine, revised 4/4/16, indicated sanitizer levels were tested and recorded prior to washing dishware.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to maintain resident food in safe storage when the facility's walk-in freezer had severe ice buildup and was not maintained in a ...
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Based on observation, interview and record review, the facility failed to maintain resident food in safe storage when the facility's walk-in freezer had severe ice buildup and was not maintained in a safe operating condition. This had the potential for equipment failure.
Findings:
During a concurrent observation and interview with Dietary Manager (DM) on 3/7/23 at 9:40 AM, the walk-in freezer was observed to have severe ice buildup on the floor, shelves, walls, ceiling, condenser fans, the piping that hooks up to the condenser fans, and black mat that covered the floor. DM confirmed the severe ice found in all locations of the walk-in freezer and stated the walk-in freezer floor is cleaned weekly or as needed, including the black mat that covered the floor.
During an interview on 3/8/23 at 2:54 PM, Maintenance Director (MND) confirmed the freezer had a severe buildup of ice and stated the defrost cycle came on four times a day and caused condensation (water that collects as droplets on a cold surface when humid air comes into contact with it). MND stated the freezer had new parts installed last year and stated the ice buildup had been an issue prior to the repairs made last year. MND stated multiple visits from the repair vendor had occurred and on 3/6/23 the repair vendor made adjustments; however, there was still condensation. MND stated actions to correct the build of ice in the walk-in freezer included scrapping the ice off, wiping everything down, and educating staff to assure the freezer door was closed.
During an interview on 3/10/23 at 10:42 AM, the facility's Administrator (ADMIN) confirmed the walk-in freezer had a severe buildup of ice and that the issue was on-going.
2022 FDA Food Code - 4-501.11 Good Repair and Proper Adjustment.
(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.
Facilities Must Be In Good Repair
FDA Food Code 2012, 6-501.11 Repairing. Physical Facilities shall be maintained in good repair.
A review of the facility's policy and procedure titled, Maintenance Service, revised 12/1/09, indicated maintenance services are provided to all areas of the facility and the maintenance department was responsible for keeping the equipment safe and operable at all times.
Mar 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
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 maintain an environment free of accident hazards for four of four samp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed maintain an environment free of accident hazards for four of four sampled residents (Resident 1, 2, 3 and 4) when post fall investigations (root cause analysis) and new care plan interventions were not initiated. This resulted in multiple repeated resident falls and had potential for all residents to be at risk for fall/injuries. Refer to F727
Findings:
A review of a policy titled Clinical Protocol for Falls revised March 2018, indicated if a resident has fallen to evaluate for possible injuries and document complete fall assessment. If certain residents continue to fall re-evaluate the situation possible reasons (root cause) for falls and reconsider the current interventions (new plan of care) to prevent further falls/injuries. It is also the facility's policy to identify interventions residents specific reduce fall risk.
1. A review of Resident 1's records indicated they were admitted to the facility on [DATE], with diagnoses including Chronic Subdural Hematoma (brain bleed), Dementia, and repeated falls at home. Upon admission, Resident 1 was identified as a high fall risk.
A review Resident 1's records indicated he had five falls at facility since admission occurring 12/3/21 at 5:37 AM, 12/3/21 at 1:35 pm, 12/4/21 at 3:07 am, 12/5/21 at 11:29 am, and 12/6/21 at 1:30 am.
A review of Resident 1's record indicated he did not have a Fall Interdisciplinary team (IDT, a group of health care disciplines that determine root cause for falls and develops new fall interventions) meeting for falls on 12/4/21, and 12/5/21.
A review of Resident 1's Fall Care Plans, one was initiated on 12/1/21, no new additional interventions were not activated until 12/8/21, five post fall.
2. A review of records on indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included brain injury chronic subdural hemorrhage (brain bleed), and (difficulty swallowing). Resident 2 was a high fall risk.
During an interview on 2/22/23 at 9:25 am, Resident stated they had many falls at facility. Resident 2 stated they're not supposed to get up without staff assistance. Resident 2 stated staff comes timely most of the time, but was slowest at shift change, and right after lunch.
A review of a record titled FALLS LOG, indicated Resident 2 had total of 11 falls dating 9/1/22,
11/25/21, 11/30/21, 12/4/21, 12/11/21, 2/12/22, 3/19/22, 4/7/22, 4/26/22, 5/29/22, and 8/15/22.
A review of the IDT Fall review records for Resident 2, there were no evaluations or new care plan interventions by the team for five of 11 falls, Fall # 1 on 11/25/21, Fall # 2 on 11/30/21, Fall # 3 on 12/4/21, Fall # 4 on 12/11/21 and Fall # 5 on 2/12/22.
3. A review of a record indicated Resident 3 was admitted to facility 7/11/20, with diagnoses which included dementia, heart failure and difficulty in walking. Resident 2 was a moderate to high fall risk.
A review of a FALLS LOG indicated Resident 3 had 24 falls. These falls occurred on 11/6/21, 11/27/21, 12/19/21, 2/2/22, 2/14/22, 2/15/22, 2/17/22, 3/2/22, 3/18/22, 4/20/22, 5/1/22, 6/10/22, 7/6/22, 7/10/22, 7/15/22, 7/19/22, 7/30/22, 8/24/22, 9/29/22, 9/29/22, 10/7/22, 10/17,22, 10/18/22, and 12/9/22.
A review of the IDT Fall review records for Resident 3, there were no evaluations or new care plan interventions by the team for eight of 24 falls, Fall # 1 11/6/21, Fall # 2 11/27/21, Fall # 4 2/2/22, Fall # 5, Fall # 6, and Fall # 7, on 2/14/22, 2/15/22, and 2/17/22, Fall # 8 3/2/22 and Fall # 9 3/18/22.
4. A review of Resident 4's record indicated she was admitted to facility on 8/1/21, diagnoses which included repeated Falls at home with chest wall injury prior to admission.
A review of a FALLS LOG indicated Resident 4 had 13 falls, that occurred on 12/18/21, 1/19/22, 3/26/22, 4/27/22, 5/3/22, 7/23/22, 8/13/22, 8/14/22, 9/4/22, 9/8/22, 9/16/22, 10/17/22, and 11/5/22.
A review of the IDT Fall review records for Resident 4, indicated there were no evaluations or new care plan interventions by the team for one of 13 falls for Fall #2 on 1/19/22.
During an interview on 2/22/23 at 9:50 am, Certified Nursing Assistant (CNA 1) stated the facility was better with staffing now, less resident falls, and that 2022 there were more falls. CNA 1 stated that in April 2022 there was no Director of Nursing (DON) at facility, up until current DON was hired in December 2022.
During an interview on 3/1/23 at 11:30 am, Administrator and DON confirmed falls triggered a Quality Improvement plan for time period [DATE] to March 2022 due to an increase in resident falls in the facility. DON confirmed Fall Program system at risk without a full time DON.
During concurrent interview and record review on 3/1/23 at 12:15 PM, DON confirmed the fall policy was not followed for Resident 1, Resident 2, Resident 3, and Resident 4, when IDT did not investigate all the falls to determine root cause to develop resident specific interventions to prevent further falls and injuries.
A review of a quality improvement plan for fall documentation initiated 3/28/22, indicated:
Problem: Fall documentation are not being completed timely or missing fall documentation and IDT post fall review.
Root Cause: IDT meeting not consistently held for post fall review. Audits not being completed and communicated with IDT. Fall investigation not completed timely by DON.
Goal: IDT to complete 30 day look back of falls by 4/18/22.
Improvement Plan: Administrator to meet the IDT and discuss the need for post fall review for every fall on 3/30/22. DON to investigate and report falls during the daily clinical meeting. IDT to review fall documentation: Change of condition, post fall evaluation, pain evaluation, risk for fall assessment, risk management, care plan, and rehab screen, and determine root cause of the fall for recommendation and update care plan as needed. IDT to start daily review at Stand Up on 4/1/22. DON or designee to communicate new fall interventions to staff for implementation. Medical Records Director to audit fall documentation within 24-72 hours post fall and report findings to DON.
1) IDT will review each fall during clinical standup the following business day after incident.
2) IDT will ensure all assessments/documentation from nursing is complete to include/neuro sheet/IMR to pharmacy/risk management/fall.
3) IDT use root cause of fall to implement an intervention for prevention of any future falls.
4) IDT will document and IDT note/short term care plan and add new intervention to long term care plan.
5) IDT will have monthly meeting to review previous months falls and interventions to see if any changes need to be made.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure the a full time Director of Nursing (DON) from 3/24/22 to 12/5/22, who was responsible for the oversight of care provided to all res...
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Based on interview and record review, the facility failed to ensure the a full time Director of Nursing (DON) from 3/24/22 to 12/5/22, who was responsible for the oversight of care provided to all residents. This failure had potential to affect the quality of care and life of residents and resulted in an increase in residents falls that put them at risk for injury. Refer to F 689.
Findings:
During a concurrent interview and record review on 2/22/23 at 11:09 am, Business Office (BO) confirmed Director of Nursing (DON 1) was employed at the facility from 5/16/21-3/24/22, DON 2 from 9/8/22-10/26/22, and DON 3 worked at two facilities, Facility 1 three days a week with a total licensed bed capacity of 115, and Facility 2, DON 3 worked two days a week with a total licensed bed capacity of 89, from 3/24/22 to 12/5/22. DON 3 was not full time at either Facility 1 or 2.
During a concurrent interview and record review on 2/22/23 at 9:30 am, Administrator (Admin) and Payroll both confirmed DON 3 was at the facility Monday, Wednesday, and Friday (not full time), then two days at a sister facility. Payroll confirmed their was no tracking or payroll documents to show the actual hours DON 3 was physically at Facility 1 or 2.
During an interview on 3/1/23 at 11:30 am, the Admin and DON confirmed the Director of Nursing was responsible for the oversight of the fall program and Interdisciplinary team (evaluates root cause and develops resident plan of care).
Sept 2019
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility's document and review of the facility's policy, the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility's document and review of the facility's policy, the facility failed to ensure one of 21 sampled residents (Resident (R) R58) was assisted with her meal in the dining room in a dignified manner.
Findings:
A review of R58's record indicated she was admitted to the facility on [DATE] with diagnoses that included depression and dementia (impaired memory loss and judgment).
During an observation of the noon meal on 09/02/19 at 12:40 PM, the Activity Director/Certified Nurse Aide (AD/CNA) was seated on a stool assisting R36 with her meal. R58 was seated in a wheelchair at the same table. The AD/CNA then stood up and gave R58 a bite of food. The AD/CNA continued to assist R58 with bites of food as she stood over the resident and then would sit down to assist the other resident throughout the entire meal.
During an interview on 09/04/19 at 2:37 PM, the AD/CNA stated that she was a CNA since 2015 and continues her training to keep her can certification. The AD/CNA was asked if she recalled the way she assisted R58. She stated that she did recall assisting the resident while standing. She was asked why she assisted the resident in that way. The AD/CNA stated she did not have a chair with wheels. The AD/CNA was reminded that when she did sit to assist R36, she sat on a stool that had wheels. The AD/CNA was asked if she had received any training in dignity. The AD/CNA responded, Yes.
During an interview on 09/04/19 at 3:13 PM, the Director of Nursing (DON) was asked what the expectations were when a staff member was assisting a resident at meal time. The DON stated, I expect staff to be seated next to the resident . When the DON was told about the observation, she stated, No staff should be standing while assisting a resident. The DON agreed it was a dignity issue. The DON was then asked for the facility's policy.
During an interview on 09/04/19 at 4:15 PM, the DON stated the facility did not have a dignity policy that specifically addressed standing while assisting residents with their meals in the dining room but did provide an in-service training titled, The Dining Experience and Meal Intake Calculation dated 01/16/19. The training included, C.N.A.s (sic) must sit . The sign in sheet included the name and signature of the AD/CNA.
Review of the facility's policy titled, Quality of Life- Dignity with a revised date of August 2009 indicated, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy Interpretation and Implementation: 1. Residents shall be treated with dignity and respect at all times .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one of 21 sampled residents (Resident (R) R64) received oxygen (O2) therapy as prescribed by the physician.
Findings: ...
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Based on observation, interview and record review, the facility failed to ensure one of 21 sampled residents (Resident (R) R64) received oxygen (O2) therapy as prescribed by the physician.
Findings:
A review of R64's record (EMR) revealed an undated, admission Record with an original admission date of 04/30/14 and a readmission date of 02/20/18. R64 was admitted with diagnosis of chronic obstructive pulmonary disease (COPD).
On 09/03/19 at 9:58 AM, R64 was observed wearing a nasal cannula and the liter flow on the O2 concentrator was set between two and a half and three liter per minute (LPM). The resident was interviewed at this time regarding how much O2 he was to receive. R64 stated, two liters I think.
On 09/04/19 at 4:00 PM, R64's O2 flow rate was set between two and a half and three LPM.
Review of R64's physician's orders dated 02/03/19 revealed, Oxygen at 2 liter/ min via Nasal Cannula .
During an interview on 09/04/19 at 4:15 PM, the Director of Nursing (DON) observed R64's oxygen concentrator and stated that it looked like the O2 was set at three LPM. The DON reviewed R64's physician's order and stated that R64's O2 concentrator should be set at two LPM. The DON further stated that staff just received training from the oxygen company on how to set the LPM on the concentrator.
Review of the EverFlo/EverFlo Q User Manual, 2008 Respironics, Inc . Chapter 2: Operating Instructions, page 6, 5. Adjust the flow to the prescribed setting by running the knob on the top of the flow meter until the ball is centered on the line making the specific flow rate .
Review of the facility's policy and procedure titled, Oxygen Administration with a revised date of October 2010 revealed, Purpose: The purpose of this is to provide guidelines for the safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • 37% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $15,537 in fines. Above average for California. Some compliance problems on record.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.
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About This Facility
What is Quartz Hill Post Acute's CMS Rating?
CMS assigns QUARTZ HILL POST ACUTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Quartz Hill Post Acute Staffed?
CMS rates QUARTZ HILL POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 37%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Quartz Hill Post Acute?
State health inspectors documented 43 deficiencies at QUARTZ HILL POST ACUTE during 2019 to 2025. These included: 43 with potential for harm.
Who Owns and Operates Quartz Hill Post Acute?
QUARTZ HILL POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by WEST HARBOR HEALTHCARE, a chain that manages multiple nursing homes. With 115 certified beds and approximately 101 residents (about 88% occupancy), it is a mid-sized facility located in REDDING, California.
How Does Quartz Hill Post Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, QUARTZ HILL POST ACUTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Quartz Hill Post Acute?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Quartz Hill Post Acute Safe?
Based on CMS inspection data, QUARTZ HILL POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Quartz Hill Post Acute Stick Around?
QUARTZ HILL POST ACUTE has a staff turnover rate of 37%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Quartz Hill Post Acute Ever Fined?
QUARTZ HILL POST ACUTE has been fined $15,537 across 4 penalty actions. This is below the California average of $33,234. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Quartz Hill Post Acute on Any Federal Watch List?
QUARTZ HILL POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.