ALTA VISTA HEALTHCARE & WELLNESS CENTRE
For profit - Limited Liability company
99 Beds
SHLOMO RECHNITZ
Data: November 2025
Trust Grade
70/100
#281 of 1155 in CA
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Alta Vista Healthcare & Wellness Centre in Riverside, California, has a Trust Grade of B, indicating it is a good choice compared to many facilities. Ranking #281 out of 1,155 in California places it in the top half, while its county rank of #10 out of 53 means only nine local options are better. The facility is improving, having reduced its number of issues from five in 2024 to one in 2025. However, it has a staffing rating of 2 out of 5, which is below average, with a turnover rate of 43%, slightly above the state average. Notably, there have been no fines, which is a positive sign, and the facility offers more RN coverage than average, helping to catch potential issues early. On the downside, there have been specific concerns raised during inspections. For example, a resident was found to have been given two different forms of the same medication for 11 days without proper assessment, which could lead to harmful side effects. Additionally, in a past inspection, overflowing garbage bins were noted, raising concerns about hygiene and pest control. While the facility has strengths, these issues highlight areas that need attention.
- Trust Score
- B
- In California
- #281/1155
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 43% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 24%
No red flags
5 → 1 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 5 issues
2025: 1 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (43%)
5 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 43%
Near California avg (46%)
Typical for the industry
Chain: SHLOMO RECHNITZ
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 44 deficiencies on record
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow the physician's order to hold the medication Furosemide (wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow the physician's order to hold the medication Furosemide (water pill) for blood pressure less than 110, for one out of three sampled residents reviewed (Resident 1).
This failure had the potential to result in hypotension, placing Resident 1 at risk for medical emergency.
Findings.
A review of Resident 1's admission recorded indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses which included localized edema (swelling) and pulmonary hypertension (high blood pressure in the arteries of the lungs).
A review of Resident 1's physician order dated January 26, 2025, indicated .Furosemide Oral Tablet 40 MG .Give 1 tablet by mouth one time a day for edema hold if SBP (systolic blood pressure - measures the pressure in the arteries when the heart beats and pumps blood) is < (less than) 110.
A review of Resident 1's Medication Administration Record (MAR) for February 2025, indicated, Furosemide was administered on February 9, 2025, when Resident 1's blood pressure was 98/68, which was outside the prescribed parameters.
On April 11, 2024, at 4:30 p.m., during a concurrent interview and record review with the Licensed Vocational Nurse (LVN). The LVN stated that she administered Furosemide on February 9, 2025, even though Resident 1's blood pressure was 98/68. The LVN further stated, the physician had given a verbal order to continue administering the medication despite the SBP being less than 110.
A further review of Resident 1's progress notes and physician order did not indicate any documentation that Furosemide was to be administered with a systolic blood pressure less than 110 on February 9, 2025. No documentation of a verbal order from the physician was found.
On April 14, 2025, at 9:22 a.m., during a concurrent interview and record review with the Director of Nursing (DON). The DON stated there was no documentation on February 9, 2025, to support the administration of Furosemide with a SBP below 110. The DON stated, there was no documentation from the licensed nurse and the physician authorizing the administration from the original medication parameters.
A review of the facility policy and procedure titled, Medication Administration, dated January 1, 2012, indicated, .Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines . Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded . When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record i.e. BP, pulse, finger stick blood glucose monitoring, etc .The Licensed Nurse will chart the drug; time administered and initial his/her name with each medication administration and sign full name and title on each page of the Medication Administration Record (MAR).
May 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure care of a peripheral intravenous (IV) access site was provided and documented in accordance wi...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure care of a peripheral intravenous (IV) access site was provided and documented in accordance with accepted standards of nursing practice and facility policy for 1 (Resident #55) of 1 sampled resident reviewed for IV site care. Specifically, the facility failed to obtain physician's orders for IV flushes and dressing changes, failed to conduct and document assessments of the IV site, and failed to ensure the IV site was discontinued promptly when not needed for IV therapy.
Findings included:
A facility policy titled, Organizational Aspects of IV Therapy, effective 07/2013, specified, General Rules of IV Documentation 1. Document per facility policy - usually every shift if resident has an infusion catheter in place, or whenever and infusion treatment is given and 5. The shift note should include the following information: a. Date, time; signature and title of Nurse. b. Location and objective description of insertion site. The policy also indicated Nursing Responsibilities in Infusion Therapy included the following:
- 8. Performing functions and procedures that are consistent with current standard of care, facility policy and procedure and that are within the scope of the State Nurse Practice Act.
- 11. Clarifying an illegible, incomplete, or incorrect order.
The policy also indicated, Scope of Practice for Specific Infusion Therapy Nursing Functions included, 5. Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters). This includes flushing, dressing changes, site assessment, site rotation (for short peripheral catheters only), changing IV tubing and needleless connection devices.
An admission Record indicated the facility re-admitted Resident #55 on 04/22/2024. According to the admission Record, the resident had a medical history that included diagnoses of pneumonia and severe sepsis with septic shock.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS did not indicate the resident had IV access on admission or while a resident.
An observation on 05/20/2024 at 9:43 AM revealed Resident #55 lying in bed with a peripheral IV access to the right foot. The dressing on the site was dated 04/29/2024, indicating the dressing had been in place for over 20 days.
A Clinical Admission progress note, dated 04/22/2024, revealed Resident #55 had the peripheral IV access on the right foot on the date of the resident's readmission to the facility.
A review of Resident #55's Order Summary Report revealed no orders for the care or maintenance of the IV access to the resident's right foot.
Resident #55's care plan included a focus statement, dated as initiated 04/24/2024, which indicated the resident had impaired immunity and was on immunosuppressive therapy. The planned interventions directed staff to monitor/document/report any signs or symptoms of infection, including fever, redness, or drainage/swelling around wounds or catheter sites. As of 05/20/2024, Resident #55's care plan did not address that the resident had a peripheral IV access site in place. The care plan included no interventions that addressed the care and monitoring of the IV site.
During an interview on 05/21/2024 at 12:38 PM, Registered Nurse (RN) Supervisor #4 stated Resident #55 returned from the hospital with the IV access to the right foot. RN Supervisor #4 stated she contacted the dialysis center to make sure they were not using it then discontinued it since it was no longer needed. She stated she discontinued it the morning of 05/21/2024. She stated she was not able to find any reason for the IV site or any care orders for the IV site, including flushes or dressing changes.
During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated if a resident had IV access, the nurse should assess the site for infection and infiltration. She stated there should be orders for care that included flushing the IV and assessing the site. She indicated the site should be monitored every shift and this should be documented in the nurses' notes. She stated a peripheral IV could stay in place for up to seven days and that the dressing over the insertion site should be changed every three days. She stated Resident #55's IV access should have been removed since they were not using the access. She stated she did not know why the IV access was not discontinued.
During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated the admitting nurse should do a full body assessment and document any IV access. She stated the facility would need orders to monitor the site and flush the IV catheter. She stated the IV access should be assessed throughout any treatment being provided, and if the resident was not receiving treatment, the access should be removed. She stated a peripheral IV line could stay in until it infiltrated and then would need to be changed out. She was not sure how often the dressing over the access site should be changed.
During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated if a resident had IV access, there should be physician's orders that included flushes, monitoring every shift, and dressing changes. She stated she thought the dressing should be changed once a week but was unsure how long a peripheral IV line could stay in place.
During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated that upon admission, the nurse should do a skin assessment. If there was IV access and it was not needed, then the nurse should get an order and the IV should be removed. She stated that sometimes, they would keep the access for a few days in case it was needed. In that case, they should have orders for flushing of the IV catheter and for care of the site. She stated a peripheral IV access could stay in as long as it was intact and patent. She stated the dressing to the site should be changed every seven days. The DON stated she was not sure if Resident #55's IV access was used and stated the resident did not have orders for IV access and care.
During an interview on 05/23/2024 at 12:36 PM, the Administrator stated if a resident was admitted with IV access, then the nurse should find out if it was needed and only keep it in place for the length of time it was needed. He stated they should have physician orders to care for the IV site.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure splints were applied as ordered for 2 (Resident #18 and Resident #46) of 3 sampled residents r...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure splints were applied as ordered for 2 (Resident #18 and Resident #46) of 3 sampled residents reviewed for positioning and mobility.
Findings included:
A facility policy titled, Restorative Nursing Program Guidelines, revised 09/19/2019, indicated the restorative nursing program may include, G. Splinting and brace application. The policy also indicated, VII. The RNA [restorative nurse aide] carries out the restorative program according on [sic] the Care Plan. The RNA documents the frequency of the program, the amount of time the resident spent in the activity and their tolerance to the program. In addition, the RNA completes a written weekly summary for all residents on a Restorative Nursing Program. The Restorative Nursing Program Coordinator co-signs the weekly progress note.
1. An admission Record indicated the facility most recently admitted Resident #18 on 02/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy (shrinkage of muscles) to multiple sites and cachexia (a metabolic syndrome characterized by muscle mass loss).
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2024, revealed Resident #18 had short-term and long-term memory problems per a staff assessment of mental status (SAMS). The MDS indicated the resident had functional limitations in range of motion with impairment to the upper and lower extremities on both sides and was dependent for all activities of daily living (ADLs). According to the MDS, the resident received no or less than 15 minutes a day of restorative nursing program services, including splint or brace assistance, during the seven-day assessment look-back period.
Resident #18's Order Summary Report, which listed active orders as of 05/22/2024, revealed the following RNA program orders:
- An order started on 12/18/2023 directed an RNA to apply the resident's right elbow extension splint for two to five hours, as safely tolerated to prevent further development of contractures every day shift.
- An order started on 12/18/2023 directed an RNA to apply the resident's right resting comfy hand splint for two to five hours as safely tolerated to prevent further development of contractures every day shift.
Resident #18's care plan included a focus area, initiated on 03/17/2022, that indicated the resident had an ADL self-care performance deficit related to dementia and musculoskeletal impairment. Interventions initiated on 07/27/2023 indicated as part of the RNA program, the RNA was to apply an elbow extension splint to the resident's right upper extremity and a resting hand splint to the resident's right upper extremity for four hours five times per week or as tolerated. Another intervention, initiated on 05/23/2024 (during the survey), indicated a RA was to don and doff a left knee extension to prevent further development of contractures. The intervention did not specify the frequency or duration the knee extension was to be applied.
During observations on 05/20/2024 at 12:58 PM, Resident #18 had contractures of all four extremities with no splints or hand rolls in place.
Observations on 05/21/2024 at 10:43 AM and 2:12 PM revealed Resident #18 did not have any splints in place.
Observations on 05/22/2024 at 9:35 AM and 12:32 PM revealed Resident #18 did not have any splints in place.
A review of Resident #18's Restorative Program forms revealed the resident's splint/brace care was not documented as provided for one or more of the resident's ordered splints/braces on 11 of 22 days between 05/01/2024 and 05/22/2024.
During an interview on 05/22/2024 at 12:15 PM, Restorative Nursing Assistant (RNA) #10 stated there were three RNAs, and two worked every day. She stated the RNAs did weights on Monday and Tuesday, and if they had time at the end of the shift, then they would do range-of-motion exercises with some of the residents, but they did not apply the splints. She stated Sunday 05/19/2024 would have been the last time the resident had the splints on. She stated she did not work, but her partner would have done it. She stated she had not had a chance to apply the splints that day.
During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated she did not apply the splints for the residents but did monitor to ensure that the splints were being put on as ordered. She stated she did not realize Resident #18's splints had not been applied the previous three days.
During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) Supervisor #4 stated if a resident had orders for splints to be applied seven days a week, then the resident should have them on daily, and if they were not being applied, then the reason should be documented. She stated splints were important to prevent contractures. She stated she did not know why Resident #18's splints had not been applied.
During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated RNA services should be provided seven days a week if that was what was ordered. She stated if it was not being done, then the reason should be documented. She stated the use of splints was important to prevent further contractures.
During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated she was also the restorative nurse. She stated the proper use of splints was important for contracture management and needed to be followed because it was an order from the physician.
During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated if RNA services were ordered seven days a week, then it should be provided seven days a week, and if not, then the reason should be documented. She stated splints were important to use for contracture management. She stated the RNA should have provided the treatment as ordered and should document why the splints were not on Resident #18.
During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he thought the RNA services were being provided. He stated they were assessing all the RNA residents to see if there had been any decline related to the services not being provided and they were doing one-on-one in-services with the RNAs. He stated they did not direct the staff to only do weights on Monday and Tuesday and were planning to revamp the Restorative system.
2. An admission Record indicated the facility re-admitted Resident #46 on 03/13/2023. According to the admission Record, the resident had a medical history that included diagnoses of muscle wasting and atrophy (shrinkage of muscles) to multiple sites and poly-osteoarthritis (joint pain that involves five or more joints).
An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had functional limitation in range of motion with impairment to the upper and lower extremities on both sides. The MDS indicated Resident #46 was dependent for all activities of daily living (ADLs). According to the MDS, restorative services were provided for eating and/or swallowing during the assessment period and splint and brace assistance was not provided.
Resident #46's care plan included a focus area initiated 08/17/2023 that indicated the resident had an ADL self-care performance deficit related to limited mobility and weakness. Interventions included an RNA program for the left resting hand splint, right elbow extension, and left elbow extension to be applied seven days a week up to five hours a day as safely tolerated.
Observation on 05/20/2024 at 9:32 AM revealed Resident #46 had contractures of bilateral hands with no hand rolls or splints in place.
Observations on 05/21/2024 at 10:32 AM and 2:10 PM revealed Resident #46 did not have any hand rolls or splints in place.
Observations on 05/22/2024 at 7:40 AM, 9:15 AM, 11:32 AM, and 12:02 PM revealed Resident #46 did not have any hand rolls/splints in place.
A review of Resident #46's Order Summary Report, revealed the following active orders:
- An order dated 12/31/2023 indicated the RNA was to apply the resident's left upper extremity elbow extension splint every day shift as safely tolerated for contracture prevention.
- An order dated 12/31/2023 indicated the RNA was to apply the resident's right upper extremity elbow extension splint every day shift as safely tolerated for contracture prevention.
A review of Resident #46's Restorative Program form revealed no documentation to indicate sling/brace care was provided for one or more of the resident's ordered splints on 12 of 22 days between 05/01/2024 and 05/22/2024.
During an interview on 05/22/2024 at 12:15 PM, Restorative Nursing Assistant (RNA) #10 stated there were three RNAs, and two worked every day. She stated the RNAs did weights on Monday and Tuesday, and if they had time at the end of the shift, then they would do range-of-motion exercises with some of the residents, but they did not apply the splints. She stated Sunday 05/19/2024 would have been the last time the resident had the splints on. She stated she did not work, but her partner would have done it. She stated she had not had a chance to apply the splints that day.
During an interview on 05/22/2024 at 2:30 PM, Licensed Vocational Nurse (LVN) #7 stated she did not apply the splints for the residents but did monitor to ensure that the splints were being put on as ordered. She stated she did not realize Resident #46's splints had not been applied the previous three days.
During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) Supervisor #4 stated if a resident had orders for splints to be applied seven days a week, then the resident should have them on daily, and it they were not being applied, then the reason should be documented. She stated splints were important to prevent contractures. She stated she did not know why Resident #46's splints had not been applied.
During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated RNA services should be provided seven days a week if that was what was ordered. She stated if it was not being done, then the reason should be documented. She stated the use of splints was important to prevent further contractures.
During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated she was also the restorative nurse. She stated the proper use of splints was important for contracture management and it was an order from the physician.
During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated if RNA services were ordered seven days a week, then it should be provided seven days a week, and if not, then the reason should be documented. She stated splints were important to use for contracture management. She stated the RNA should have provided the treatment as ordered and should document why the splints were not on Resident #46. The DON stated they were doing a full sweep of all the RNA residents and revamping the program to make sure there was not anything that had been missed and involving the Director of Rehabilitation (DOR). She stated they started in-servicing with the RNAs and put it on their Quality Assurance Performance Improvement (QAPI) to monitor.
During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he thought that the RNA services were being provided. He stated they were assessing all the RNA residents to see if there had been any decline related to the services not being provided and they were doing one-on-one in-services with the RNAs. He stated they did not direct the staff to only do weights on Monday and Tuesday and were planning to revamp the Restorative system.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication order was limited to 14 days unless there was documented ration...
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Based on interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication order was limited to 14 days unless there was documented rationale for the extended use and a specific duration of the order. This affected 1 (Resident #27) of 5 residents reviewed for unnecessary medications. Resident #27 had a PRN order for Ativan (a benzodiazepine) with no stop date or documented rationale for the continued use.
Findings included:
A facility policy titled, Behavior/Psychoactive Drug Management, revised 11/2018, specified, Any Psychoactive Medication ordered on a prn basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed the 14-day time frame.
An admission Record indicated the facility admitted Resident #27 on 05/01/2021. According to the admission Record, the resident had a medical history that included diagnoses of schizophrenia, bipolar disorder, anxiety disorder, major depressive disorder, and unspecified dementia.
An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/2024, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had taken antianxiety medications during the last seven days of the assessment period.
Resident #27's care plan included a focus area, revised 02/07/2024, that indicated the resident used anti-anxiety medication that included Ativan related to anxiety disorder manifested by verbal agitation and verbal outbursts. Interventions directed staff to administer anti-anxiety medication as ordered by the physician and monitor for side effects and effectiveness every shift. The care plan indicated the resident used Ativan 0.5 milligrams (mg) with instructions to give one tablet by mouth every six hours as needed for anxiety manifested by verbal agitation and verbal outbursts.
A review of Resident #27's physician orders revealed the resident received an order on 04/12/2024 for Ativan 0.5 mg with instructions to give one tablet by mouth every six hours as needed (PRN) for anxiety manifested by verbal agitation and verbal outbursts. There was no stop date to the order.
A review of Resident #27's April 2024 Medication Administration Record (MAR) revealed the resident received the PRN Ativan on 04/21/2024 at 8:00 PM.
A review of Resident #27's May 2024 MAR revealed the resident received the PRN Ativan twice on 05/10/2024 at 5:00 PM and 11:00 PM; and again on 05/13/2024 at 6:26 AM.
A review of Resident #27's progress notes revealed no documentation of the resident being reassessed for the rationale of the ongoing use of the PRN Ativan.
During an interview on 05/23/2024 at 8:52 AM, Registered Nurse (RN) #4 stated psychotropic medications included anxiety medications, and the resident could have a PRN order but should have a stop date of 14 days. She stated after 14 days, the resident should be reassessed to determine the ongoing need for the medication. She stated she was not sure why Resident #27 did not have a stop date on their Ativan.
During an interview on 05/23/2024 at 9:08 AM, Licensed Vocational Nurse (LVN) #5 stated she was the desk nurse and did admissions. She stated a resident could have a PRN order for an anti-anxiety medication with a 14-day stop date until the resident was reassessed. She stated she was unsure why Resident #27's Ativan did not have a stop date.
During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated a resident could have a PRN order for a psychotropic medication, but it should have a stop date.
During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated a resident on a PRN psychotropic medication would need to have the order renewed after 14 days, and they would need to be assessed prior to the reordering of the medication to determine the ongoing need. She stated Resident #27 did have the behaviors to warrant the use of the medication.
During an interview on 05/23/2024 at 12:36 PM, the Administrator stated there needed to be a 14-day stop date for psychotropic medications but deferred to the DON for the specifics. He stated Resident #27 may have just slipped through the cracks.
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 observations, interviews, record review, and facility policy review, the facility failed to ensure a glucometer (device used to check blood glucose levels) was cleaned and disinfected between...
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Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a glucometer (device used to check blood glucose levels) was cleaned and disinfected between use to prevent the potential spread of infection for 2 (Resident #7 and Resident #26) of 4 residents observed receiving blood glucose checks.
Findings included:
A facility policy titled, Cleaning & [and] Disinfection of Resident Care Equipment, revised 01/01/2012, specified, Resident-care equipment, including reusable items and durable medical equipment is cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. The policy also indicated the following:
- II. Reusable items are cleaned and disinfected or sterilized between residents.
- VI. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions.
Observations on 05/22/2024 at 4:12 PM revealed Licensed Vocational Nurse (LVN) #3 performed a blood glucose test on Resident #7. The LVN performed a fingerstick using a lancet and applied a droplet of Resident #7's blood to the test strip which was inserted into the glucometer. After completing the test, LVN #3 took the glucometer out of Resident #7's room and placed it on top of the medication cart without cleaning or disinfecting it. LVN #3 continued to administer medications to other residents and then at 4:19 PM, entered Resident #26's room with the same uncleaned glucometer and performed a blood glucose test on Resident #26. LVN #3 then took the machine out to the medication cart and set the machine on top of the cart without cleaning or disinfecting it.
During an interview on 05/22/2024 at 4:25 PM, LVN #3 stated the glucometer should be cleaned with the germicidal wipes between each use. He stated he was nervous trying to remember everything and forgot to disinfect the glucometer after using it.
During an interview on 05/23/2024 at 11:46 AM, the Infection Preventionist stated glucometers should be cleaned before and after each use with a chemical approved by the Environmental Protection Agency (EPA) and they were currently using the purple-top wipes (Sani-wipe germicidal cloths). She stated it was important to do this to prevent the possible spread of bloodborne infections.
During an interview on 05/23/2024 at 8:52 PM, Registered Nurse (RN) Supervisor #4 stated the glucometer should be cleaned before and after each use with the purple-top germicidal wipes to prevent the spread of infection.
During an interview on 05/23/2024 at 9:08 AM, LVN #5 stated the glucometer should be cleaned with germicidal Sani-wipes after each use.
During an interview on 05/23/2024 at 9:22 AM, the Director of Staff Development (DSD) stated the glucometer should be cleaned before and after use with an EPA-approved disinfectant.
During an interview on 05/23/2024 at 11:05 AM, the Director of Nursing (DON) stated glucometers should be cleaned before and after each use with an EPA-approved chemical that was based on the manufacturer's recommendations. She stated it was important to do this for infection control and to prevent the transmission of infections.
During an interview of 05/23/2024 at 12:36 PM, the Administrator stated the glucometer should be cleaned before and after use with an EPA-approved solution or chemical.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
4. An admission Record indicated the facility originally admitted Resident #55 on 05/25/2022 and re-admitted the resident on 04/22/2024. According to the admission Record, the resident had a medical h...
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4. An admission Record indicated the facility originally admitted Resident #55 on 05/25/2022 and re-admitted the resident on 04/22/2024. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder, bipolar disorder, and major depressive disorder.
An admission MDS, with an Assessment Reference Date (ARD) of 04/29/2024, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses that included anxiety disorder, depression, bipolar disorder, and schizophrenia, and the resident received antipsychotic and antidepressant medications during the seven-day look back period. Further review of the MDS indicated Resident #55 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.
Resident #55's care plan included a focus area, initiated 04/27/2024 and revised 05/22/2024, that indicated the resident had a positive Level I PASRR screening, indicating diagnoses of anxiety, depression, schizoaffective disorder, and bipolar disorder, and indicated that the resident was taking psychoactive medications. Interventions directed staff to coordinate provisions of special needs with the state Medical/Medicaid Agency (initiated 04/27/2024) and to provide psychiatric evaluation and treatment as needed (revised 05/22/2024).
Resident #55's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 04/27/2024, indicated there were recommended specialized services to supplement the nursing facility's care to address the resident's mental health needs. The document indicated that the report was based on a review of the resident's medical and social history which revealed a significant medical condition with mental stressors that required nursing services. The report indicated a Level II evaluation was completed on 04/26/2024.
During an interview on 05/22/2024 at 3:33 PM, MDS Coordinator #1 stated PASRR information was included on comprehensive MDS assessments, which included admission, annual, and significant change assessments. She stated she had access to the PASRR information from their system and she was able to see if a Level II was in place. She stated the admission Coordinator provided the Level I and Level II PASRR information to the Director of Nursing (DON). She stated the MDS staff were responsible for completing section A of the MDS, which included the Level II PASRR information. She stated the DON was responsible for checking to see if the PASRR had been completed and reviewed the determination letter, then the DON notified the MDS staff if a Level II was in place. She stated the MDS staff were responsible to ensure the MDS information was accurate. After review of Resident #55's MDS, MDS Coordinator #1 confirmed that it was not accurate.
During an interview on 05/23/2024 at 11:05 AM, the DON stated the MDS staff were responsible for the accuracy of the MDS assessments and since she signed the completed MDS assessment, she was also responsible. She stated the accuracy of the MDS assessments was important to provide quality care. The DON stated that going forward they would log into the online portal a couple of times a day to see if there was any PASRRs available to code on the MDS assessments. The DON stated that Resident #55's MDS was not accurate.
During an interview on 05/23/2024 at 12:36 PM, the Administrator stated he expected the MDS assessments to be accurate. He stated they had a consultant at the facility to compete one-on-one training with the MDS staff the previous day. The Administrator stated the DON would be reviewing the PASRRs to ensure that the MDS was coded correctly. He stated he received PASRR portal access for more users in the facility and they were going to be doing ongoing education. The Administrator stated the accuracy of the MDS was important so they could provide the proper services for the resident that was specific to their needs.
Based on record review, interviews, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) user's manual, the facility failed to accurately code the Minimum Data Set (MDS) (a comprehensive assessment used to develop a resident's care plan) to reflect a Preadmission Screening and Resident Review (PASRR) Level II for 4 (Residents #14, #55, #62, and #80) of 6 sampled residents reviewed for MDS accuracy.
Findings included:
During an interview on 05/22/2024 at 9:00 AM, the Director of Nursing (DON) revealed that the facility did not have a policy on MDS accuracy and stated they followed the RAI manual.
The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, revealed All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions. The manual revealed Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. The manual revealed Coding Instructions for section A1500 included Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.
1. An admission Record revealed the facility admitted Resident #14 on 04/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of unspecified psychosis not due to a substance or known physiological condition and vascular dementia.
An admission MDS, with an Assessment Reference Date (ARD) of 04/09/2024, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. MDS section A1500 indicated Resident #14 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had an active diagnosis of psychotic disorder and had taken an antipsychotic medication during the seven-day look-back period.
Resident #14's care plan revealed a focus area, initiated 04/11/2024, that revealed the resident was prescribed psychotropic medication for behavior management related to a diagnosis of psychosis.
Resident #14's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 04/06/2024, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 04/05/2024.
During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed that Resident #14 had a PASRR Level II evaluation completed and was receiving psychiatrist services. The SS Supervisor indicated the MDS staff were responsible for coding section A of the MDS.
2. An admission Record revealed the facility admitted Resident #62 on 10/18/2022. According to the admission Record, the resident had a medical history that included diagnoses of schizoaffective disorder (bipolar type), anxiety disorder, bipolar disorder, and major depressive disorder.
A significant change MDS, with an Assessment Reference Date (ARD) of 03/11/2024, revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. MDS section A1500 indicated Resident #62 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of anxiety disorder, depression, bipolar disorder, and schizophrenia and had taken an antipsychotic, antianxiety, and antidepressant medications during the seven-day look-back period.
Resident #62's care plan included a focus area initiated 01/31/2023, that indicated the resident was prescribed psychotropic medications related to bipolar disorder, anxiety disorder, and schizoaffective disorder.
Resident #62's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 11/18/2023, revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 11/15/2023.
During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed Resident #62 had a PASRR Level II and was receiving psychiatric and psychology services. The SS Supervisor further revealed that the MDS staff were responsible for coding section A of the MDS.
3. An admission Record revealed the facility admitted Resident #80 on 01/22/2024. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder, other recurrent depressive disorders, and post-traumatic stress disorder (PTSD).
An admission MDS, with an Assessment Reference Date (ARD) of 01/29/2024, revealed Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. MDS section A1500 indicated Resident #80 was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The MDS revealed the resident had active diagnoses of anxiety disorder, depression, and post-traumatic stress disorder and had taken an antidepressant medication during the seven-day look-back period.
Resident #80's care plan included a focus area, initiated 02/07/2024, that indicated the resident was prescribed psychotropic medications related to behavior management.
Resident #80's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 01/28/2024 revealed there were specialized services recommended to supplement the nursing facility's care to address the resident's mental health needs. The document indicated the determination report was based on a review of the resident's medical and social history, which revealed a significant medical condition with mental stressors that required nursing care. The report indicated a Level II evaluation was completed on 01/25/2024.
During an interview on 05/21/2024 at 3:20 PM, the Social Services (SS) Supervisor revealed Resident #80 had a PASRR Level II and was receiving psychiatrist services. The SS Supervisor revealed the resident refused the psychiatric services and preferred to talk it out with the resident's family and children. The SS Supervisor further revealed the MDS staff were responsible for coding section A of the MDS.
During an interview on 05/23/2024 at 11:04 AM, the Director of Nursing (DON) revealed that a resident's PASRR was checked upon admission. The DON revealed it was hers and the MDS Coordinator's responsibility to check the PASRR portal daily. The DON indicated PASRR Level II evaluations were discussed in the daily morning meetings. The DON indicated she was aware the PASRR Level IIs should be coded in section A on the MDS assessments. She indicated it was the responsibility of the MDS coordinators to code section A of the MDS. The DON further indicated it was important that the MDS was coded accurately to ensure the resident received the appropriate care. The DON indicated it was her expectation that the MDS was coded accurately, and she was the registered nurse (RN) who signed off on them. The DON revealed going forward the facility planned to check the PASRR portal website a couple times a day for PASRR Level II evaluations. The DON revealed he MDS coordinators did not have access to the PASRR portal until April 2024 .
During an interview on 05/23/2024 at 12:28 PM, the Administrator revealed that a Corporate MDS RN provided one-on-one training on coding section A of the MDS accurately on 05/22/2024. The Administrator revealed it was important that residents' MDS assessments were coded accurately so that the residents were in the proper setting and were receiving appropriate care. The Administrator indicated the DON and the Corporate MDS RN would be reviewing the assessments for accuracy going forward. The Administrator indicated it was his expectation that MDS assessments were accurate .
Dec 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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, and record review, the facility failed to ensure one of three residents, (Resident 3), was assi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three residents, (Resident 3), was assisted with his meal in a dignified manner when the Certified Nursing Assistant (CNA 2), stood over the resident.
This failure caused Resident 3 to feel rushed and had the potential for compromised dignity.
Findings:
On November 29, 2023, at 11:48 a.m., an unannounced visit to the facility on a complaint investigation was initiated.
On November 29, 2023, at 1:15 p.m., observed Resident 3 sitting in a wheelchair in the hallway. Resident 3's lunch tray was on the over-bed table in front of Resident 3. CNA 2 was standing beside Resident 3 as he was feeding Resident 3.
On November 29, 2023, at 1:34 p.m., an interview was conducted with Resident 3. Resident 3 stated he needed assistance with eating his lunch. Resident 3 stated he felt rushed while CNA 2 was assisting him with lunch.
On November 29, 2023, at 1:58 p.m., an interview was conducted with CNA 2. CNA 2 stated that he should have been seated while assisting Resident 3 with his lunch.
A review of Resident 3's medical record indicated he was admitted on [DATE], with diagnoses of amyotrophic lateral sclerosis, (ALS - is also called Lou Gehrigsdisease. It's a neuromuscular disorder that causes muscle weakness), anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension), and major depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 3's History and Physical dated January 31, 2023, indicated he had the capacity to understand and make decisions.
A review of Resident 3's Care Plan initiated May 23, 2023, indicated Focus . The resident has an ADL self-care performance deficit r/t Limited Mobility, Weakness secondary to left humerus fracture (history), Amyotrophic Lateral Sclerosis .Interventions . EATING: Extensive with one person assist .
A review of a Nursing Times article titled Assisting Patients with Eating and Drinking to Prevent Malnutrition dated October 9, 2017, indicated .Assisting patients .Helping patients who cannot eat and drink independently takes time, understanding and patience. It must not be rushed and any nurse who is involved in this task should not be interrupted . 7. Sit down at the patient's eye level. This aids effective communication but also provides reassurance the patient that you have the time to help the patient to eat .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure basic accommodations of needs were met when on...
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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 basic accommodations of needs were met when one of three residents, (Resident 1) ' s call light was not within reach.
This failure had the potential for Resident 1 to have unmet needs and unable to call for assistance.
Findings:
On November 29, 2023, at 11:48 a.m., an unannounced visit to the facility on a complaint investigation was initiated.
On November 29, 2023, at 12:54 p.m., observed Resident 1 sitting on the right side of his bed in a wheelchair. His over-bed table was in front of him, and his call light was on the left side of the bed on the floor, outside of Resident 1 ' s reach.
On November 29, 2023, at 12:54 p.m., an interview was conducted with Resident 1. Resident 1 stated he used his call light to call for assistance. Resident 1 stated he would not be able to reach his call light and was concerned that he could not call for assistance.
On November 29, 2023, at 1:19 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated she was taking care of Resident 1. The CNA stated the call light should always be within reach. The CNA stated Resident 1 ' s call light was not within his reach.
A review of Resident 1 ' s medical records indicated he was admitted to the facility on [DATE], with diagnoses of stroke with hemiplegia, (paralysis of one side of the body), hemiparesis, (weakness of one side of the body), affecting right dominant side, aphasia, (affects a person's ability to express and understand written and spoken language), dysphagia, (difficulty swallowing), and anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension).
A review of Resident 1 ' s History and Physical dated September 29, 2023, indicated he had the capacity to understand and make decisions.
A review of Resident 1 ' s Care Plan dated September 29, 2023, indicted Focus .The resident has an ADL, [activities of daily living], self-care performance deficit r/t, [related to], Limited Mobility, Weakness .Interventions .Encourage the resident to use bell to call for assistance .
A review of the facility ' s policy and procedure titled Communication - Call System revised January 1, 2012, indicated .The Facility will provide a call system to enable residents to alert the nursing staff from their rooms . II. Call cords will be placed within the resident's reach in the resident's room. A. When the resident is out of bed, the call cord will be clipped to the bedspread in such a way as to be available to a wheelchair bound resident .
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to prevent administration of unnecessary medication to one of five sampled residents (Resident 1), when Resident 1 was administered with Depak...
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Based on interview and record review, the facility failed to prevent administration of unnecessary medication to one of five sampled residents (Resident 1), when Resident 1 was administered with Depakote (medication used to treat seizures and bipolar disorder)DR (delayed released -delayed release of drugs in the body) and Depakote ER (extended released-drug is released slowly to provide a prolonged therapeutic effect), at bedtime without adequate indication for duplicated use.
The facility failure had resulted in Resident 1 receiving unnecessary medication for 11 days which could potentially cause drug adverse reaction, complications, and unnecessary hospitalization.
Findings:
On August 7, 2023, at 10:25 a.m., an unannounced visit was conducted to investigate quality care issues.
On August 7, 2023, Resident 1 ' s record was reviewed. The Physician ' s Order by Licensed Vocational Nurse (LVN) 1, dated 06/27/2023, at 4:54 p.m., indicated an order for, Depakote ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for SCHIZOAFFECTIVE DISORDER (D/O) BIPOLAR TYPE (mental illness that can affect thoughts, mood, and behavior) MANIFESTED BY (M/B) MOOD SWINGS INFORMED CONSENT (I/C) OBTAINED BY MEDICAL DOCTOR (M/D).
The resident ' s record further indicated another order from Registered Nurse (RN) 1, on June 28, 2023, at 13:27 p.m., for, Depakote Oral Tablet Delayed Release (DR) 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for M/B MOOD SWINGS IC OBTAINED.
On October 2, 2023, at 2:35 p.m., RN 1 was interviewed on Depakote ER and Depakote DR orders made on June 27, 2023, and June 28, 2023, respectively. RN 1 stated ER stands for extended release and DR was for delayed release. RN 1 stated that if there had been a previous order already for Depakote ER, she should have clarified with the MD first before ordering Depakote DR. RN 1 stated she did not see the order for Depakote ER. RN 1 stated it should have been discontinued before ordering the Depakote DR to avoid duplication of orders. RN 1 indicated both medications belong to the same drug classification.
A review of June 2023 and July 2023, MAR (Medication Administration Record) was conducted with RN 1. The MAR indicated both Depakote ER and DR were administered at 9 p.m., on June 28, 2023, through July 7, 2023. The resident's Depakote DR was discontinued on July 11, 2023, when the resident ' s (family member) visited and found the resident swollen and having difficulty breathing.
A review of Resident 1's record documented on July 11, 2023, at 7:52 p.m., titled, Change in Condition (CIC), indicated, Situation: The Change In Condition/s report and mood stabilizer on this CIC Evaluation are/were: Altered mental status Other change in condition Tired, Weak, Confused, or Drowsy .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily roused, difficult to arouse) Increased confusion (e.g. disorientation); Functional Status Evaluation: General Weakness .Nursing observations, evaluation, and recommendations are: Resident appears to have decreased level of consciousness with weakness accompanied with decreased O2 saturation .Family is at bedside and have been notified regarding change of condition. Doctor (Dr-name of doctor ' s PA-Physician ' s Assistant) is aware Resident has been transferred to (name of hospital) at 7:56 pm.
On October 2, 2023, at 2:53 p.m., the Director of Staff Development (DSD) was interviewed regarding Resident 1 ' s Depakote ER and Depakote DR medication. The DSD stated ER was extended release and DR was delayed release. The DSD stated they belong to same family of medication but different and separate medication. The DSD stated the medication should have been reviewed with MD. The DSD stated that there could be a potential adverse reaction for new medication like changes in cognitive status or changes in condition like lethargy and changes in VS (vital signs). The DSD stated to prevent it from happening again, the licensed nurses had to verify and double check for any previous orders to avoid duplication of medication orders.
On October 2, 2023, at 3:10 p.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 verified her initials made on July 1, 2023, Medication Administration Record (MAR), signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 2 stated it was an unnecessary medication. LVN 2 stated, to prevent duplication, one had to pay attention to previous orders to prevent error.
On October 2, 2023, at 3:24 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 verified her initials made on June 28, 2023, July 3, 4, 9, and 10, 2023 MAR, signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 3 stated both Depakote ER and DR belong to same classification of medication. LVN 3 stated to prevent it from happening in the future, make sure to check the previous order before entering new ones to avoid duplication. LVN 3 stated duplication can cause over-medication and patient may get lethargic. LVN 3 stated she heard the family was saying the resident was more sleepy and not as active, and it caused him to be lethargic. LVN 3 stated it could cause changes with mentation and residents may not be able to protect themselves from a potential fall.
On October 2, 2023, at 4:12 p.m., the Director of Nursing (DON) and the Administrator (ADM) were interviewed regarding Resident 1 ' s Depakote ER 500 mg at bedtime and Depakote DR 500 mg at bedtime medication duplication of orders, and interviews conducted with nurses verifying they have administered both medications on June 28, 2023, through July 11, 2023. The order produced unnecessary medication to address behavior management.
A review of the facility policy titled, Medication - Verification, dated January 1, 2012, indicated, Purpose: Medications are administered safely and appropriately as ordered. Policy: I. It is the responsibility of Nursing Staff to be aware of the classification, action, correct dosage, and side effects of medication before administration.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to assess the need for duplicated medication (Depakote-medication for seizure and mood stabilizer for behavior management) to manage behavior ...
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Based on interview and record review, the facility failed to assess the need for duplicated medication (Depakote-medication for seizure and mood stabilizer for behavior management) to manage behavior for one of five sampled residents (Resident 1).
This failure had resulted for Resident 1 to receive two different forms of Depakote for 11 days which could potentially cause drug adverse reaction, complication, and hospitalization.
Findings:
On August 7, 2023, at 10:25 a.m., an unannounced visit was conducted to investigate quality care issues.
On August 7, 2023, Resident 1 ' s record was reviewed. The Physician ' s Order by Licensed Vocational Nurse (LVN) 1, dated 06/27/2023, at 4:54 p.m., indicated an order for, Depakote ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for SCHIZOAFFECTIVE DISORDER (D/O) BIPOLAR TYPE (mental illness that can affect thoughts, mood, and behavior) MANIFESTED BY (M/B) MOOD SWINGS INFORMED CONSENT (I/C) OBTAINED BY MEDICAL DOCTOR (M/D).
The resident ' s record further indicated another order from Registered Nurse (RN) 1, on June 28, 2023, at 13:27 p.m., for, Depakote Oral Tablet Delayed Release (DR) 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for M/B MOOD SWINGS IC OBTAINED.
On October 2, 2023, at 2:35 p.m., RN 1 was interviewed on Depakote ER and Depakote DR orders made on June 27, 2023, and June 28, 2023, respectively. RN 1 stated ER stands for extended release and DR was for delayed release. RN 1 stated that if there had been a previous order already for Depakote ER, she should have clarified with the MD first before ordering Depakote DR. RN 1 stated she did not see the order for Depakote ER. RN 1 stated it should have been discontinued before ordering the Depakote DR to avoid duplication of orders. RN 1 indicated both medications belong to the same drug classification.
A review of June 2023 and July 2023, MAR (Medication Administration Record) was conducted with RN 1. The MAR indicated both Depakote ER and DR were administered at 9 p.m., on June 28, 2023, through July 7, 2023. The resident's Depakote DR was discontinued on July 11, 2023, when the resident ' s (family member) visited and found the resident swollen and having difficulty breathing.
A review of Resident 1's record documented on July 11, 2023, at 7:52 p.m., titled, Change in Condition (CIC), indicated, Situation: The Change In Condition/s report and mood stabilizer on this CIC Evaluation are/were: Altered mental status Other change in condition Tired, Weak, Confused, or Drowsy .Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily roused, difficult to arouse) Increased confusion (e.g. disorientation); Functional Status Evaluation: General Weakness .Nursing observations, evaluation, and recommendations are: Resident appears to have decreased level of consciousness with weakness accompanied with decreased O2 saturation .Family is at bedside and have been notified regarding change of condition. Doctor (Dr-name of doctor ' s PA-Physician ' s Assistant) is aware Resident has been transferred to (name of hospital) at 7:56 pm.
On October 2, 2023, at 2:53 p.m., the Director of Staff Development (DSD) was interviewed regarding Resident 1 ' s Depakote ER and Depakote DR medication. The DSD stated ER was extended release and DR was delayed release. The DSD stated they belong to same family of medication but different and separate medication. The DSD stated the medication should have been reviewed with MD. The DSD stated that there could be a potential adverse reaction for new medication like changes in cognitive status or changes in condition like lethargy and changes in VS (vital signs). The DSD stated to prevent it from happening again, the licensed nurses had to verify and double check for any previous orders to avoid duplication of medication orders.
On October 2, 2023, at 3:10 p.m., a concurrent record review and interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 verified her initials made on July 1, 2023, Medication Administration Record (MAR), signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 2 stated it was an unnecessary medication. LVN 2 stated, to prevent duplication, one had to pay attention to previous orders to prevent error.
On October 2, 2023, at 3:24 p.m., a concurrent record review and interview was conducted with LVN 3. LVN 3 verified her initials made on June 28, 2023, July 3, 4, 9, and 10, 2023 MAR, signifying she had administered Depakote ER 500 mg and Depakote DR 500 mg at bedtime. LVN 3 stated both Depakote ER and DR belong to same classification of medication. LVN 3 stated to prevent it from happening in the future, make sure to check the previous order before entering new ones to avoid duplication. LVN 3 stated duplication can cause over-medication and patient may get lethargic. LVN 3 stated she heard the family was saying the resident was more sleepy and not as active, and it caused him to be lethargic. LVN 3 stated it could cause changes with mentation and residents may not be able to protect themselves from a potential fall.
On October 2, 2023, at 4:12 p.m., the Director of Nursing (DON) and Administrator (ADM) were interviewed regarding Resident 1 ' s Depakote ER 500 mg at bedtime and Depakote DR 500 mg at bedtime medication duplication of orders, and interviews conducted with nurses verifying they have administered both medications on June 28, 2023, through July 11, 2023. The order produced unnecessary medication to address behavior management.
A review of the policy and procedure titled, Medication- Administration, dated January 1, 2012, indicated, .To ensure the accurate administration of medications for residents in the facility .If the Attending Physician increases or changes a medication order, this is an automatic stop or discontinue order for original order .Nursing staff will keep in mind the seven 'rights' of medication when administering medication .
A review of the facility policy titled, Behavior/Psychoactive Drug Management, dated November 2018, indicated, Policy: It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being .G. Appropriate dosage must be prescribed .The treatment should be at the lowest possible dose to improve the target symptoms being monitored .
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the licensed nurse completed an assessment for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the licensed nurse completed an assessment for self-administration of medications for one of three residents (Resident 2).
This failure had the potential for unsafe self-administration of medications, duplication of medications, and interactions with other medications for Resident 2.
Findings:
On February 10, 2023, at 11:45 a.m., an announced visit to the facility was conducted to investigate an allegation of abuse.
On February 10, 2023, at 1:25 p.m., a concurrent observation and interview were conducted with Resident 2. Resident 2 stated he was purchasing his own supplies during his stay in the facility. Resident 2 opened the top drawer of the dresser and took out various medications. Resident 2 stated he has Benadryl cream for bites on his legs, Tums tablets for his heartburn, Benadryl tablets (anti-allergy medication), and Pepto Bismol liquid (for heartburn).
On February 14, 2023, at 12:20 p.m., an interview with Resident 2 was conducted. Resident 2 stated he ordered his medications online and have them delivered. Resident 2 further stated, he used the Pepto Bismol, Benadryl, Tums, and cream on himself when needed. Resident 2 stated the facility did not have stock of these medications when he requested them. Resident 2 stated, the facility knew he had these medications.
Review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a disorder of the central nervous system), Seizures (temporary abnormalities in muscles and movement), Gastro-Esophageal Reflux Disease (acid or bile in the stomach irritates the food pipe).
Further review of Resident 2's record indicated no documentation that the licensed nurse completed an assessment for Resident 2 for self-administration of medications.
On February 14, 2023, at 1 p.m., the Director of Nursing (DON) was interviewed. She stated the resident could not keep medications at bedside without a self-administration of medication assessment.
On February 14, 2023, at 1:30 p.m., a concurrent interview and record review with the DON was conducted. The DON stated, Resident 2 did not have a self-administration assessment completed. The DON further stated the resident could not keep medications at bedside.
On February 14, 2023, at 2:30 p.m., an interview with the Licensed Vocational Nurse (LVN) was conducted. The LVN stated, Resident 2 had no orders for Tums or cream for Resident 2's bites on his legs. The LVN further stated, he was not aware Resident 2 kept medications in his dresser to use when necessary.
On February 14, 2023, at 3:15 p.m., an observation of the LVN was conducted. The LVN went to Resident 2's room, removed the medications from the resident's drawer, and brought them to the nurse's station. The LVN removed one bottle of Pink Bismuth Subsalicylate (Pepto Bismol), one bottle of Tum's chewable tablets, and one bottle of Diphenhydramine (Benadryl) tablets.
A review of the facility's policy and procedure titled Medication-Self Administration, dated January 1, 2012, indicated .To provide residents with the opportunity to self-administer medications determined by the attending physician and the Interdisciplinary Team (IDT) .the IDT will assess the resident's cognitive, physical and visual ability to carry out this responsibility based on a review of an assessment by a licensed nurse .the Assessment for Self-Administration of Medications .The resident may not begin self-administration of medications prior to the approval of the IDT and the Attending Physician .The Attending Physician must provide a written order permitting the resident to self-administer medications .
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the safeguarding of the resident's information against loss for one of three sampled residents (Resident A), when Resident A's medic...
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Based on interview and record review, the facility failed to ensure the safeguarding of the resident's information against loss for one of three sampled residents (Resident A), when Resident A's medical chart could not be located.
This failure had the potential for Resident A's care being compromised which could have a negative impact on resident's physical and psychosocial wellbeing.
Findings:
On February 2, 2023, at 11:30 a.m., an unannounced visit to the facility was conducted to investigate an Administrative issue.
A review of Resident A's record, indicated, Resident A was admitted to the facility November 28, 2022, with diagnoses which included anxiety disorder (a feeling of worry, nervousness).
A review of Resident A's facility document titled, Follow-up Report, dated January 20, 2023, indicated, .On 1/17/2023, the Nurse Practitioner (NP) for patient (name of resident) carne to the facility to do patient visit. When NP asked for patients' chart, the facility realized it was missing. Facility has performed extensive search for missing chart and cannot locate it at this time .
On February 2, 2023, at 11:40 a.m., during an interview with the Medical Records Director (MRD), the MRD stated there is a process for the facility to safeguard the medical records. The MRD stated only an authorized employee can access a resident's medical record. The MRD stated the residents' medical charts were placed at the nurses station. The MRD stated the facility utilized a laminated plastic to indicate which department borrowed a resident's medical chart. The MRD stated on January 17, 2023, she was unable to locate resident's medical chart and did not know who had borrowed it. The MRD stated she created a new medical chart for the resident.
On February 3, 2023, at 12:05 p.m., Resident A was interviewed. He stated the staff informed him that his medical chart was lost.
On March 6, 2023, at 4:02 p.m., during an interview with the Director of Nursing (DON), the DON stated the staff seacrhed the entire facility to locate the lost medical chart of the resident.
On May 4, 2023, at 9:50 a.m., during an interview with the DON , the DON stated Resident A's medical chart was not found.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bilateral floor mats were in place 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 ensure bilateral floor mats were in place for one of three
residents reviewed, (Resident 3). This failure had the potential to increase the risk for injury during an incident of fall for Resident 3.
Findings:
On March 29, 2023, at 11:30 a.m., an unannounced visit to the facility was initiated for a complaint investigation.
On March 29, 2023, at 1:56 p.m., observed Resident 3 in bed on her back. The bed was in the lowest position, and she had a floor mat on the left side of the bed.
On March 29, 2023, at 2:33 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated Resident 3 was a fall risk, and floor mats should be on both sides of the bed.
On March 29, 2023, at 2:44 p.m., an interview was conducted with the Licensed Vocational Nurse, (LVN 1). LVN 1 stated floor mats are supposed to be on both sides of the bed. LVN 1 stated Resident 3 only had one floor mat and did not know why it was only on one side.
On March 29, 2023, at 2:56 p.m., an interview was conducted with LVN 2. LVN 2 stated floor mats are required on each side of the bed.
A record review of Resident 3 ' s medical records indicated she was admitted on [DATE], with diagnoses of Polyosteoarthritis, (related to the process of aging, as water content of body cartilage increases, and the protein makeup of cartilage degenerates), stroke, dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning),bipolar disorder, (a mental health condition that causes extreme mood swings that include emotional highs and lows), and hypothyroidism, (a condition resulting from decreased production of thyroid hormones).
A review of Resident 3 ' s Fall Risk Evaluation dated January 14, 2023, at 1:28 p.m., indicated she was at risk for falls.
A review of Resident 3 ' s Care Plan initiated August 18, 2022, indicated Focus .The resident is at risk for falls r/t, (related to), Confusion, balance problems, Poor communication/comprehension, Unaware of safety needs .Interventions .bilateral floor mats .Follow facility fall program .
A review of the facility ' s policy and procedure titled Fall Management Program revised March 13, 2021, indicated .The facility will implement a Fall Management Program that supports providing an environment free from fall hazards .The licensed nurse will complete a fall risk assessment. If a fall risk factor is identified, document interventions on the care plan .
Jul 2021
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 for two of eight residents reviewed:
1. An Advance Directive...
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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 for two of eight residents reviewed:
1. An Advance Directive (written instruction, such as a living will or durable power of attorney for healthcare, recognized under State Law, relating to the provision of healthcare when the individual is incapacitated) was discussed with their responsible party, for Resident 43; and
This failure had the potential for the residents to not receive their preplanned treatment and services in the event they were incapacitated and/or unable to speak for themselves.
2. The Advance Directive was in the medical chart and easily accessible to the staff for Resident 51.
This failure had the potential for Resident 51's Advance Directive to not be readily retrievable by the staff, by the physician, not knowing the wishes of the resident regarding medical treatment.
Findings:
1. Resident 43's record was reviewed. Resident 43 was admitted to the facility on [DATE], with diagnosis which included cerebrovascular disease (stroke).
The document titled, Advance Healthcare Directive (AHCD) Acknowledgement Form, dated June 14, 2019, indicated, .I do not have Advance Healthcare Directive (AHCD) and I do not want any information at this time . The document was signed by Resident 43's responsible party.
Resident 43's document titled HISTORY AND PHYSICAL EXAMINATION, dated June 26, 2021, indicated, Resident 43 did not have the capacity to understand and make decisions. Resident 43 had a surrogate decisionmaker.
There was no documentation in Resident 43's record that the resident representative was provided information regarding formulation of the advance directive after June 14, 2019.
On July 23, 2021, at 9:42 a.m., the Social Service Assistant (SSA) was interviewed. She stated the advance directive was discussed during the quarterly care conference meeting. The SSA stated she offered the resident and resident representative information regarding formulation of the Advance Directive. The SSA stated if the resident did not have the capacity to make decisions, she would not offer and provide information regarding formulation of the Advance Directive to the resident representative.
A review of the facility policy and procedure titled, Advance Directive, date revised July 2018, indicated .Upon admission, the admission Staff or designee will provide written informaton to the resident concerning his or her right to make decisions concerning medical care .During the Social Services Assessment process, the Director of Social Services or desginee will also ask the resident whether he or she has a written advance directive .If a resident does not have an Advance Directive, the facility will provide the resident and /or resident next of kin with information about advance health directives .
2. Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and senile degeneration of the brain.
Resident 51's document titled, HISTORY AND PHYSICAL EXAMINATION, dated May 22, 2021, indicated Resident 51 had the capacity to understand and make decisions.
The document titled, Advance Healthcare Directive (AHCD) Acknowledgement Form, dated May 19, 2021, indicated Resident 51 had an Advance Directive.
There was no Advance Directive in the chart accessible to staff.
On July 23, 2021, at 10:04 a.m., during a concurrent interview and record review with the Social Service Assistant (SSA), the SSA stated Resident 51's Advance Directive was not in the chart. The SSA stated the Advance Directive should be in the chart accessible to the staff.
A review of the facility policy and procedure titled, Advance Directive, date revised July 2018, indicated .If the resident has an Advance Directive, the Facility shall obtain a copy of the document and place it in the resident's medical record .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the licensed nurse notified the physician of the resident's ...
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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 licensed nurse notified the physician of the resident's change of condition for one of 18 residents reviewed (Resident 88).
This failure had the potential for Resident 88 not to receive the appropriate treatment to address his medical needs.
Findings:
Resident 88's record was reviewed. Resident 88 was admitted to the facility on [DATE], with diagnoses which included old cerebrovascular accidents (stroke), ESRD ( End stage renal disease - long standing disease of the kidneys leading to renal failure) on hemodialysis (medical procedure to remove fluid and waste products from the blood), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation).
Resident 88's record titled, Physician Order, indicated, DNR (instructs health care providers not to do cardiopulmonary resuscitation [CPR] if a patient's breathing stops or if the patient's heart stops beating). SELECTIVE TREATMENT, HOSPITAL TRANSFER ONLY IF COMFORT NEEDS CANNOT BE MET IN FACILITY .
A review of Resident 88's record titled, Physician Orders for Life-Sustaining Treatment (POLST), indicated, Do Not Attempt Resuscitation/DNR (Allow Natural death) .selective treatment- goal of treating medical conditions while avoiding burdensome measures .Request transfer to hospital only if comfort needs cannot be met in current location .
A review of Resident 88's record titled, Progress Notes, indicated the following:
a. On [DATE], at 10:06 a.m., .4-27-2021 ( [DATE]), V/S (vital sign) 97.8, P (Pulse) 76, R (respiration) 18, B/P (blood pressure) 134/84, O2 (oxygen) 96%. Alert and oriented X(times) 1, and is nonverbal with staff meeting all needs, respiration's (sic) even non-labored with symmetric chest rises and drops noted. Lungs are clear and present in all lobes .
b. On [DATE], at 04:22 a.m., .Received resident ( Resident 88) @(at) 10 pm with shallow breathing with occasional moaning noted, made comfortable as possible turned and repositioned, O2 continuously on @2LPM (Liter Per Minute), HOB (head of bed) elevated .V/S (vital sign): 136/53, 64, 16, 98.6. O2 sat (saturation) 97% with O2 .continue to have shallow and labored breathing even with O2 on .Resident ceased breathing @ (at)approximately 0200H (2:00 a.m.), body warm, no vital signs appreciated is a DNR status .0215h (2:15 a.m.) ( Name of Physician) notified . (name of Resident 88's family member) made aware @0220H (2:20 a.m.) .
There was no documented evidence Resident 88's change of condition was reported to the physician.
On [DATE], at 3:59 p.m., during an interview with Licensed Vocational Nurse (LVN 6), she stated when she received Resident 88 on [DATE], at 10 p.m., the resident had shallow breathing and the resident was in declining condition. She stated Resident 88 had a change of condition and she should have notified the physician for further orders. LVN 6 stated she did not notify the physician.
On [DATE], at 8:46 a.m., during an interview with the Director of Nursing (DON), she stated if POLST indicated DNR, it means do not resuscitate if breathing or heart stops. She stated in case of change of condition for resident with DNR status, the licensed nurse should notify the physician and the responsible party. The DON stated Resident 88 had shallow breathing on [DATE]. She stated Resident 88 had a change of condition and the physician should have been notified by the licensed nurse. The DON stated there was no documentation the physician and the responsible party was notified by the licensed nurse.
The facility's policy and procedure titled, Change of Condition Notification, dated [DATE], indicated, .residents, family, legal representative, and physicians are informed of changes in the resident's condition in a timely manner .the facility will promptly inform the resident, consult with the resident attending physician, and notify the resident's legal representative or an interested family member when the resident endures a significant change in their condition .A Licensed Nurse will notify the resident's Attending Physician and legal representative or an appropriate family member when .A significant change in the resident physical, mental or psychological status, e.g., deterioration in health .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to address a concern on room temperature during mealtime, for one of sixteen residents observed (Resident 25). This failure had ...
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Based on observation, interview, and record review, the facility failed to address a concern on room temperature during mealtime, for one of sixteen residents observed (Resident 25). This failure had the potential to result in resident not having the quality of life she deserved.
Findings:
On July 19, 2021, at 12:02 p.m., during dining observation, Resident 25 while waiting for her lunch tray, the resident complained to the staff that she was freezing cold. There was no response from the staff.
On July 19, 2021, at 12:18 p.m., Restorative Nursing Assistant (RNA) 3 was observed beside Resident 25. Resident 25 informed RNA 3, the room was cold.
On July 19, 2021, at 12:29 p.m., Resident 25 complained to RNA 3, the room was cold. RNA 3 stated this is the coldest room in the facility.
On July 19, 2021, at 12:47 p.m., Resident 25 was observed beside Licensed Vocational Nurse (LVN) 4. Resident 25 stated it's always this cold. LVN 4 stated the room was cold.
On July 19, 2021, at 12:50 p.m., Resident 25 stated she did not like it when the room was cold. LVN 4 stated the cold air was directly above Resident 25's head.
There was no intervention provided to Resident 25 when the resident complained multiple times to the staff regarding the room temperature.
On July 19, 2021, at 12:56 p.m., the Maintenance Director (MD) was asked to check the room temperature. The MD stated the room temperature was 67°F. The MD stated he forgot to adjust temperature for this room.
On July 19, 2021, at 3:59 p.m., RNA 3 was interviewed. RNA 3 stated when a resident complained of the room temperature, she would find a jacket or moved the resident to another area. RNA 3 stated Resident 25 complained about the room temperature and she did not move the resident to another area.
On July 23, 2021, at 8:44 a.m., the Director of Nursing (DON) was interviewed. The DON stated if the room temperature was cold, the staff should have called the maintenance to adjust the temperature. The DON stated the staff should have provided intervention for the resident like layering the resident's clothes.
A review of the facility policy and procedure titled, Resident Rooms and Environment, dated January 1, 2021, indicated, .To provide residents with a safe, clean, comfortable and homelike environment .Facility Staff aim to create a personalized, homelike atmosphere, paying close attention to the following .Comfortable temperatures .
A review of the facility policy and procedure titled, Dining Program, dated January 1, 2012, indicated, .To ensure that the Facility serves meals in a timely manner, provides residents with adequate supervision and/or assistance during meal times .Environmental Services Staff .check the temperature of rooms prior to meals .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan to address impairment in communi...
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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 care plan to address impairment in communication was implemented, when the language communication board was not accessible for the staff to use when providing care for one of five residents reviewed (Resident 62).
This failure has the potential for the resident not to be able to effectively communicate his needs to the staff which could result in unmet needs.
Findings:
On July 19, 2021, at 11 a.m., Resident 62 was observed in the room, with eyes closed, not responsive, to greetings.
On July 19, 2021, at 1:08 p.m., in an interview with Certified Nurse Assistant (CNA) 1, she stated Resident 62 understands only Spanish. She stated the resident responds with gestures.
On July 19, 2021, at 3:25 p.m., CNA 1 was observed talking in Spanish to Resident 62. Resident 62 was observed staring at her, with no response.
In a review of Resident 62's record, the record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), and schizophrenia (hearing/seeing things that are not there).
Resident 62's history and physical dated March 10, 2021, indicated he does not have the capacity to understand and make decisions.
Resident 62's MDS (minimum data set- an assessment tool), dated March 15, 2021, Section B0600 Speech Clarity, indicated, .No speech, absence of spoken words .
Resident 62's care plan dated March 16, 2021, indicated, Primary language is: Spanish. Risk for difficulty making needs known. Care plan goal: Staff will be able to anticipate needs. Intervention .Encourage use of non- verbal communication techniques .Communication board .
On July 19, 2021, at 1:08 p.m., in an interview with Licensed Vocational Nurse (LVN) 2, she verified there was no communication board by Resident 62's bedside. The LVN 2 stated the communication board, is for him to point out what he needs.
A review of the facility policy and procedure titled, Comprehensive Person-Centered Care Planning, with revised date of November 2018, indicated, .It is the policy of the facility to provide person-centered .care that reflects best practice standards for meeting the highest physical, mental, psychosocial well being .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician orders were followed in accordance w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician orders were followed in accordance with the professional standards of practice, for one of five residents (Resident 2), when Zinc (supplement) was not transcribed correctly and was not administered according to the physicians order for Resident 2.
These failures had the potential for residents to experience unmet healthcare needs .
Findings:
1. On July 21, 2021, at 10:20 a.m., an observation of medication administration (med pass) was conducted with Licensed Vocational Nurse (LVN) 5 for Resident 2. LVN 5 confirmed the order on the medication administration record (MAR) was for Resident 2. LVN 5 administered Zinc 220 mg (a unit of measure) one tab PO (by mouth).
On July 21, 2021, at 3:30 p.m., in a concurrent interview and record review with LVN 2, she confirmed the telephone order (TO). LVN 2 stated the over the counter zinc supplement is only stocked in 220 mg. LVN 2 stated the licensed nurses should have called the physician.
A review of telephone orders dated July 6, 2021,indicated, Zinc 200 mg 1 tab /cap po daily x 60 days.
There was no documentation indicating the physician order for Zinc 200 mg on July 6, 2021, was clarified with the physician, prior to using Zinc 220 mg (dose in stock at the facility) for Resident 2.
A review of Resident 2's record indicated he was admitted to the facility on [DATE] with diagnosis of chronic kidney disease, metabolic encephalopathy (chemical imbalance in the brain), enterocolitis due to Clostridium Difficile (infectious bacteria in the bowels).
A review of the facility's policy and procedure titled, Telephone orders for Medication, dated January 01, 2012, indicated, .To ensure the proper channels of communication while making an accurate delivery of medications and treatments to all residents .The Facility will administer medications and treatments ordered by an Attending physician and or a nurse practitioner or physician assistant including orders received via telephone .Receiving a written order .An attending physician or a nurse practitioner must write the order .An order sheet should be complete and include the date and physician or nurse practitioner signature .
A review of the facility policy and procedure titled, Medication Administration,dated January 01, 2012, indicated, .Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an environment free of accident hazard, when 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 an environment free of accident hazard, when a floor mat on the right side of the bed was not provided in accordance to the plan of care for one of four residents reviewed (Resident 19).
This failure had the potential for Resident 19 to sustain injuries from a fall.
Findings:
On July 19, 2021, at 10:38 a.m., and on July 20, 2021, at 11:35 a.m., Resident 19 was observed lying in bed,with one floor mat on the left side of the bed. There was no floor mat observed on the right side of the bed.
A review of Resident 19 record indicated the resident was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), personal history of traumatic fracture (broken bone), impulse disorder (condition in which a person has trouble controlling emotions or behaviors).
The facility document titled, Morse Fall Risk Assessment, dated April 16, 2021, indicated, .Resident is High Risk. Implement high risk fall prevention interventions .
Resident 19's care plan dated April 21, 2021, indicated, .bed will remain in low position and floor mats in place when resident is in bed. Will have no injuries .IDT (Interdisciplinary Team) will review appropriateness quarterly and as needed .
On July 22, 2021, at 10:22 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1, she stated Resident 19 was on fall precaution measures. She stated there was no floor mat observed on the right side of Resident 19's bed. LVN 1 stated there should be two floor mats, left and right side of the bed as the care plan indicated.
On July 23, 2021, at 9:14 a.m., during an interview with the Director of Nursing (DON), she stated when a resident was identified as high fall risk, then fall risk measures should be in place, including floor mats on each side of the bed.
The Facility's policy and procedure titled, Fall Management Program, dated March 13, 2021, indicated, .provide residents a safe environment that minimizes complications associated with falls .if a fall risk factor is identified, document interventions on the residents care plan .the licensed nurse will evaluate the resident's response to the intervention .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed address the pharmacy recommendation on Ativan (lorazepam- used to trea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed address the pharmacy recommendation on Ativan (lorazepam- used to treat anxiety) use, for one of five residents reviewed for unnecessary medications (Resident 4).
This failure had the potential for Resident 4 to receive Ativan unnecessarily. In addition, Resident 4 was not reevaluated by the physician prior to continuing the use of Ativan.
Findings:
A review of Resident 4's record indicated, she was admitted to the facility on [DATE], with diagnoses which included depression, and anxiety disorder (feeling of worry, nervousness).
Resident 4's history and physical examination, dated January 2, 2021, indicated she has the capacity to understand and make decisions.
Resident 4s Pharmacist recommendation April 5, 2021, indicated Ativan (Lorazepam) 0.5 mg Daily PRN (date ordered- 3/16/2021) Suggest discontinue the current order for PRN anxiolytic (anti-anxiety drugs). PRN anxiolytics should be initially ordered up to 14 days only. After 14 days, the order should be discontinued or re-evaluated by the ID Team and physician to determine if a change in therapy is indicated.
There is no documented evidence that the nurse acted on the pharmacy recommendation.
On July 23, 2021, at 1:39 p.m., in a concurrent interview and record review with the Director of Nursing (DON), she verified the pharmacy recommendation on April 5, 2021, was not acted upon. The DON stated if this is not followed up this could lead to unnecessary use of Ativan by Resident 4.
A review of the facility document, titled, CONSULTANT PHARMACIST, effective date August 1, 2010, indicated, .The consultant pharmacist medication regimen review reports are processed as follows .The consultant pharmacist provides the report .Nursing personnel provide a written response to the review within two weeks after the report is received .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure expired and outdated medications were not stored and readily available for use. This failure could expose residents to...
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Based on observation, interview, and record review, the facility failed to ensure expired and outdated medications were not stored and readily available for use. This failure could expose residents to expired medications with questionable potency and efficacy.
Findings.
On July 21, 2021, at 11:15 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 2, during a medication storage inspection in the designated yellow zone. One unopened box labeled; Geri-care Ear drops (carbamide peroxide 6.5% Ear wax removal solution) with expiration date of June 21, 2021, was observed stored in the top shelf of the medication storage cabinet.
On July 21, 2021, at 11:20 a.m., LVN 2 stated the Geri-care Ear drops for ear wax removal should not have been in the cabinet past the expiration date. LVN 2 stated the medication was expired and should be disposed of according to the standards of the facility.
On July 22, 2021, at 4:31 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated if any medication is noticed to be expired it would be disposed of immediately.
During a review of the facility policy and procedure titled, DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES, dated August 1, 2010, indicated, .Discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed .Ointments, creams, and similar substances are to be returned to the pharmacy or to be destroyed by a certified medication destruction company .Tablets, capsules, and liquids are returned to the pharmacy or to be destroyed by a certified medication destruction company .The provider pharmacy is contacted if the facility is unsure of proper disposal methods for a medication .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, for two of 18 residents reviewed (Residents 49 and 79), the...
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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, for two of 18 residents reviewed (Residents 49 and 79), the following:
a. The routine A1C (blood test that measures blood sugar level over the past three months), CMP (comprehensive metabolic panel blood test often used to evaluate liver function, kidney function, and nutrient levels) and lipid panel (the amount of specific fat molecules called lipids in the blood) was obtained, as ordered by the physician for Resident 49.
This failure resulted for the routine laboratory to not be completed as ordered which could result in the delay in Resident 49's care and treatment; and
b. The urine analysis was reported to the physician promptly for Resident 79.
This failure had the potential to result in the delay of care and treatment for Resident 79 medical condition.
Findings:
a. A review of Resident 49's record indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (condition that affects the way the body processes blood sugar) and hyperlipidemia (condition in which there are high levels of fat particles in the blood).
Resident 49's record titled, Physician Order Summary, dated April 16, 2021, indicated, .ROUTINE: A1C, CMP AND LIPID PANEL EVERY 3 MONTHS [MAY, AUG (August), NOV (November), FEB (February)] .
There was no lab work done on May 2021.
On July 21, 2021, at 2:54 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the physician ordered for lab work on May, August, November, and February. She further stated the practice was to follow the physician order for the lab draw.
On July 23, 2021, at 8:55 a.m., in an interview with the Director of Nursing (DON), the DON stated Resident 49's routine lab work should have been done on May 2021, as per physician order and it was not done.
A review of the facility policy and procedure titled, Laboratory Services, dated January 1, 2012, indicated, .The facility will provide laboratory services in an accurate and timely manner to meet the needs of the residents per attending physician .
2. Resident 79's record was reviewed. Resident 79 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level).
Resident 79's progress notes dated July 13, 2021, indicated, .While in facility doing rounds MD (physician) met with residnet (sic) who verbalized dysuria (pain in urination) .MD gave order for BMP (basal metabolic panel) and UA (urine analysis) with C&S (culture and sensitivity) .
Resident 79's document titled, Laboratory Report, dated July 14, 2021, indicated .UA C.S IF IND (if indicated) .CULTURE, URINE .Final .<10,000 cfu/ml (colony-forming unit per milliliter) . No sensitivities required .Abnormal Summary .CHARACTER .slightly-Cloudy .PROTEIN .100 .GLUCOSE .>=500 .LEUKOESTERASE (presence of white blood cells in the urine) .Trace .WBC (white blood cells) .8 .BACTERIA .Small .MUCUS .Few .
There was no documentation Resident 79's urine analysis was reported on July 14, 2021.
On July 22, 2021, at 9:25 a.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated she reported the urine analysis result on July 19, 2021. RNS 1 stated the urine analysis result was available on July 14, 2021. She stated there was no documentation Resident 79's urine analysis result was reported to the physician. RNS 1 stated when a urine analysis result had abnormal findings, the physician should be notified right away. RNS 1 stated Resident 79's urine analysis result had abnormal findings and the physician should have been notified right away.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
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 specialized rehabilitative (rehab) services, ...
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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 specialized rehabilitative (rehab) services, as ordered by the physician, for one of two residents reviewed for rehab (Resident 59), when PT and OT did not evaluate and treat Resident 59.
This failure had the potential to result in Resident 59's difficulty in attaining and maintaining her highest practicable level of physical, mental, functional, and psycho-social well-being.
Findings:
On July 19, 2021, at 4:17 p.m., Resident 59 was observed in bed. In a concurrent interview, Resident 59 stated she was admitted to the facility for neuropathy (a disease that causes weakness, numbness, and pain from nerve damage, usually in the hands and feet), and was supposed to get rehab services (PT and OT). Resident 59 stated she did not receive PT and OT evaluation and treatment.
Resident 59's record was reviewed. Resident 59 was admitted to the facility on [DATE], with diagnoses which included: dry beriberi (a disease that causes neuropathy, weakness, and pain in the limbs), spinal stenosis (pressure on the spinal cord and nerves), and spinal enthesopathy (a spinal problem, affecting the joints).
Resident 59's Physician Orders, was reviewed. The physician order, dated June 1, 2021, indicated, .PT evaluation and treatment as indicated .OT evaluation and treatment as indicated .
Resident 59's care plan was reviewed. The care plan indicated, .At risk for falls d/t (due to) .limited mobility .poor balance .decreased endurance .unsteady gait .refer for Rehabilitation consult .Care Plan Goal: Bathe Independently .Refer to Occupational Therapy to work on ADL (Activities of Daily Living re-training) .Requires assistance with transfers .Care Plan Goal: Transfer Independently .Refer to Physical Therapy for evaluation .
On July 21, 2021, at 2:19 p.m., in a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 59 did not receive any PT or OT treatment.
On July 21, 2021, at 2:30 p.m., in a concurrent interview and record review with the Director of Rehab (DOR), the DOR stated Resident 59 did not receive a PT and OT evaluation and treatment.
On July 21, 2021, at 2:40 p.m., in a concurrent interview and record review with the Director of Nursing (DON), and the Director of Staff Development (DSD), the DON stated there was no documentation that a PT and OT evaluation had been completed or that a PT and OT treatment had been started, as ordered by the physician. The DON stated the physician's order was not followed. The DSD stated the screening recommendation from Rehab to establish RNA (Restorative Nursing Assistant) program was not followed.
The facility policy and procedure titled, Restorative Nursing Program Guidelines, revised September 19, 2019, was reviewed. The policy indicated, .The Restorative Nursing Program provides nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible .Restorative Nursing Programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy. A resident with restorative nursing needs may be started on a Restorative Nursing Program upon admission to the facility, but is not a candidate for formalized rehabilitation therapy, or when restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
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, for one of 18 residents reviewed (Resident 79...
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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, for one of 18 residents reviewed (Resident 79), an adequate indication for the use of Macrobid (antibiotic to treat urinary tract infection ) . This failure had the potential to result in emergence of antibiotic resistant organisms.
Findings:
Resident 79's record was reviewed. Resident 79 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level).
Resident 79's document titled, Laboratory Report, dated July 14, 2021, indicated .UA (urine analysis) C.S (culture sensitivity) IF IND (if indicated) .CULTURE, URINE .Final .<10,000 cfu/ml (colony forming unit per milliliter) . No sensitivities required .Abnormal Summary .CHARACTER .slightly-Cloudy .PROTEIN .100 .GLUCOSE .>=500 .LEUKOESTERASE (presence of white blood cells in the urine) .Trace .WBC (white blood cells) .8 .BACTERIA .Small .MUCUS .Few .
Resident 79's progress notes dated July 19, 2021, indicated, Received U/A result with abnormal reading reported .with new order of MACROBID 100mg po BID (twice a day) x (for) 7 days .
On July 22, 2021, at 9:25 a.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated she reported the urine analysis result on July 19, 2021. RNS 1 stated the physician ordered for Macrobid twice a day for seven days. RNS 1 stated the urine analysis result had abnormal findings.
On July 22, 2021, at 9:50 a.m., the Infection Preventionist (IP) was interviewed. The IP stated the licensed nurse would communicate with her regarding the use of antibiotic. The IP stated the facility used the McGeer's criteria for the use of antibiotic in UTI. She stated if the resident's urine analysis result did not meet the criteria for UTI, the antibiotic use was not warranted. The IP stated she was not aware Resident 79 was on antibiotic.
In a concurrent review of Resident 79's record, the IP stated there was no indication for the use of antibiotic Macrobid. The IP stated the McGeer's criteria was not met, since Resident 79 had less than 100,000 colonies in her urine.
According to McGeer's Criteria for Long Term Care Surveillance Definitions for Infections, updated 2012, indicated, .Urinary Tract Infecions (UTI's) .New Criteria for UTI without a Catheter: (Both criteria 1 and 2 must be present) .Criteria 1 .At least one of the following signs or symptoms criteria: a. Acute dysuria or acute pain .Criteria 2 .a. At least 105 cfu/ml of no more than 2 species of microorganisms in a voided urine sample .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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, for two of five residents reviewed:
a. Education was provi...
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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, for two of five residents reviewed:
a. Education was provided to Resident 65 when the resident refused the influenza vaccine.
This failure did not honor the resident right to be notified in order to make an informed choice for Resident 65 regarding the vaccine.
b. Education was provided to the resident's responsible party about pneumococcal vaccine (prevents infection by Streptococcus [bacterium that causes one of the most common and severe forms of pneumonia] [pneumonia-lung inflammation]), benefits and potential side effects.
This failure did not honor the responsible party's right to be notified in order to make an informed choice for Resident 75 regarding the vaccine.
Findings:
a. A review of Resident 65's record indicated he was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (ESRD- inability of the kidney to make urine and remove waste from the blood) and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood).
Resident 65's history and physical dated August 21, 2020, indicated he has the capacity to understand and make decisions.
Resident 65's Influenza Vaccination, Informed Consent or Refusal on 9/24/2020, Resident 65 verbally declined.
On July 22, 2021, at 9:19 a.m., in a concurrent interview and record review with the Infection Preventionist (IP), she verified Resident 65 had declined the influenza vaccine on September 24, 2020. The IP stated there were no documented evidence the risk and benefit of the influenza vaccine was discussed with Resident 65.
A review of the facility policy and procedure titled, Influenza Prevention and Control, date revised September 10, 2020, indicated, .Before offering the influenza vaccine, each Resident or Resident's representative will be given education regarding the risk and benefits and potential side effects of the immunization .
b. In a review of Resident 75's record, indicated she was admitted to the facility, July 13, 2021, with diagnoses which included encephalopathy (brain disease, damage, or malfunction) and ESRD.
Resident 75' s history and physical examination dated March 23, 2021, indicated she can make needs known but cannot make medical decisions.
On July 22, 2021, at 9:19 a.m., in a concurrent interview and record review with the Infection Preventionist (IP), she verified Resident 75 had declined the pneumococcal vaccine on March 21, 2021 and April 14, 2021. The IP stated there were no documented evidence the risk and benefit of the pneumococcal vaccine was discussed with Resident 75's responsible party.
A review of the facility policy and procedure titled, Pneumococcal Disease Prevention, date revised February 18, 2021, indicated, .Before offering PCV 13 (Pneumococcal conjugate vaccine), each Resident or the Resident's representative must be given education regarding the benefits and potential side effects of the immunization .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
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 the request for COVID 19 (Corona virus disease 2019- 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 accommodate the request for COVID 19 (Corona virus disease 2019- a respiratory disease caused by a virus that can be transmitted from person to person) vaccine for one of five residents reviewed for immunization for COVID 19 (Resident 78). This failure had the potential to result in Resident 78 not getting the protection from the virus.
Findings:
On July 19, 2021, at 8:56 a.m., during an interview with Resident 78, she stated she had a flu like symptom in the past that is why she requested to have the vaccine in the facility. Resident 78 requested the COVID 19 vaccine from the facility a month ago and she did not received it yet.
During a review of Resident 78's record, she was admitted to the facility on [DATE], with diagnoses which included, fracture of the right tibia (larger bone of the leg) and post motor vehicular accident.
Resident 78's history and physical exam dated June 19, 2021, indicated she was alert, and cooperative.
On July 19, 2021, at 8:56 a.m., in an interview with the Infection Preventionist (IP), she stated that facility test resident for COVID 19 on the 14th day of observation, then they were offered the vaccine. She stated it will not take more than two weeks, for a resident to get the vaccine once they were notified.
Resident 78 was tested on [DATE] (the 14th day of observation), for COVID 19, and there was no documented evidence Resident 78 was offered COVID 19 vaccine.
On July 21, 2021, at 8:35 a.m., in an interview with Treatment Nurse (TN) 1, he stated Resident 78 made the request that she want to be vaccinated about 3 days after her admission and I told the charge nurse about her request.
On July 21, 2021, at 8:40 a.m., in an interview the IP, she stated she was not aware of the request.
A review of the facility policy and procedure titled, COVID-19 Vaccination Program, dated December 14, 2020, indicated, .the facility will support local health department (LHD) immunize staff and Residents against COVID-19 infection .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included senile ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Resident 51's record was reviewed. Resident 51 was admitted to the facility on [DATE], with diagnoses which included senile degeneration of the brain.
Resident 51's HISTORY AND PHYSICAL EXAMINATION, dated May 22, 2021, indicated Resident 51 was admitted under hospice care.
The document titled, 60-Day Physician Recertification of Terminal Illness, dated March 12, 2021, indicated .I certify that this patient is terminally ill with a life expectancy of six months or less .
The physician order dated May 15, 2021, indicated, admit to (name of) hospice on routine level of care with diagnosis of senile degeneration of the brain .
Resident 51's document titled, Preadmission Screening and Resident Review (PASRR) Level 1 Screening Document, dated May 15, 2021, indicated .Level 1 - Negative .Section IV - Categorical Determination .No .Terminal Illness. The resident has a terminal illness as defined for hospice purposes .The attending physician certified the resident's life expectancy is less than six months .
On July 23, 2021, at 11:32 a.m., Resident 51's record was reviewed with Registered Nurse Supervisor (RNS) 1. RNS 1 stated the licensed nurses were responsible for completion of the PASRR. She stated Resident 51 was admitted on hospice. RNS 1 stated the terminal illness in the PASRR should be coded yes. RNS 1 stated the PASRR was inaccurately coded.
2b. Resident 67's record was reviewed. Resident 67 was admitted to the facility on [DATE], with diagnosis which included intellectual disabilities.
Resident 67's PASRR dated February 27, 2020, indicated, .Level 1 - Negative .Section VI - Intellectual or Developmental Disability (ID)/(DD) or Related Condition (RC) Screen .No .Does the resident have or is suspecting of having a primary diagnosis of ID/DD/RC .
On July 23, 2021, at 2:36 p.m., the Director of Staff Development (DSD) was interviewed. She stated PASRR's completion would be based on the documents received, the residents diagnoses, and reports from the registered nurses. The DSD stated looking at Resident 67's PASRR, and she stated the PASRR should have been coded yes for intellectual disability and the level would be affected.
Based on interview and record review, the facility failed to ensure, for three of five residents reviewed for PASRR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care):
a. The evaluation for PASRR level II (identifies the specialized services required by the resident) was cooordinated with State-Designated Authority (SDA), for Resident 75.
This failure may result to the facility's inability to incorporate PASRR Level II evaluation in the resident's care plan. In addition, Resident 75 specialized services were not met, and
b. PASRR level I assessment was coded accurately for Residents 51 and 67.
This failure had the potential to result in admitting residents that were not appropriate in the facility and for Residents 51 and 67 not to receive the appropriate services.
Findings:
a. A review of Resident 75's record, indicated she was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disease, damage, or malfunction).
Resident 75' s history and physical examination dated March 23, 2021, indicated she can make needs known but cannot make medical decisions.
Resident 75's PASRR dated March 19, 2021, indicated, LEVEL I SCREEN INDICATES THE NEED FOR A PASARR LEVEL II EVALUATION .
On July 21, 2021, at 9 a.m., in a concurrent interview and record review with the Director for Staff Development (DSD), she verified she did not follow up Level II PASRR evaluation with the SDA. She further stated this failure can cause inappropriate placement in the facility. The DSD stated this level II PASRR evaluation should have been followed up.
A review of the facility policy and procedure titled, Pre- admission Screening level 11 Resident Review, revised date of September 2017, indicated, .The BOM (business office manager)/Designee will report the status of the PASARR, including level 11 determinations .the DON will review the .level 11 determinations .the Designee will print and evaluators report .and bring to Stand-up Meeting for IDT(interdisciplinary team including the physician, Administrator, DON, DSD, licensed nurses, dietary, department heads etc.). The IDT will review the level 11 evaluation report to develop a care plan, and arrange the Specialized Services recommended for the resident. Specialized Services are add-on to the facility services - they are of a higher intensity and frequency than the services provided by the facility . If the PASRR level 11 report indicates that he/she needs specialized services, and the IDT identifies that he/she is not receiving them, the BOM will notify the Medical/Medicaid agency for authorization for payment of this services .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
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 provide treatment and care in accordance with the professional stan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for two of 18 residents reviewed (Residents 67 and 88) when:
1a. The licensed nurse did not clarify the dose of the medication Roxanol (Morphine: opioid medicine used to treat moderate to severe pain) with the physician for Resident 88.
This failure had the potential for Resident 88 to receive the wrong dose of Roxanol;
1b. The intake and output was not monitored as ordered by the physician for Resident 88.
This failure had the potential to result in fluid overload.
2. Turning and repositioning was not implemented in accordance to the schedule for Resident 67.
This failure had the potential to result in skin breakdown for Resident 67.
Findings:
1a. Resident 88's record was reviewed. Resident 88 was admitted to the facility on [DATE], with diagnoses which included old cerebrovascular accidents (stroke), ESRD ( End stage renal disease - long standing disease of the kidneys leading to kidney failure) on hemodialysis (medical procedure to remove fluid and waste products from the blood), Hepatitis C (liver infection caused by the hepatitis C virus).
Resident 88's record titled, Physician Order summary, indicated, .ROXANOL 20MG (milligram)/ML (milliliter) (MORPHINE SULPHATE) GIVE 0.25MG VIA GTUBE (tube inserted through the abdomen that delivers nutrition directly to the stomach) EVERY (4) HOURS AS NEEDED FOR PAIN MANAGEMENT. HOLD FOR RESPIRATION LESS THAN 14 BPM (breaths per minute) .
Resident 88's record titled, Medication Administration Record (MAR), dated April 2021, indicated, Roxanol 20mg/ml( morphine sulphate) Give 0.25mg via G-tube every four hours as needed for pain management .The MAR further indicated Licensed Vocational Nurse (LVN) 5 administered Roxanol on April 28, 2021, and April 29, 2021.
The facility document titled, NARCOTIC AND HYPNOTIC RECORD, dated April 27, 2021, indicated, MORPHINE SULF 100MG/5 ML SOLUT (solution) GIVE 0.25ML (5MG) VIA G-TUBE EVERY 4 HOURS AS NEEDED FOR PAIN MANAGEMENT .Qty: 30ML .
On July 22, 2021, at 1:16 p.m., during a concurrent interview and record review with LVN 5, she stated she administered 0.25 ml (equivalent to 5 mg of the medication) Roxanol to Resident 88. LVN 5 stated she thought the physician order was 0.25 ml, and not 0.25 mg as indicated. LVN 5 stated she should have clarified the medication with the physician before administering the medication. When asked about the actual amount of medication to be administered, LVN 5 stated that she did not have to calculate medication and medication comes calculated for her by the pharmacist.
On July 22, 2021, at 1:55 p.m., during an interview with LVN 1, she stated Roxanol 0.25mg equals to 0.0125 ml. She stated 0.0125 ml of medication could not be given through the g-tube. LVN 1 stated the medication order needed clarification.
On July 22, 2021, at 4:59 p.m., an interview with the Director of Staff Development (DSD) was conducted. She stated she received the order from the physician for medication Roxanol. The DSD stated she made a mistake while transcribing physician order. The DSD stated the physician order was Roxanol 0.25 ml and not Roxanol 0.25mg.
On July 23, 2021, at 8:04 a.m., during an interview with Pharmacy Tech (PT), the PT stated if there was a physician order that needed clarification, the pharmacist would call the facility and verify the order with the licensed nurse. The PT stated the pharmacist called the facility and clarified the order with the licensed nurse. She stated the licensed nurse (LVN 5) clarified that the dose of the medication Roxanol was 0.25 ml not 0.25 mg.
There was no documented evidence the dose of the medication was clarified with the physician.
The facility's policy and procedure titled, Telephone Orders for Medication, date revised January 01, 2012, indicated, .before terminating a conversation with Physician or Nurse Practitioner, the order willbe repeated back to clarify and ensure that the following necessary information is included .name of the medication .dosage .Clarification of Attending Physician orders must be obtained promptly .
1b. Resident 88's record was reviewed. Resident 88 was admitted to the facility on [DATE], with diagnoses which included old cerebrovascular accidents (stroke), ESRD ( End stage renal disease - long standing disease of the kidneys leading to renal failure) on hemodialysis (medical procedure to remove fluid and waste products from the blood), Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation).
A review of Resident 88's record titled, Physician Order, dated April 17, 2021 indicated, .MONITOR INTAKE AND OUTPUT PM (afternoon shift) TO TOTAL AMOUNT DAILY .
Resident 88's care plan with the start date of February 10, 2021, indicated, Category UTI (Urinary Tract Infection), Renal Failure, End Stage Renal Dialysis .Intervention .Monitor fluid intake and output per physician order. Observe for signs of dehydration .
There was no documented evidence Resident 88's intake and output was monitored.
On July 22, 2021, at 4:55 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated there was no documentation of Resident 88's intake and output monitoring. The DSD stated there was no documentation in the progress notes that the intake and output was monitored for Resident 88.
On July 23, 2021, at 8:46 a.m., during an interview with the Director of Nursing (DON), the DON stated residents' intake and output should have been completed when the physician ordered to monitor the residents' intake and output.
The facility's policy and procedure titled, Intake and Output Recording, dated April 15, 2021, indicated, .provide a record of the resident fluid intake and/or output .The facility will record intake and output, as ordered by the physician .
2. On July 19, 2021, at 8:14 a.m., Resident 67 was observed laying on his back.
Resident 67 was observed on the following dates and times:
- July 19, 2021, at 3:39 p.m.;
- July 20, 2021, at 9:11 a.m.;
-July 20, 2021, at 11:27 a.m.;
- July 21, 2021, at 4:04 p.m.;
- July 22, 2021, at 10:18 a.m.;
- July 22, 2021, at 11:36 a.m.;
-July 22, 2021, at 2:11 p.m.;
On July 22, 2021, at 2:14 p.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated she was familiar with Resident 67, and she stated Resident 67 required total care with his activities of daily living. CNA 2 stated Resident 67 was nonverbal and the staff had to anticipate for his needs. CNA 2 stated she would turn and repositioned the resident every two hours to prevent skin breakdown. CNA 2 stated the facility had a turning schedule for residents, and she stated at this time, Resident 67 should be facing the door. CNA 2 stated Resident 67 was laying on his back and not facing the door, as scheduled.
In a concurrent review of the turning schedule with CNA 2, she stated Resident 67 should be repositioned and turned for the following times:
- 9 a.m. to 11 a.m., the resident should be facing the window;
- 11 a.m. to 1 p.m., the resident should be on his back;
-1 p.m. to 3 p.m., the resident should be facing the door; and
- 3 p.m. to 5 p.m., the resident should be facing the window.
Resident 67's record was reviewed. Resident 67 was admitted to the facility on [DATE], with diagnoses which included contracture (permanent shortening of the muscle and joints).
Resident 67's care plan indicated the following:
a.Activities of Daily Living .intervention .Resident performance: Bed mobility - Total one person assist .Turn and reposition every two hours and as needed .
b.Skin .Minimize risk for skin breakdown .Intervention .Assist with turning and repositioning .
The document titled,Braden Scale Risk Assessment - For Predicting Pressure Sore Risk, dated February 27, 2020, indicated, .Braden Risk Total Score .9 .Braden Risk Level .The resident is Very High Risk for the development of pressure ulcers .
On July 23, 2021, at 8:44 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 67 could not move by himself and the CNA should assist him with turning and repositioning. The DON stated the resident should be repositioned and turned every 2 hours to prevent skin breakdown.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 restorative nursing services (nursing interven...
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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 restorative nursing services (nursing interventions that promote quality of life by increasing the resident level of strength and mobility and maintain his or her maximum functional capacity) as ordered by the physician for three of five residents reviewed for limited range of motion (ROM-the full movement potential of joint) (Residents 19, 52, and 67).
This failure had the potential to result in the resident's decline in ROM and deterioration in their ability to perform activities of daily living (ADL).
Findings:
1. On July 19, 2021, a review of Resident 19's record indicated that Resident 19 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), personal history of traumatic fracture (broken bone), and abnormal posture.
A review of Resident 19's Minimum Data Set (an assessment tool) dated April 14, 2021, indicated .Section G .Functional Limitation in Range of Motion .Hip, Knee, Ankle, Foot .Impairment on both side .
A review of the facility document titled, Physician Orders, dated April 16, 2021, indicated, .RNA (Restorative Nurse Assistant) FOR PROM (passive range of motion) TO THE JOINTS OF THE BLE (bilateral lower extremities) AS SAFELY TOLERATED BY PATIENT QD (every day) 5x (times) /WEEK .
A review of the facility document titled, Restorative Nursing Program, dated July 2021, indicated, .PROM to the joints of BLE QD 5x/week as tolerated .Apply of knee extension splints for 1.2 hr (hours)/day 5x/week tolerated.
The document further indicated the following:
a. On Week One (July 1 to July 7, 2021), ROM exercises, was provided on July 1, 2, 3, 4 and 7, 2021; (PROM to the joints of BLE and knee extension splints).
b. On Week Two (July 8 to July 14, 2021), ROM exercises provided on July 8 and 14, 2021. There was no documentation Resident 19 was provided PROM and knee extension splints on July 9, 10, 11, 12, and 13, 2021; and
c. On Week Three (July 15 to July 21, 2021), ROM exercises, provided on July 19, 20, and 21, 2021. There was no documentation indicating Resident 19 was provided PROM and knee extension splints on July 15, 16, 17, and 18, 2021.
On July 23, 2021, 1:37 p.m., during a concurrent record review and interview with RNA 1, she stated sometimes they get reassigned as Certified Nursing Assistant to care for residents. RNA 1 stated they were not able to do RNA program for residents when they get reassigned to care for residents.
On July 23, 2021, at 2:10 p.m., during an interview with the Director of Nursing (DON), the DON stated RNA program should be done as ordered by the physician. She stated after every RNA treatment, the treatment provided to the residents should have been documented. The DON stated if there is no documentation of RNA treatment, then it was probably not done.
The facility's policy and procedure titled, Restorative Nursing Program Guidelines, dated September 19, 2019, indicated, .this program actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning unless a decline is unavoidable .frequency of the RNA program will be determined by the medical necessity and physician order .
3. Resident 67's record was reviewed. Resident 67 was admitted to the facility on [DATE], with diagnoses which included intellectual disabilities and contracture (permanent shortening of the muscle or joint), multiple sites.
The physician order dated August 29, 2020, indicated, RNA (Restorative Nursing Assistant) program for: AROM (active range of motion) of LUE (left upper extremities). PROM (passive range of motion) of RUE (right upper extremities). Resting hand splint 4-6 hours. QD (every day) X7 times/week or as safely tolerated.
Resident 67's Minimum Data Set (an assessment tool) dated June 10, 2021, indicated that the resident had an impairment on both sides of the upper and lower extremities.
The document titled, RESTORATIVE NURSING PROGRAM, for the month of July 2021, indicated the following:
a. Week One (July 1 to July 7, 2021), there was no documentation indicating Resident 67 was provided AROM, PROM, and resting hand splint from July 1 to July 7, 2021;
b. Week Two (July 8 to July 14, 2021), ROM treatment was provided on July 11 and July 12, 2021. There was no documentation Resident 67 was provided AROM, PROM, and resting hand splint on July 8, 9, 10, 13, and 14, 2021; and
c. Week Three (July 15 to July 21, 2021), ROM treatment was provided on July 15, 16, 17, and 21, 2021. There was no documentation Resident 67 was provided AROM, PROM and resting hand splint on July 18, 19, and 20, 2021.
On July 22, 2021, at 2:28 p.m., Restorative Nursing Assistant (RNA) 3 was interviewed. RNA 3 stated she was providing ROM treatment for Resident 67. RNA 3 stated she would document in the restorative program form when Resident 67 was provided ROM exercises and the resting hand splint was applied to Resident 67. She stated if there was no documentation in the RNA program form, the ROM and resting hand splints were not provided and applied to the resident. RNA 3 stated there were times when she was reassigned to work on the floor. She stated RNA program for Resident 67 was not provided on days when she was reassigned as a certified nursing assistant.
2. On July 19, 2021, at 12:34 p.m., Resident 52 was observed eating by herself with her left hand holding a spoon. The resident's right hand was observed in pinching position with the thumb and the index finger is in direct contact with each other.
A review of Resident 52's record, indicated she was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke).
Resident 52's MDS (minimum data set- an assessment tool) related to Functional Limitation in Range of Motion, dated November 28, 2020, indicated Resident 52 had an impairment on one side of the upper extremity.
Resident 52's Health and Social History dated October 13, 2020, indicated that the resident goes for dialysis every Monday, Wednesday and Friday.
Resident 52's Restorative Nursing Program, indicated, .Plan- PROM (passive range of motion) of RUE (right upper extremities) QD (daily) on non- dialysis days as tolerated. The document indicated the following:
a. For the month of June 2021:
1. Week One (June 1 to June 7, 2021) ROM exercises,was provided two times;
2. Week Two (June 8 to June 14, 2021), ROM exercises. was provided two times;
3. Week Three (June 15 to June 21, 2021), ROM exercises was provided two times;
4. Week Four (June 22 to June 28, 2021), ROM exercises was provided only two times; and
5. Week Five (June 29 and 30, 2021), ROM exercises was provided only once.
For the month of July 2021:
1. Week One (July 1 to July 7, 2021), ROM was provided only three times;
2. Week Two (July 8 to July 14, 2021), ROM was provided only once; and
3. Week Three (July 15 to July 21, 2021), ROM was provided only four times.
On July 23, 2021, at 2:36 p.m., in a concurrent interview and record review with Restorative Nurse Assistant (RNA) 2, she verified there were multiple instances the PROM exercises were not performed. RNA 2 stated when exercises were not done, it was when RNA duties were reassigned to CNA.
A review of the facility policy and procedure titled Restorative Nursing Program Guidelines, date revised September 19, 2019, indicated, .The RNA carries out the restorative program according to the Care Plan .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain safe food handling practices when:
1. The food products located in the resident's refrigerator were not labeled.
2...
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Based on observation, interview, and record review, the facility failed to maintain safe food handling practices when:
1. The food products located in the resident's refrigerator were not labeled.
2a. The interior of the microwave oven was observed with dark yellowish substance; and
2b. The convection oven was observed with dust particles and dark brownish material.
These failures had the potential to result in foodborne illnesses in the highly susceptible resident population.
Findings.
1. On July 23, 2021 at 11:12 a.m., during the inspection of the resident's refrigerator in the Yellow zone with the Infection Preventionist (IP), the following were observed:
a. One bag filled with multiple sandwiches was found not labeled with names and date;
b. One white plastic bag containing food was not labeled with name and date;
c. One brown paper bag with a glass container with food inside, was not labeled with name and date.
A concurrent interview was conducted with the IP. The IP stated all food in the resident's refrigerator should be labeled with a name and date. The IP stated the bag of sandwiches, plastic bag with food, and the brown bag with container and food inside should be discarded immediately.
2 a. On July 19, 2021, at 8:48 a.m., during the initial tour of the kitchen with the Dietary Supervisor (DS), a dark yellowish substance was observed on the interior of the microwave oven.
In a concurrent interview with the DS, the DS stated dark yellowish substance inside the right inner side of the microwave oven could be a splattered food or soup. She stated microwave should be cleaned after every use.
2b. On July 19, 2021, at 8:51 a.m., during the initial tour of the kitchen with the Dietary Supervisor (DS), the convestion oven was observed with dust particles and dark brownish material outside the convection oven/
In a concurrent interview with DS, she stated convection oven should be cleaned after each use.
According to FDA Federal Food Code 2017, .Section 4-601.11 Equipment, Food -Contact Surfaces, Nonfood-Contact Surfaces, and Utensils .(c) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris .Section 4-602.12 Cooking and Baking Equipment .The cavities and door seals of microwave ovens shall be cleaned .
Sept 2019
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the diagnosis of mental illness was coded accurately in the ...
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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 diagnosis of mental illness was coded accurately in the Preadmission Screening and Resident Review (PASARR - a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs) for one of two residents reviewed for PASARR (Resident 10). This failure had the potential to result in admitting residents that were not appropriate in the nursing facility and for Resident 10 not to receive the appropriate services.
Findings:
Resident 10's record was reviewed. Resident 10 was readmitted to the facility on [DATE], with diagnosis which included depression (persistent feeling of sadness and loss of interest) and schizoaffective disorder (mental disorder).
The Preadmission Screening and Resident Review (PASARR) Level I screening Document, dated April 8, 2019, indicated, .Diagnosed Mental Illness. 26. No (choosen answer) Does the resident have a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder (mental disorder)Psychotic/Psychosis(abnormal condition of the mind that results in difficulties determining what is real and what is not) .Depression (mood disorder) .Psychotropic Medication(medication capable of affecting the mind, emotions, and behavior). 28. No (choosen answer) Has the resident been prescribed psychotropic medications ? .
A review of Resident 10's physician orders dated April 8, 2019, indicated the following:
a. Risperdal (antipsychotic medication - psychotropic medication) for psychosis (mental disorder); and
b. Celexa (antidepressant medication - psychotropic medication) for depression.
On September 6, 2019, at 9:49 a.m., the admission Coordinator (AC) was interviewed. The AC stated she was assigned to do the PASARR.
In a concurrent review of Resident 10's PASARR, the AC stated Resident 10's PASARR was not coded correctly.
On September 6, 2019, at 10:21 a.m., the AC was again interviewed. The AC stated the reason for doing the PASARR was to prescreen the resident and to know if the facility would be able to meet the resident's needs. The AC stated miscoding the PASARR would affect the screening and evaluation process for the resident.
On September 6, 2019, at 2:12 p.m., the MDS (minimum data set - an assessment tool) Coordinator (MDSC) was interviewed. The MDSC stated she would check for completion and accuracy of the PASARR during MDS assessment. The MDSC stated she would revise the PASARR if there were corrections. The MDSC stated Resident 10 had a mental disorder and the PASARR should have been coded yes for mental illness.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed for re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed for resident's dental problem for one of two residents reviewed for dental issues(Resident 21). This failure had the potential to result in Resident 21's dental needs not to be addressed and could impact the quality of care and services received.
Findings:
On September 3, 2019, at 9:25 a.m. Resident 21 was observed with upper denture and no lower denture. In a concurrent interview with Resident 21, Resident 21 stated she did not have her lower denture for two months.
Resident 21's record was reviewed. Resident 21 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss).
The Dental Progress Notes, dated June 24, 2019, indicated, .per pt (patient) lower denture is too thick .tissue condition/relines: low (lower) denture .; and on July 25, 2019, Pt says dentist took the lower denture a month ago .Recommend new FLD (full lower denture) .
There was no care plan developed for Resident 21's dental problem.
On September 5, 2019, at 10:40 a.m., the MDS (Minimum Data Set- an assessment tool) Coordinator (MDSC) was interviewed. The MDSC stated she was responsible for doing the care plan during the comprehensive assessment for Resident 21. The MDSC stated Resident 21 had a comprehensive assessment done on December 16, 2018. The MDSC stated there was no care plan developed for Resident 21's dental problem. The MDSC further stated there should be a care plan so the needs of the resident could be addressed.
The policy and procedure titled Comprehensive Person-Centered Care Planning, dated November 2018, was reviewed. The policy and procedure indicated, .Comprehensive Care Plan .Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .the comprehensive care plan will also be reviewed and revised at the following times .Onset of new problems .and other times as appropriate or necessary .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 10's record was reviewed. Resident 10 was readmitted to the facility on [DATE], with diagnoses which included conges...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 10's record was reviewed. Resident 10 was readmitted to the facility on [DATE], with diagnoses which included congestive heart failure (heart muscle does not pump blood as well as it should) and chronic kidney disease (gradual loss of kidney function).
The physician order dated April 8, 2019, indicated, 1000 ML (milliliter) FLUID RESTRICTION . Dietary- Breakfast =120 lunch-120 D (dinner)- 120 Nursing 7-3= 340 3-11= 200 11-7=100 .
The document titled, INTRAVENOUS (within a vein) PHYSICIAN ORDER FORM, dated August 30, 2019, indicated, Vancomycin (medication to treat bacterial infections) 1 gm (gram) stat .diagnosis .wound infection .Vancomycin pharmacy to dose X (for) 1 (one) week .
The document titled, Intake & (and) Output Record, from August 26, 2019 to September 5, 2019, indicated the daily 24 hour total oral fluid intake for the following dates:
August 26, 2019 - 1380 cc (cubic centimeter = ml)
August 28, 2019 - 1160 ml
August 29, 2019 - 1160 ml
August 30, 2019 - 1160 ml
August 31, 2019 - 1120 ml
September 1, 2019 - 1120 ml
September 2, 2019 - 1140 ml
September 5, 2019 - 1200 ml.
The document did not indicate the intake received by Resident 10 intravenously from August 30, 2019 to September 5, 2019.
On September 6, 2019, at 8:15 a.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated Resident 10 was on Vancomycin once a day for wound infection. RNS 1 stated the medication was premixed with 250 ml of normal saline. RNS 1 stated the licensed nurse should have recalculated the fluid received by Resident 10 to include the IV fluid from the antibiotic medication.
On September 6, 2019, at 8:22 a.m., the Director of Nutrition Service (DNS) was interviewed. The DNS stated Resident 10 was on 1000 ml fluid restriction for 24 hours. The DNS stated for the dietary, the fluid given would not be affected. The DNS stated nursing had to adjust the fluid being given to the resident to include fluid received through intravenous route.
On September 6, 2019, at 8:49 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 10 was on fluid restriction. The DON stated the vancomycin was premixed in 500 ml or 250 ml depending on the vancomycin dose. The DON stated Resident 10's fluid intake should have been adjusted and the physician should have been notified. The DON stated the fluid restriction order was not followed as prescribed by the physician.
The policy and procedure titled, Fluid Restrictions, dated January 1, 2012, was reviewed. The policy and procedure indicated, .Residents on fluid restriction will be monitored for intake and will receive appropriate interventions to alleviate discomfort from the fluid restriction for the duration of the Attending Physician order .The Licensed Nurse will .Initiate strict intake measurement per the Attending Physician Order .Total the amount of fluid each 24 hours and compare it against the Fluid Restriction Guidelines .Review Intake and Output summary weekly and address the adequacy of fluids and accuracy of documentation .
3. On September 3, 2019, at 3:36 p.m., Resident 188 was observed with a reddish black discoloration on the left upper arm measuring approximately 6.5 centimeters (cm) by 6.5 cm.
In a concurrent interview with Resident 188, Resident 188 stated there was an old intravenous site on her left upper arm. Resident 188 stated she was on blood thinner medication.
Resident 188's record was reviewed. Resident 188 was admitted to the facility on [DATE], with diagnoses which included chronic atrial fibrillation (long standing irregular heart rate and rapid heart beat).
The Resident admission Assessment, dated August 27, 2019, indicated Resident 188 had an old intravenous (within a vein) site on the left upper arm. There was no indication Resident 188 had skin discoloration on the left upper arm.
There was no documentation an evaluation or an assessment was done on Resident 188's reddish black discoloration on the left upper arm.
The document titled Communication Log for Daily Rounds, dated September 2, 2019, indicated, Resident 188 had ecchymosis (pooling of blood under the skin) on left chest. There was no documentation of skin discoloration on the left upper arm.
The Resident Care Plan, dated August 27, 2019, indicated Resident is at risk for bleeding related to .Medication(s) Eliquis (blood thinner) .Monitor for signs and symptoms of bleeding .
On September 4, 2019, at 4:18 p.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated she was assigned to Resident 188 on September 3 and September 4, 2019. CNA 2 stated Resident 188 had discolorations to lower extremities but not on the upper extremities. CNA 2 further stated Resident 188 had no skin changes.
On September 4, 2019, at 4:25 p.m., the Treatment Nurse (TN) was interviewed. The TN stated she was not aware Resident 188 had skin discoloration on her left upper arm. The TN stated Resident 188 came in with multiple ecchymosis and discolorations (bruising).
In a concurrent review of Resident 188's record, the TN stated there was no documentation indicating Resident 188 had skin discoloration on her left upper arm. The TN stated if the discoloration was present on admission, the licensed nurse should have documented in the resident's record.
On September 5, 2019, at 7:53 a.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated Resident 188 came in with discoloration to the left upper arm. LVN 4 stated there should have been an assessment of the resident's skin discoloration. LVN 4 further stated there should have been a monitoring of the skin discolorations to know if there was progression of Resident 188's skin condition.
On September 5, 2019, at 8:44 a.m., the Wound Doctor (WD) was interviewed. The WD stated he saw Resident 188 on September 2, 2019. The WD stated he observed Resident 188 had an ecchymotic lesion on the posterior lateral chest area and it was an old skin lesion. The WD was asked about the skin discoloration on the left upper arm and he stated the ecchymotic lesion on the left upper arm was dark and was kind of new and he was not sure when it happened or if there was progression of the skin lesion.
The policy and procedure titled Pressure Injury and Skin Integrity Treatment, dated August 12, 2016, was reviewed. The policy and procedure indicated, .A Skin Integrity Progress Report .will be initiated when a resident is admitted with or develops a skin problem such as .discoloration .or other skin condition .
Based on observation, interview, and record review, the facility to failed to ensure four of 93 residents received treatment and care in accordance with the professional standards of practice when:
1. A prescribed medication, Amlodipine Besylate (used to treat high blood pressure) was not administered in accordance to the physician's order for Resident 64. In addition, the physician was not notified that the medication was not given.
These failures placed Resident 64's quality of life at risk potentially causing additional blood pressure irregularities.
2. Fluid restriction was not followed in accordance with the physician's order for Resident 10.
This failure had the potential for Resident 10 to have fluid overload.
3. There was no assessment of Resident 188's discoloration on the left upper arm.
This failure had the potential for the resident not to receive treatment to the left upper arm discoloration.
Findings:
1. On September 5, 2019, at 8:34 a.m. during observation of the medication pass with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed taking Resident 64's blood pressure. The blood pressure reading was documented and recorded as 115/82 and pulse of 110 on the Medication Administration Record (MAR). LVN 2, documented on the (MAR), the Amlodipine Besylate 10 milligrams was not given.
In a concurrent interview, LVN 2 stated, We don't give Resident 64 the Amlodipine on the days he goes to dialysis because when he goes to dialysis the blood pressure will go lower.
LVN 2 documented on the MAR, that she was not going to give the Amlodipine on September 5, 2019.
A review of Resident 64's record indicated the resident was admitted to the facility on [DATE], with diagnoses of hypertension (high blood pressure), chronic kidney disease stage 5/dialysis (kidney no longer functioning and requiring a dialysis machine to clean the kidney), and chronic systolic (congestive) heart failure ( progressive heart disease that affects pumping action of the heart muscles).
Resident 64's physician orders indicated the following:
a. On March 20, 2019, (name of dialysis center) Tues (Tuesday), THurs (Thursday), Sat (Saturday); and
b. On March 20, 2019, Amlodipine Besylate10 milligrams 1 tab (tablet) PO (by mouth) QD (once daily).
The physician order for Amlodipine did not indicate to hold Amlodipine on days Resident 64 goes to dialysis.
On September 5, 2019, at 11 a.m., in an interview conducted with the Director of Nursing (DON) regarding the Amlodipine, the DON confirmed the staff should have called the physician when the medication was not given.
On September 6, 2019, a review of facility policy titled, Medication-Administration, dated and revised January 1, 2012, indicated, .iii. Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foot care was provided for two residents (Resi...
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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 foot care was provided for two residents (Residents 21 and 17). This failure had the potential to result in foot problems which could affect the resident's mobility and foot health.
Findings:
1. On September 3, 2019, at 9:33 a.m., Resident 21 was interviewed. Resident 21's toe nails were observed to be long. Resident 21 stated her toe nails were long and were not trimmed since June 2019. Resident 21 stated she wanted her toe nails trimmed.
Resident 21's record was reviewed. Resident 21 was admitted to the facility on [DATE], with diagnoses which included polyneuropathy (disease of the nerves).
The Resident Care Plan, dated July 1, 2016, indicated, Resident needs assistance with .personal hygiene .Approach .Provide assistance with ADL (Activities of Daily Living) care as needed .
On September 5, 2019, at 8:55 a.m., Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated trimming of nails were part of the CNAs responsibilities. CNA 3 stated if the residents' toe nails were long, she would ask the licensed nurse if she could trim the resident's nails.
On September 5, 2019, at 9:01 a.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated she was not aware Resident 21's toe nails were long. RNS 1 stated the CNAs were responsible for trimming residents' nails. RNS 1 stated Resident 21 was not diabetic and CNAs were responsible for trimming of the nails.
On September 5, 2019, at 10:08 a.m., CNA 3 was interviewed. CNA 3 stated Resident 21's toe nails were long and needed trimming.
2. On September 4, 2019, at 10:58 a.m., Resident 17 was interviewed. Resident 17 stated her toe nails were pretty long, and the podiatrist (foot doctor) had not seen her. Resident 17 stated she had callous on her right big toe, and her right big toe nail were digging into her shoe. Resident 17 stated she told the staff about her toe nails since the beginning of last month (August 2019).
Resident 17's record was reviewed. Resident 17 was admitted to the facility on [DATE], with diagnoses which included rheumatoid arthritis (warm, swollen, and painful joints) and cerebrovascular accident (stroke).
The Resident Care Plan, dated June 20, 2019, indicated, Resident needs assistance with .personal hygiene .Approach .Provide assistance with ADL (Activities of Daily Living) care as needed .
On September 5, 2019, at 10:08 a.m., CNA 3 was interviewed. CNA 3 stated Resident 17 had long toe nails and needed to be trimmed.
On September 5, 2019, at 4:11 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated trimming of nails were part of the ADL care. The DSD stated the CNAs were allowed to trim the residents' toe nails; however, the CNAs had to let the charge nurse know regarding the status of the resident's nails for possible podiatry (medical care and treatment of the human foot) referral. The DSD further stated the licensed nurse could trim resident's toe nails depending on the condition of the toe nails.
The facility policy and procedure titled, Foot - Care of, dated January 1, 2012, was reviewed. The policy and procedure indicated, To provide hygienic care of the feet, to prevent skin breakdown or infections and to promote comfort .Foot care is provided to residents as a component of a resident's hygienic program .Trim nails as needed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 recognize, evaluate and address the needs of one of th...
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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 recognize, evaluate and address the needs of one of three sampled residents reviewed for nutrition (Resident 45),who had an insidious weight loss of six pounds and 3.9 percent, from December 2018 to June 2019.
This deficient practice had the potential to result in Resident 45's further unplanned weight loss and compromised nutritional status.
Finding:
On September 3, 2019, at 12:25 p.m., a lunch dining observation was conducted. Resident 45's meal ticket indicated regular diet, fortified soup, four ounces (oz.) of milk and eight oz. of water. Resident 45 ate only the fruit mix crumble cake, mashed potatoes and drank all the fortified soup and four oz. of milk. Resident 45 used the fork to mash the roast beef, carrots and zucchini a few times, however; Resident 45 did not eat the food. Resident 45 did not receive any staff assistance for cutting up the food nor been offered any food substitution when he was not able to chew the meat and vegetables.
A concurrent interview with Resident 45 was conducted. Resident 45 stated he could not chew and eat the roast beef, carrots, and zucchini, because they were too hard to chew. Resident 45 showed his dentition that he had no upper teeth and only few front bottom teeth left. He stated he did not have any dentures. Resident 45 stated that he was hungry and no one assisted him to cut up the roast beef , carrots and zucchini in the dining room. Resident 45 stated he would want more mashed potatoes and milk.
Resident 45's record was reviewed. Resident 45 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis that included anemia (a condition resulted from a lack of red blood cells in the body), gastrointestinal hemorrhage (all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum), dementia (memory loss), cachexia (weakness and wasting of the body due to severe chronic illnesses), hypothyroidism (a condition resulted the thyroid gland did not produce enough thyroid hormone), and dysphagia with oropharyngeal phase (a condition of difficulty transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process).
A review of Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated January 22, 2019, indicated Resident 45 was not on mechanically altered diet and had no dentition problem on oral and dental status. The MDS indicated Resident 45 needed supervision and meal set up on eating.
A concurrent interview with the MDS coordinator (MDSC) on September 4, 2019, at 9:40 a.m. was conducted. The MDSC stated Resident 45 had few teeth left. The MDSC stated the MDS assessment was completed in January of 2019, and there was no dentition issue at that time. The MDSC stated she was aware Resident 45 had difficultly chewing during lunch meal on September 3, 2019, but was not aware that Resident 45 needed assistance to cut up the roast beef, carrots, and zucchini.
A review of the facility document titled, Resident Care Plan: Nutrition and Hydration,revised on July 27, 2019, did not address Resident 45's need a for assistance with meals nor his lack of ability to chew related to poor dentition. There was no indication that a referral to Speech therapy for evaluation was initiated.
A review of Resident 45's weight record from December 2018 to June 2019, indicated the following:
December 1, 2018 - 151.4 pounds
January 6, 2019 - 152.4 pounds
February 2, 2019 - 151.6 pounds
March 1, 2019 - 152 pounds
April 2, 2019 - 151.2 pounds
May 2, 2019 - 148.2 pounds
June 7, 2019 - 145.4 pounds
Resident 45 had a slow progressive weight loss of six pounds which yielded 3.9 percent from December 2018 to June 2019.
A review of the facility document titled, Nutritional Assessment: Annual, dated January 23, 2019, indicated the Director of Nutrition Service (DNS) completed a screening on January 22, 2019. The DNS assessment indicated Resident 45 has a chewing problem. The document indicated the Registered Dietitian (RD) completed an assessment on January 23, 2019, which indicated Resident 45 was underweight with Body Mass Index (BMI-a measurement of a person's weight with respect to the height) of 18.55 kilogram per meter square. The RD assessment indicated that it would be beneficial for Resident 45 to have gradual weight gain. The RD assessment did not include documentation about Resident 45's dentition status and chewing difficulty. There was no documentation nor follow up RD notes to identify, evaluate and assess Resident 45's needs with his slow progressive weight loss from December 2018 to June 2019.
A review of the facility document titled, Quarterly Nutritional Assessment, completed on April 19, 2019 and July 15, 2019, indicated both assessments were completed by the DNS. The quarterly assessments indicated Resident 45 has chewing problem. There was no assessment nor review by the RD for both quarterly nutritional assessments.
An interview was conducted on September 3, 2019, at 3:35 p.m., with the RD. The RD stated she was new working at the facility since August 22, 2019. The RD stated she completed a weight loss consultation on September 3, 2019, for Resident 45. The RD stated she did not do any dining observation during the three times she visited the facility. She stated she was not aware of Resident 45's dentition status, chewing difficulty, and the need for assistance in cutting up the food items.
A concurrent interview and record review of Resident 45's nursing progress notes, nursing weekly summary, weight record and nutrition assessments was conducted with the Director of Nursing (DON) on September 4, 2019 at 9:10 a.m. The DON stated there was no documentation from the RD nor the nurses regarding Resident 45's weight loss. In addition, she stated the facility did not identify Resident 45's insidious (slow progressive) weight loss from December 2018 to June 2019. The DON stated Resident 45's physician was not notified about Resident 45's weight loss.
The DON agreed the facility did not recognize, evaluate and address Resident 45's needs and his weight loss from December 2018 to June 2019.
A review of facility document titled, Nutritional Status Evaluation Committee, revised June 2018, indicated, The nutritional status evaluation committee may include .director of nursing services and or designee, dietician/food and nutrition manager, administrator, occupational therapist, speech language pathologist, director of social services, director of activities .Residents that meet the following criteria .for discussion .insidious weight change over a three to twelve month period .committee members will receive a list of the identified residents .the committee may meet weekly, but must meet no less than monthly .objectives .A. Identifying medical or pharmacological condition, which may affecting weight changes .B. Evaluating changes in diet, food preferences and increase caloric intake .D. Identifying residents with signs and symptoms of dysphasia (chewing or swallowing problems) for proper intervention and diet modification .G. Identifying behaviors in the feeding environment that may contributing to weight loss/gain .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen was administered in accordance with the...
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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 oxygen was administered in accordance with the physician order for one of two residents reviewed for oxygen (Resident 10). This failure had the potential for Resident 10 to experience respiratory complications such as shortness of breath and difficulty in breathing.
Findings:
On September 3, 2019, at 11:07 a.m., Resident 10 was observed in bed without the nasal cannula (device that consists of a plastic tube that are placed in the nostrils to deliver oxygen).
On September 3, 2019, at 11:18 a.m., Resident 10 was observed in bed and without oxygen. Resident 10's nasal cannula was observed hanging on the right side of the bed rail.
In a concurrent interview with the family member (FM), the FM stated Resident 10 was on continuous oxygen. The FM stated Resident 10 could not remove her nasal cannula by herself.
On September 3, 2019, at 11:28 a.m., Licensed Vocational Nurse (LVN) 4 was interviewed. LVN 4 stated Resident 10 did not have the nasal cannula in place. In addition, she stated Resident 10 should be on continuous oxygen.
Resident 10's record was reviewed. Resident 10 was readmitted to the facility on [DATE], with diagnoses which included congestive heart failure (CHF - condition that affects the pumping power of the heart muscles) and anemia (low red blood cells affecting delivery of oxygen to body tissues).
A review of the physician order dated April 8, 2019, indicated, OXYGEN AT 2L (liters) PER MIN (minute) VIA (by) NASAL CANNULA CONTINUOUSLY.
The Resident Care Plan, dated April 8, 2019, indicated, Alteration in respiratory function related to .CHF .shortness of breath .Approach .Administer medications, treatments, and oxygen as necessary .
The policy and procedure titled, Oxygen Therapy, dated November 2017, was reviewed. The policy and procedure indicated, .Licensed Nursing staff will administer oxygen as prescribed .Administration of Oxygen .Administer oxygen as per physician order .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the tuberculin purified protein derivative (PP...
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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 tuberculin purified protein derivative (PPD - used to test for tuberculosis [an infectious lung disease]) vial was labeled with an open date. This failure had the potential to administer an expired medication which could affect potency and accuracy of result.
Findings:
On [DATE], at 2:50 p.m., during inspection of the medication room in Station 1 with Licensed Vocational Nurse (LVN) 4, a multi-dose vial of tuberculin PPD was observed opened and undated. In a concurrent interview with LVN 4, LVN 4 verified the PPD vial was open and undated. LVN 2 stated the vial should have been dated.
On [DATE], at 8:53 a.m., the Director of Nursing (DON) was interviewed. The DON stated the licensed nurse should label an opened vial with an opened date.
A review of the Tuberculin PPD manufacturer's instructions indicated, .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency .
The facility undated policy and procedure titled, Date Open Stickers, was reviewed. The policy and procedure indicated, The facility's Pharmaceutical Services Committee and Infection Control Committee will establish expiration date policies for multi-dose containers .date open stickers will be applied to certain medication containers to aid the staff to comply with individual facility policies dealing with the shelf time of multiple dose containers after opening .Date Open Policy .Aplisol (PPD) . Expiration After Opening .30 days .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the meal tray card (guidance to staff regarding the resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the meal tray card (guidance to staff regarding the resident's preferences, allergies and intolerances) was followed for Resident 10. Resident 10 has a fluid restriction order. This failure had the potential to result in negative health outcome.
Findings:
On September 3, 2019, at 11:12 a.m., Resident 10's family member (FM) was interviewed. The FM stated Resident 10 did not like the food served and the food was not good.
Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses which included congestive heart failure (CHF - condition that affects the pumping power of the heart muscles) and anemia (low red blood cells affecting delivery of oxygen to body tissues).
A review of Resident 10's physician order dated April 8, 2019, indicated, 1000 ML (milliliter) Fluid Restriction, The physician order indicated for the dietary to provide 120 ml for breakfast, 120 ml for lunch and 120 ml for dinner.
Resident 10's tray card was reviewed. The tray card indicated, .No cheese, no coffee, tea, no fish, no jello, no soup .
On September 3, 2019, at 1:07 p.m., Certified Nursing Assistant (CNA) 2 was observed coming in to Resident 10's room with soup from the kitchen. CNA 2 was observed mixing the soup with Resident 10's mashed potato. In a concurrent interview with CNA 2, CNA 2 stated she mixed the tomato soup to add flavor to the food.
On September 6, 2019, at 8:22 a.m., the Director of Nutrition Service (DNS) was interviewed. The DNS verified that the tray card indicated no coffee or tea, and no soup. The DNS stated Resident 10 was on fluid restriction so staff would be aware not to give extra fluid to Resident 10.
The facility policy and procedure titled, Fluid Restriction, revised January 1, 2012, indicated, .The Registered Dietitian will review the resident's needs and food/fluid preferences and develop Dietary Plan with the amount of fluid to be allowed at each meal, and the amount to be given between meals by Nursing Staff .Substitute fluids will be provided as necessary and in compliance with dietary restrictions to ensure adequate hydration .CNAs will .Provide the resident with fresh fluids according to the resident's care plan .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility document review, the facility failed to ensure one resident (Resident 45) received food in the form that he can chew and eat. This failure had the potenti...
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Based on observation, interview, and facility document review, the facility failed to ensure one resident (Resident 45) received food in the form that he can chew and eat. This failure had the potential to negatively affect the resident's food intake which could cause a decline in nutritional health status of Resident 45.
Finding:
A review of facility document titled, Summer Menus: Week 1 Tuesday, dated September 3, 2019, showed regular diet consisted of herb and spice roast Beef with gravy, zucchini and carrots, mashed potatoes, Caesar salad with Caesar dressing, fruit mix crumble cake and milk for lunch meal.
On September 3, 2019, at 12:25 p.m., an observation of dining at lunch meal was conducted. Resident 45's meal ticket indicated regular diet, fortified soup, four ounces (oz.) of milk and eight oz. of water. Resident 45 ate only the fruit mix crumble cake, mashed potatoes and drank all the fortified soup and four oz. of milk. Resident 45 used the fork to mash the roast beef, carrots and zucchini a few times but he could not eat them.
During a concurrent interview with Resident 45. Resident 45 stated he could not chew and eat the roast beef, carrots and zucchini. He stated they were too hard to chew. Resident 45 showed his dentition, he had no upper teeth and only few front bottom teeth left. He stated he did not have any denture. Resident 45 stated that he was hungry and would want more mashed potatoes and milk.
The Dining staff brought Resident 45, a plate of grounded texture of roast beef with gravy and mashed potatoes, and eight oz. of milk. Resident 45 ate all the meat and mashed potatoes and drank all the milk provided.
On September 3, 2019, at 3:35 p.m., the Registered Dietitian (RD) was interviewed. The RD stated she was new working at the facility since August 22, 2019. She stated she completed consultation for weight loss on September 3, 2019, for Resident 45. The RD stated she did not do any dining observation during the three visits she conducted at the facility. She stated she was not aware of Resident 45's dentition condition and chewing difficulty.
A review of a facility document titled, Nutritional Assessment: Annual, dated January 23, 2019, showed the Director of Nutrition Service (DNS) completed the screening on January 22, 2019, which indicated that Resident 45 has a chewing problem. The document indicated that the RD completed the assessment on January 23, 2019. The RD assessment indicated Resident 45 was underweight with Body Mass Index (BMI- measurement of a person's weight with respect to the height) of 18.55 kilogram per meter square, and would be beneficial for Resident 45 to have a gradual weight gain. The documentation did not address Resident 45's dentition status and chewing difficulty.
A review of the facility document titled, Quarterly Nutritional Assessment, completed on April 19, 2019 and July 15, 2019, indicated the assessments were completed by the DNS. The DNS' assessment indicated Resident 45 has a chewing problem. There was no assessment and review by the RD for both quarterly nutritional assessments.
On September 4, 2019, at 9:40 a.m., The MDS (minimum data set-an assessment tool) Coordinator (MDSC) was interviewed. She stated she was aware that Resident 45 had difficultly chewing during lunch meal on September 3, 2019, and she would monitor and reassess for the upcoming quarterly assessment.
A review of the facility document titled, Nutrition Assessment, revised February 1, 2014, indicated, .The Dietitian will complete a nutritional assessment .upon admission .readmission, annually .change of condition .The Dietary Manager will initiate .Assessment .utilizing information .ability to chew/swallow .the dietitian will provide a narrative of recommendations in the assessment section and identify any weight loss or dehydration risk factors .the nutrition assessment must be signed and dated by the Dietitian on the day of completion .
A review of the facility document titled, Dining Program, revised January 1, 2012, indicated, .Each resident will be assigned to a dining program .based on the resident's needs .residents will be evaluated .for nutritional status .Residents who have difficulty with eating .will be referred to Occupational Therapy (OT) or Speech Therapy (ST) for evaluation .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the clinical record reflected a complete and accurate documen...
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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 clinical record reflected a complete and accurate documentation of the care and services provided for one of three sampled residents reviewed for closed records (Resident 88). This failure resulted in the inaccurate presentation of the resident's health condition during facility stay.
Findings:
Resident 88's record was reviewed. Resident 88 was readmitted to the facility on [DATE], with diagnoses which included chronic kidney disease (CKD- condition characterized by a gradual loss of kidney function). Resident 88 expired at the facility on [DATE].
On [DATE], at 2:16 p.m., a telephone interview was conducted with Registered Nurse Supervisor (RNS) 2. RNS 2 stated on [DATE], the following event occurred related to Resident 88:
a. At approximately 2 a.m., Resident 88 was noted with restlessness and agitation.
RNS 2 stated the resident's blood sugar was checked and it was within normal range. RNS 2 stated the resident settled down after he was given something to eat.
b. At approximately 4 a.m., Resident 88 continued to be agitated.
RNS 2 stated she called the physician to inform him the resident was still agitated and doesn't look good. RNS 2 stated she got an order to transfer Resident 88 to the acute care hospital. RNS 2 stated she came back to Resident 88 and asked if he was in pain. RNS 2 stated the resident pointed to his upper chest area. RNS 2 stated she called the physician again and received an order for Nitroglycerin (medication for chest pain). RNS 2 stated after the nitroglycerin was administered, the resident calmed down.
A review of Resident 88's Sliding Scale Insulin and/or blood glucose record, dated [DATE], at 6:30 a.m., indicated Resident 88 was given six units of regular insulin.
Resident 88's record indicated the time of death was at 5:22 a.m., on [DATE].
Resident 88's Medication Administration Record (MAR) dated [DATE], indicated nitroglycerin 0.4 mg (milligrams) was given at 11 p.m. to 7 a.m. shift. The document did not indicate the actual time the nitroglycerin was administered, the reason why the medication was administered, and the response of the resident after the medication was administered.
On [DATE], at 7:56 a.m., a concurrent interview and record review was conducted with RNS 2. RNS 2 stated she did not document the assessment and care provided to Resident 88 when he had a change of condition and complained of chest pain on [DATE]. RNS 2 stated the licensed nurse should have documented the correct time when the blood sugar was checked and when the nitroglycerin was given. In addition, she stated there should have been a detailed documentation of Resident 88's change in condition and the interventions provided for the residents.
The facility policy and procedure titled, Change of Condition Notification, revised [DATE], indicated, .The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate .Documentation .A Licensed Nurse will document the following .Date, time and pertinent details of the incident and the subsequent assessment in the Nursing Notes .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. On September 5, 2019, at 2:19 p.m., Resident 239 was observed awake and lying in bed. Resident 239 had a PICC line in his rig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. On September 5, 2019, at 2:19 p.m., Resident 239 was observed awake and lying in bed. Resident 239 had a PICC line in his right upper arm. Resident 239's transparent dressing over the PICC line was observed with a date of August 26, 2019.
On September 5, 2019, at 2:37 p.m., a concurrent observation and interview was conducted with Registered Nurse Supervisor (RN) 1. RNS 1 observed and confirmed the dressing on the transparent dressing over the PICC line of Resident 239 had a date of August 26, 2019. RNS 1 stated the dressing should have been changed on September 3, 2019, as per facility policy. RNS 1 also stated not changing the dressing after 7 days could pose a risk for infection.
Resident 239's record was reviewed. Resident 239 was admitted to the facility on [DATE], with diagnoses that included malignant neoplasm (cancer.)
The physician order dated August 27, 2019, indicated, .Central line location RUA (right upper arm) .PICC .Change central line dressing .within 24 hrs (hours) of admission, then every 7 days and PRN (as needed) .
A review of the facility policy titled, IV Therapy Policies and Procedures .PICC dressing Change,revised date December 2007, indicated, .The PICC line catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection .a transparent dressing is the preferred dressing .Initial PICC dressings are changed 24 hours after placement of line .Transparent dressing are changed every 7 days and sooner if the integrity of the dressing has been compromised .
C. On September 3, 2019, at 9:43 a.m., Resident 82 was observed in bed. The enteral feed tubing attached to the enteral feeding bottle was observed with a blank tag (no date and time of when it was hung.)
On September 3, 2019, at 10:09 a.m., a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 was conducted. LVN 1 came in the room of Resident 82, observed the enteral feed tubing, and stated the enteral feed tubing should have a label indicating the date and time of when it was hung. LVN 1 stated there was no way to tell when the enteral feeding bottle was hung.
On September 3, 2019, at 11:23 a.m., Resident 20 was observed in bed. The enteral feed tubing attached to the enteral feeding bottle was observed with a blank tag (no date and time of when it was hung.)
On September 3, 2019, at 11:26 a.m., a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 was conducted. LVN 1 came in the room of Resident 20, observed the enteral feed tubing, and stated the tubing should have a label indicating the date and time of when it was hung. LVN 1 also stated there is no way to tell when the enteral feeding bottle was hung.
Resident 20's record was reviewed. Resident 20 was re-admitted to the facility on [DATE], with diagnoses which included gastrostomy status.
Resident 20's physician orders dated June 26, 2019, indicated, .Nepro (a brand of enteral feeding formula) 50 ml (milliliters)/hr (hour) .
Resident 82's physician orders dated April 1, 2019, indicated, .GT (gastrostomy tube - a flexible feeding tube placed through the abdominal wall into the stomach) feeding Jevity (a brand of TF formula) 1.5 @ 95 cc (cubic centimeters)/hr (hour) .
Resident 82's record was reviewed. Resident 82 was re-admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing.)
A review of the facility policy titled, Enteral Feeding, revised date of January 1, 2012, indicated, .Label the formula container and tubing with date and time hung .
Based on observation, interview, and record review the facility failed to ensure infection control standards were followed for five of five residents (Residents 18, 20, 64, 82, and 239) when:
A.During medication administration, Licensed Vocational Nurse (LVN) 2 failed to sanitize the medication tray used to pass medications for two residents (Residents 64 and 18);
This failure had the potential to increase the potential for microorganisms to be transferred from resident to resident.
B. The transparent dressing for a peripherally inserted central catheter (PICC-a catheter inserted into a vein) line was not changed every seven days for one resident (Resident 239) ; and
This failure had the potential to result in vascular catheter associated infection.
C. The enteral feed (nutrition taken through the mouth or through a tube) tubing was not labeled with the date and time it was hung for two residents (Residents 20 and 82).
This failure increased the risk for infection which could result in health complication for Residents 20 and 82.
Findings:
A.On September 5, 2019, at 8 a.m., during the medication pass observation, LVN 2 was observed preparing medication cups unto a blue tray which was used during med pass. LVN 2 used the blue tray when she passed medication from one resident to another resident.
LVN 2 was not observed cleaning the blue tray, as she passed medications from one resident to another resident. (Residents 64 and 18).
In a concurrent interview with LVN 2, she was interviewed regarding proper sanitation of tray used to carry medication from one room to another. LVN 2 was unaware of any process for cleaning the blue tray between residents.
In an interview with LVN 3 on September 5, 2019, around 9 a.m., LVN 3 stated, It's an infection control issue and they trained us to clean the tray between residents when we pass medication.
A review of an article from the Center for Disease Control (CDC) indicated, Handle patient-care equipment and instruments/devices according to Standard Precautions .common use of equipment for multiple patients .clean and disinfect such equipment before use on another patient .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 a written communication was maintained between the facility ...
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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 a written communication was maintained between the facility staff and the dialysis (treatment that filters and purifies the blood using a machine) center for four of eight residents reviewed for dialysis(Residents 61, 64, 65, and 69). These failures had the potential for miscommunication of any concerns regarding the health and well-being of the residents between the facility and the dialysis center.
Findings:
1. Resident 61's record was reviewed. Resident 61 was readmitted to the facility on [DATE], with diagnoses that included end stage renal disease (condition characterized by a gradual loss of kidney function) with hemodialysis.
On September 5, 2019, at 4:17 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated the license nurse will assess the resident before and after dialysis treatment using the dialysis communication form. LVN 2 stated the staff from the dialysis center completes the dialysis unit section of the form.
In a concurrent review of Resident 61's dialysis communication form dated August 19, 20, 27, and 31, 2019, the dialysis unit section of the form were all blank.
On September 5, 2019, at 4:19 p.m., LVN 2 stated the dialysis unit section of the form should not be left blank. LVN 2 stated if the resident comes back from dialysis and the section for the dialysis staff was blank or was not completed, the licensed nurse has to call or fax the form to the dialysis center to follow up with any changes or recommendations.
2. Resident 64's record was reviewed. Resident 64 was readmitted to the facility on [DATE], with diagnoses that included end stage renal disease (condition characterized by a gradual loss of kidney function).
The physician's order dated March 20, 2019, indicated Resident 64 goes to dialysis every Tuesdays, Thursdays, and Saturdays.
A review of Resident 61's dialysis communication form dated August 29 and 31, 2019, indicated the dialysis unit section of the form was blank.
3. Resident 65's record was reviewed. Resident 65 was readmitted on [DATE], with diagnoses that included end stage renal disease (condition characterized by a gradual loss of kidney function).
The Minimum Data Set (MDS - an assessment tool) dated July 29, 2019, indicated Resident 65 is receiving dialysis treatment.
A review of Resident 65's dialysis communication form dated August 5 and 30, 2019, indicated the dialysis unit section of the form was blank.
4. Resident 69's record was reviewed. Resident 69 was readmitted to the facility on [DATE], with diagnoses that included end stage renal disease (condition characterized by a gradual loss of kidney function).
The physician order dated August 7, 2019, indicated Resident 69 goes to dialysis every Tuesdays, Thursdays
and Saturdays.
A review of Resident 69's dialysis communication form dated September 5, 2019, indicated the dialysis unit section of the form was blank.
On September 6, 2019, at 9:56 a.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated the dialysis communication form was a way to communicate recommendations and physician orders between the facility and the dialysis center. RNS 1 stated the nurses should call the dialysis center to ensure the form was completed by the dialysis nurse.
On September 6, 2019, at 1:04 p.m., Residents 61, 64, 65, and 69's dialysis communication forms were reviewed with the Director of Staff Development (DSD). The DSD stated the forms should have been filled out. The DSD further stated the licensed nurse has to call or fax the form to the dialysis center as soon as possible, to discuss any instructions from the dialysis center.
The facility policy and procedure titled, Dialysis Care, revised October 1, 2018, indicated, .The facility will arrange .a method of communication between the dialysis provider and the Facility .The Dialysis Provider will communicate in writing to the Facility any problems encountered while the resident was at the dialysis provider and any ongoing monitoring required .Documentation .All documentation concerning dialysis center and care of the dialysis resident will be maintained in the resident's medical record .Dialysis Communication Record .The Nursing Staff will send a dialysis communication form to the dialysis center every time a resident is scheduled for off -site dialysis .The provider's dialysis nurse will be responsible for documentation of dialysis treatment .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:
1. The ice machin...
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Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:
1. The ice machine was not cleaned and sanitized per manufacturer's recommendation;
2. Dirty dishes and a dirty steam table strainer were stored in the clean and ready to use storage areas;
3. The facial hair of Dietary Aide (DA) 1 was not covered during meal preparation;
4. One Dietary Aide was unable to articulate the correct process of manual dishwashing using the 3-compartment sink; and
5. The reach-in-refrigerator and dry storage contained expired food items.
These failures had the potential to cause food-borne illness in a highly susceptible population of 86 out of 93 residents who received food from the kitchen.
Findings:
1. An observation of the facility ice machine was conducted with the Maintenance Supervisor (MS) on September 3, 2019, at 4:05 p.m., and the following were observed:
a. The inner top part at the hinge of the ice machine was covered with a white paper towel, and had a significant amount of black and brown residue; and
b. Reddish and slimy residue observed during wiping of the inner top part of the ice machine evaporator.
In a concurrent interview with the MS he confirmed the residue was present and agreed it was not acceptable.
The MS stated he was responsible for cleaning and sanitizing the inside and outside of the ice machine. The MS stated the ice machine was scheduled for deep cleaning twice a year, and the last deep cleaning was done on June 12, 2019. The MS stated normal cleaning of the ice machine was conducted monthly.
The MS explained the steps for deep cleaning the ice machine. The MS stated he would clean and sanitize each parts of the ice machine. The MS was asked if he would use the sanitizing solution through the ice-machine and the MS responded, No twice.
A review of an undated ice machine manufacturer's guidelines titled, Section 4 Maintenance: Interior Cleaning and Sanitizing, indicated, .The ice machine must be taken apart for cleaning and sanitizing .ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime .step 9 .clean all food zone surfaces of the ice machine .ice machine top cover .step 15 wait about two minutes or until water starts to flow over the evaporator. Add the proper amount (manufacture brand) sanitizer to the water trough by pouring between the water curtain and evaporator .and running for 20 minutes .
2. During observation of the clean and ready to use items at the storage areas on September 3, 2019, at 9:20 a.m., with the Director of Nutrition Service (DNS), the following were observed:
a. The steam table strainer covered with yellow, white, and grease residue was stored with the clean pots and pan.
In a concurrent interview with the DNS, she agreed the steam table strainer was dirty.
b. Three small dishes covered with green and brown food residue were stored in the clean and ready to use storage area.
In a concurrent interview with the DNS, she confirmed the three dishes were not clean and were improperly stored.
On September 5, 2019, at 9:50 a.m., the dietary staff were asked for the policy and procedure process for monitoring and cleanliness of the dishes, pots and pans. The Regional Dietary Manager (RDM) provided the facility policy and procedure of dish machine operation and cleaning which did not reflect any information of the process and monitoring of cleanliness of the equipment and utensils, such as dishes, pots, and pans.
A review of the Federal Food Code 2017, indicated, Cleaning of Equipment 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 .
3. During observation of the lunch meal preparation on September 3, 2019, at 11:42 a.m., Dietary Aide (DA) 1 was observed with uncovered facial hair. The DNS confirmed DA 1 was not wearing a facial hair restraint.
A review of facility document titled, Dietary Department - Infection Control for Dietary Employees, revised November 9, 2016, indicated, .Personal cleanliness is required in sanitary food preparation .Clean hair - covered with an effective hair restraint while in all kitchen and food storage areas. (And beard/mustache covering when applicable) .
4. During the initial kitchen tour observation and concurrent interview with Dietary Aide (DA) 1 on September 3, 2019, at 9:10 a.m., the dietary aide was asked regarding the process for manual dishwashing using the 3-compartment sink. DA 1 stated he would scrape the food debris; wash the dishes/pots/pans with warm water; put sanitizer in the middle sink; and then he would rinse the dishes, pots and pans with warm water. DA 1 stated the pots and the dishes would be immersed in the sanitizer water solution for 10 seconds.
On September 3, 2019, at 11:25 a.m., the Director of Nutrition Service (DNS) was interviewed regarding the process of manual dishwashing using the 3-compartment sink. The DNS stated the order of using the 3-compartment sink provided by DA 1 was not in the correct order. She stated the process should be wash, rinse and sanitize. The DNS agreed that DA 1's statement regarding sanitizer immersion time should be at least 60 seconds.
A review of the facility document titled, Pot and Pan Cleaning, revised on October 1, 2014, indicated, .Pots and pans will be routinely washed, rinsed and sanitized using the 3 compartment sink .scrape food particles from pots and pans into the garbage disposal .scrub the pots and pans in the first compartment .rinse pots and pans free of detergent in the second compartment .sanitize the pots and pans in the third compartment by immersing them in the sanitizer water solution for a minimum of 60 seconds, or per manufacturer recommendation .
5. During observation of the dry storage on September 3, 2019, at 8:52 a.m., with the Director of Nutrition Service (DNS), There was an opened one-gallon bottle of sesame oil with date opened on June 22, 2019, and use by date of July 29, 2019. The DNS agreed the opened bottle of sesame oil use by date was past and the oil should have been discarded.
On September 3, 2019, at 9:15 a.m., during an observation of the reach-in refrigerator with the DNS, the reach-in refrigerator contained the following:
a. A tray of nine small dishes of salad with a preparation date of August 30, 2019, and a use by date of September 2, 2019;
b. A jar of diet punch with preparation date of August 31, 2019, and a use by date of September 1, 2019.
The DNS agreed all of the food items' use by date had passed, and all of them should be discarded.
A review of the undated facility document titled, Storage of Food and Supplies, indicated .No food will be kept longer than the expiration date on the product .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview, the facility failed to ensure three of three garbage disposal bins were not overflowing and the lids were closed. This failure had the potential for possible pest infe...
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Based on observation, interview, the facility failed to ensure three of three garbage disposal bins were not overflowing and the lids were closed. This failure had the potential for possible pest infestation and spread of diseases in the facility.
Findings:
On September 3, 2019, at 9:22 a.m., three of three garbage disposal bins were observed with the lids not securely covering the bins. The three garbage disposal bins overflowed with trash.
A concurrent interview was conducted with the Director of Nutrition Service (DNS). The DNS stated the dumpsters were overflowing with trash and it was not acceptable. The DNS stated the Maintenance Supervisor (MS) was responsible for the dumpsters.
An interview with the MS on September 3, 2019 at 9:30 a.m., was conducted. The MS stated he was aware of the three dumpsters which were overflowing. He stated he was unable to close the lids and agreed that it was not acceptable.
An interview with the facility administrator (ADM) on September 4, 2019 at 4:20 p.m. was conducted. The ADM stated her expectation for the trash bins were that the dumpster lids should remain tightly closed.
In review of Federal Food Code 2017, the receptacles (containers) and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment must be designed and constructed to have tight-fitting lids, doors, or covers.
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.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 43% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Alta Vista Healthcare & Wellness Centre's CMS Rating?
CMS assigns ALTA VISTA HEALTHCARE & WELLNESS CENTRE 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 Alta Vista Healthcare & Wellness Centre Staffed?
CMS rates ALTA VISTA HEALTHCARE & WELLNESS CENTRE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 43%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 73%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Alta Vista Healthcare & Wellness Centre?
State health inspectors documented 44 deficiencies at ALTA VISTA HEALTHCARE & WELLNESS CENTRE during 2019 to 2025. These included: 44 with potential for harm.
Who Owns and Operates Alta Vista Healthcare & Wellness Centre?
ALTA VISTA HEALTHCARE & WELLNESS CENTRE 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 SHLOMO RECHNITZ, a chain that manages multiple nursing homes. With 99 certified beds and approximately 93 residents (about 94% occupancy), it is a smaller facility located in RIVERSIDE, California.
How Does Alta Vista Healthcare & Wellness Centre Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, ALTA VISTA HEALTHCARE & WELLNESS CENTRE's overall rating (4 stars) is above the state average of 3.2, staff turnover (43%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Alta Vista Healthcare & Wellness Centre?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Alta Vista Healthcare & Wellness Centre Safe?
Based on CMS inspection data, ALTA VISTA HEALTHCARE & WELLNESS CENTRE 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 Alta Vista Healthcare & Wellness Centre Stick Around?
ALTA VISTA HEALTHCARE & WELLNESS CENTRE has a staff turnover rate of 43%, 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 Alta Vista Healthcare & Wellness Centre Ever Fined?
ALTA VISTA HEALTHCARE & WELLNESS CENTRE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Alta Vista Healthcare & Wellness Centre on Any Federal Watch List?
ALTA VISTA HEALTHCARE & WELLNESS CENTRE 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.