RIVERSIDE VILLAGE HEALTHCARE CENTER
For profit - Limited Liability company
59 Beds
BVHC, LLC
Data: November 2025
Trust Grade
50/100
#893 of 1155 in CA
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Riverside Village Healthcare Center has a Trust Grade of C, which means it is average and sits in the middle of nursing home options. Ranking #893 out of 1155 facilities in California places it in the bottom half, and #42 out of 53 in Riverside County indicates that there are only a few better choices nearby. Unfortunately, the facility's trend is worsening, with reported issues increasing from 10 in 2024 to 21 in 2025. While staffing is a relative strength with a turnover rate of 33%, which is below the state average, the facility has concerning RN coverage, being lower than 87% of other California homes. Notably, there have been significant concerns raised, such as failures to properly monitor a resident's medical needs and maintain food safety standards, including issues with food storage and cleanliness that could impact residents' health. Overall, while there are some strengths, families should carefully weigh these issues when considering care options.
- Trust Score
- C
- In California
- #893/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 33% 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 17 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 59 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 23%
No red flags
10 → 21 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 21 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 (33%)
15 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below California average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 33%
13pts below California avg (46%)
Typical for the industry
Chain: BVHC, LLC
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 59 deficiencies on record
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 monitor emotional distress after an abuse and neglect allegation, f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor emotional distress after an abuse and neglect allegation, for one of three residents reviewed (Resident 1), when the resident alleged abuse and neglect by the nursing staff at the General Acute Hospital (GACH). This failure could result in staff not recognizing Resident 1's emotional distress and being unable to provide necessary psychosocial support. Findings:On September 9, 2025, at 11:14 a.m., an unannounced visit was conducted at the facility to investigateOn September 9, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included postlaminectomy syndrome (a condition characterized by persistent or recurrent pain and other symptoms after a laminectomy surgery [a surgical procedure that involves removing part or all of the lamina, which are the bony arches that cover the spinal cord]), diabetes mellitus (abnormal blood sugar), and fibromyalga (a chronic condition characterized by widespread pain, fatigue, and other symptoms). A review of Resident 1's Progress Notes, dated July 29, 2025, at 10:28 a.m., indicated, .admission H&P (History and Physical).Patient has capacity to make medical decisions.A review of Resident 1's Progress Notes, dated August 18, 2025, indicated, .spoke to resident TX (Treatment) Nurse regarding her report to Tx Nurse about feeling neglected in the emergency room at the hospital over the weekend. Resident stated she felt the nurse in the emergency room at (name of hospital) was very dismissive towards her and did not give her the care that she needed while she was there.Further review of Resident 1's record, indicated there was not follow up monitoring of resident's psychosocial condition after the resident reported the allegation against the GACH.On September 9, 2025, at 2:48 p.m., during an interview conducted with Licensed Vocational Nurse (LVN) 1, LVN 1 stated residents were to be monitored for 72 hours after a change of condition (COC).On September 9, 2025, at 5:14 p.m., during an interview conducted with the Administrator (ADM), the ADM stated Resident 1 reported an allegation of neglect while at the emergency room of the GACH. The ADM stated 72-hour monitoring should have been implemented and documented when Resident 1 reported an allegation of neglect.A review of the facility's policy and procedure titled, Change in a Resident's Condition or Status, dated May 2017, indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an).significant change in the resident's physical/emotional/mental condition.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
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 F0692
(Tag F0692)
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 meal substitutes were offered to the residents when the food...
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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 meal substitutes were offered to the residents when the food intake was below 50% (percent), for one of three residents reviewed (Resident 2).This failure had the potential for Resident 2 to have weight loss and affect the resident's overall health condition.Findings:On September 9, 2025, at 11:14 a.m., an unannounced visit was conducted at the facility to investigateOn September 9, 2025, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included gastroenteritis (an inflammation of the stomach and intestines that causes an upset stomach ) and protein-calorie malnutrition (a condition resulting from insufficient intake of protein and calories to meet the body's needs).A review of Resident 2's Weight and Vitals Summary, indicated the following weights:-August 16, 2025; 114.8 lbs. (pounds - unit of measurement);-August 19, 205; 111 lbs.;-August 27, 2025; 104 lbs.; 7 lbs. weight loss in a week; 6.3% in a week;-September 3, 2025; 106 lbs.; 2 lbs. weight gain in a week.A review of Resident 2's Document Survey Report, for the month of August and September 2025, indicated Resident 2 had food intake below 50% (percent) and was not offered substitute/alternative menu on the following dates:-August 17, 2025; Lunch (L)-August 19, 2025; breakfast (BF), lunch (L), dinner (D);-August 20, 2025; BF, D;-August 22, 2025; BF, L;-August 23, 2025; L;-August 24, 2025; L, D;-August 25, 2025; BF, L, D;-August 26, 2025; L;-August 27, 2025; BF, L;-August 28, 2025; BF, L;-August 29, 205; L;-August 30, 2025, BF-August 31, 2025; BF, L, D;-September 1, 2025; L;-September 3, 2025; L;-September 4, 2025; BF, L, D;-September 5, 2025; BF, L, D; and-September 6, 2025; BF, L, D.On September 16, 2025, at 10:22 a.m., during an interview with the Director of Nursing (DON), the DON stated that the facility offers an alternative menu for residents who do not like the served food or have poor intake.On September 16, 2025, at 1:32 p.m., during a concurrent interview and record review with the Food and Nutritional Services Director (FNSD), the FNSD stated the CNA should offer a meal substitute if a resident refused or disliked their meal or if the resident consumed less than 50% of the meal. Resident 2's meal intake for the month of August and September 2025 was reviewed with the FNSD. The FNSD stated the CNA should have offered a meal substitute when Resident 2 had food intake below 50%.A review of the facility's undated policy and procedure titled, Resident Food Preferences, indicated, .If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with.The Food Service Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night.
Aug 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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate reconciliation of medications on admission was cond...
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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 accurate reconciliation of medications on admission was conducted for one of three sampled residents (Resident 1), when continuous use of oxygen therapy was not reflected in the physician order for a resident admitted on oxygen. This failure has the potential to result in lack of physician oversight, which could negatively affect the resident's current health condition.Findings: On August 12, 2025, at 9 a.m., an unannounced visit to the facility was conducted to investigate quality care issues. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included Encephalopathy (a declining ability to reason, concentrate and memory loss), chronic systolic cardiac failure (the heart weakens and cannot pump adequate blood through the body), ischemic cardiomyopathy (due to damage from lack of oxygen to the heart muscle), atherosclerotic heart disease (a buildup of plaque that causes the heart blood vessels to narrow), non-rheumatic aortic valve stenosis (heart valve does not open fully and heart must work harder) and difficulty walking. A review of Resident 1's admission Assessment Summary, dated July 10, 2025, at 17:47 (5:47 p.m.), indicated, .admitted to the facility with oxygen 2 lpm (liters per minute) via nasal canula in place.A review of the physician's orders dated July 10, 2025, through July 15, 2025, did not indicate that the resident was oxygen therapy. On August 12, 2025, at 12 p.m., during an interview and record review, the Director of Nursing (DON) confirmed that Resident 1's record lacked any physician order for oxygen upon admission or subsequently. The DON stated the resident used oxygen continuously during her stay, as indicated in the admission summary, and acknowledged that the order should have been included in the admission orders. She stated the licensed nurse should have verified the orders for accuracy and contacted the physician for the oxygen order at that time.A review of the facility's policy and procedure titled, Reconciliation of Medications on Admission, dated July 2017, indicated, .to ensure medication safety by accurately accounting for resident's medication, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list .c. admission order sheet .Medications reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process .if a there is a discrepancy.contact the physician to resolve the discrepancy.
Jun 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
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 scheduled hemodialysis (a treatment using a machine and spec...
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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 scheduled hemodialysis (a treatment using a machine and special filter to clean the blood of a kidney failure person) treatments were provided timely, for one of three residents reviewed (Resident 5), when the transportation to the dialysis center was not arranged.
This failure resulted in Resident 5 to missed dialysis treatments while at the facility. In addition, this failure had the potential for Resident 5 to increased risk of medical complications including fluid overload (excess fluid in the blood), edema (swelling), shortness of breath, and high blood pressure.
Findings:
On May 29, 2025, at 8 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding quality of care and treatment.
On May 29, 2025, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a severe condition where the kidneys have permanently lost most of their ability to function). Resident 5 was readmitted back to the facility on May 17, 2025.
A review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated May 6, 2025, indicated as follows:
- Resident 5 had a BIMS (Brief Interview of Mental Status) score of 10 (moderate cognitive impairment), and;
- Resident was on hemodialysis.
A review of Resident 5's Order Summary, included a physician's order, dated April 2, 2025, which indicated, .Dialysis: Dialysis Center: (Name of Center) .On T-Th-S (Tuesday-Thursday-Saturday) Chair Time:12PM (p.m.) Transportation: (Name of Company) .Pick up at 11:00AM (a.m.) .
A review of Resident 5's Nurse ' s Note, dated May 20, 2025, indicated, .pt (patient) missed HD (hemodialysis) today d/t (due to) transportation not arriving .
On May 29, 2025, at 1 p.m, an interview was conducted with the Social Service Director (SSD). The SSD stated the transportation for the dialysis schedule should be pre-arranged prior to admission to the facility. The SSD stated if there would be an issue with transportation to the dialysis clinic on the scheduled dialysis, the licensed nurse should call the transport company, notify the dialysis center, physician, and the resident or resident representative. The SSD stated the facility should have followed up with the transport company about Resident 5's dialysis schedule and pick up when the resident was readmitted back to the facility.
On May 29, 2025, at 1:45 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 5 did not receive her dialysis treatment on May 20, 2025, due to transportation did not show up. LVN 2 stated the transportation should have been followed up and arranged prior to dialysis to avoid missed dialysis treatments. LVN 2 further stated, if a resident would not receive dialysis, Resident 5 could have complications such as shortness of breath and edema that could lead to hospitalization.
On June 2, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected for all licensed nurses to follow the facility's policy and procedure of dialysis care. The DON stated the transportation should have been followed up or arranged prior dialysis treatment and should have been communicated to avoid miss treatment. The DON further stated if the resident would not receive a dialysis treatment, resident would increase the risks for medical condition such as fluid overload, respiratory problems and high blood pressure.
A review of the facility ' s policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, dated September 2010, indicated, .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .
A review of the facility ' s transfer agreement titled, NURSING HOME DIALYSIS TRANSFER AGREEMENT, dated, April 2024, indicated, .Facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center, including the selection of the mode of transportation, qualified personnel to accompany the Designated Resident and transportation equipment usually associated with this type of transfer including the use of appropriate life support measures in accordance with the applicable federal and state laws and regulations .
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the necessary care and treatment was provided,...
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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 necessary care and treatment was provided, for one of five sampled residents (Resident 4), when:
1. Resident 4 ' s left forehead laceration was not evaluated and referred to a physician for suture removal. This failure had the potential for the delay in necessary care and treatment of possible complications related to skin injuries/problems;
2. Resident 4 ' s blood sugar level was not monitored after the insulin medication was discontinued on March 13, 2025. This failure had potential for Resident 4 ' s blood sugar level to be inadequately control which could alter the resident's mental status and affect the resident's overall health condition.
3. Resident 4 ' s baseline weight was not obtained timely after admission on [DATE]. This failure had the potential for the delay in necessary care and further complications of malnourishment;
4. Resident 4 ' s change of condition (COC) of low blood pressure was not relayed to a physician for appropriate management. This failure has the potential to result in deterioration of Resident ' s 4 health condition; and
5. Resident 4 ' s oral care after meals was not provided on March 27, 2025. This failure had the potential to cause serious health issues and could affect Resident ' s psychosocial well-being.
Findings:
On May 29, 2025, at 8 a.m., an unannounced visit was conducted to the facility for the investigation of a complaint regarding quality of care and treatment.
1. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain disorder) and sepsis (blood infection).
A review of Resident 4 ' s History and Physical, dated March 2, 2025, indicated Resident 4 was mentally incapable of understanding.
A review of Resident 4's BODY CHECK, dated March 13, 2025, indicated, .Pt (patient) returned to facility with laceration to L (left) forehead measuring 4.5 x (by)1.0 cm. (centimeter-unit of measurement) with 6 sutures .
A review of Resident 4's Order Summary, dated March 13, 2025, indicated, .L (left) forehead laceration-clean with ns (normal saline), pat dry, apply betadine, leave OTA (open to air) every day shift for 14 days .
A review of Resident 4's Care Plan Report, dated March 14, 2025, indicated, .Surgical Wound .Lt (left) forehead laceration, 6 sutures .Provide skin care .Treatment as ordered, notify MD .
A review of Resident 4's WEEKLY SKIN ALTERATION REPORT, dated March 18, 2025, indicated the following:
- Resident 4 ' s left forehead with six (6) surgical sutures has no drainage, peri wound was dry with quality 90% epithelial tissue (wound's progression towards healing and restoration) and 10% scab, and;
- Resident 4 ' s current treatment orders indicated, . weekly assessment of Lt forehead wound .Sites Healing .
A review of Resident 4's acute hospital records titled, Daily Focus Assessment Report, dated March 27, 2025, indicated, .Removed stiches from patients forehead that were placed by (name of hospital) on March 12, 2025 .
On May 29, 2025, at 11:25 a.m., during a concurrent interview and record review with the Treatment Nurse (TN), the TN stated there was no wound and suture evaluation conducted on the fourth week stay of Resident 4 and was not relayed to a physician. The TN stated the healing surgical wound with suture should have been reported to the physician. The TN stated the suture should have been removed to prevent complications such as overgrowth or the skin and could lead to skin irritation and infection. The TN further stated if the surgical wound would not be evaluated and reported, the skin condition would fall through the cracks.
On June 2, 2025, at 2:45 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected to the nurses follow the procedure guidelines for wound care. The DON stated the surgical wound with sutures should have been monitored and relayed to a physician. The DON further stated the healed wound with sutures should have been evaluated and should have been removed to prevent complications such as skin irritation and infections.
A review of the facility's policy and procedure titled, Staple and Suture Removal, dated September 2013, indicated, .The purpose of this procedure is to provide guidelines for the removal of staples or sutures from a healing wound .Review the resident ' s care plan, current orders, and diagnoses to determine if there are special residents needs .Report other information in accordance with facility policy and professional standards of practice .
2. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus II (DM II-abnormal blood sugar).
A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, .glipiZIDe Oral Tablet 10 MG (Milligram-unit of measurement) .Give 1 tablet by mouth two times a day for DM II; Give with meals .
A review of Resident 4's Care Plan Report, dated March 2, 2025, indicated, .Risk for hypo/hyperglycemia (low/high blood sugar level) secondary to: Diabetes Mellitus .Test the resident ' s blood glucose (sugar) .Blood sugar check as ordered .Monitor for s/s (signs and symptoms) low blood sugar .Monitor for s/s of high blood sugar .
A review of Resident 4 ' s Lab Results Report, indicated the following:
- March 18, 2025, glucose 176, high, and:
- March 23, 2025, glucose 154, high.
A review of Resident 4 ' s Blood Sugar Summary, dated March 2025, indicated, Resident 4 ' s last blood sugar level was 107 mg/dL (milligrams per deciliter) was documented on March 13, 2025, and no documentation of Resident 4's blood sugar continued after March 13, 2025.
On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the Registered Nurse (RN), the RN stated Resident 4 ' s insulin was discontinued on March 4, 2025, and she did not clarify to a physician if the blood sugar check would be continued. The RN stated Resident 4 ' s blood sugar level should have been checked and should have been monitored to prevent complications of diabetes. The RN further stated if Resident 4 ' s blood sugar level would not be monitored, it could alter mental status and potentially lead to hospitalization.
On June 2, 2025, at 2:45 p.m., during an interview with the DON, the DON stated she expected for the nurses to follow the facility ' s policy and procedure for diabetes management. The DON stated Resident 4 ' s blood sugar level should have been monitored and checked to prevent complications. The DON further stated if blood sugar would not be monitored it would lead to serious condition such as diabetic coma or shock.
A review of the facility's policy and procedure titled, Diabetes-Clinical Protocol, dated November 2020, indicated, .As indicated, the Physician will order appropriate lab tests .and adjust treatments based on results and other parameters .Examples of blood glucose monitoring for various situations might include the following: (1) For the resident on oral medication(s) who is well controlled: monitor blood glucose level at least twice a weekly .(3) For resident receiving insulin who is well controlled: monitor blood glucose levels twice a day .
3. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included muscle waiting and atrophy (loss of muscle mass).
A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, .Fortified diet .for Nutrition .
A review of Resident 4 ' s 12 MINI NUTRITIONAL ASSESSMENT, dated March 1, 2025, indicated, Resident 4 has a score of 5 with a category of malnourished.
A review of Resident 4 ' s Care Plan Report, dated March 1, 2025, indicated, .NUTRITIONAL RISK .Monitor weight and notify MD for any undesirable weight changes .Refer for dietary/RN (Registered Dietician) consult .
A review of Resident 4 ' s Weight Summary, dated March 2025, indicated the following:
- March 3, 2025, 109 lbs. (pounds - unit of measurement);
- March 11, 2025, 107 lbs;
- March 19, 2025, 105 lbs; and
- March 25, 2025, 101 lbs.
On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the Restorative Nursing Assistant (RNA), the RNA stated Resident 4 was admitted on [DATE], and she took the weight on March 3, 2025. The RNA stated Resident 4 ' s weight should have been taken upon admission or the next day so it would be reported to the nurse the accurate weight of resident upon admission. The RNA further stated it was two days delayed.
On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the RN, the RN stated Resident 4 ' s weight should have been taken upon admission or the next day so the nurses could identify if there was a need to notify a dietician regarding nutritional management. The RN stated if there was a delay of obtaining weight, it would potentially result to a further weight loss.
On June 2, 2025, at 2:45 p.m., during a follow up phone interview with the DON, the DON stated she expected the staff follow policy and procedure of weight loss management. The DON stated Resident 4 should have been weighed upon admission or the next day of admission. The DON further stated if weight would not be obtained timely, there was a potential delay of care to Resident 4.
A review of the facility's policy and procedure titled, Weight Assessment and Intervention, dated September 2008, indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter .
4. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included hypertension (HTN - elevated blood pressure).
A review of Resident 4 ' s Order Summary, dated March 1, 2025, indicated, Carvedilol (medication to treat hypertension) Oral Tablet 3.125 MG .Give 1 tablet by mouth one time a day for HTN .
A review of Resident 4's Care Plan Report, dated March 2, 2025, indicated, .Hypertension .Resident will maintain clinically acceptable range of blood pressure .Monitor BP and refer to MD for changes .
A review of Resident 4 ' s Blood Pressure Summary, dated March 2025, indicated the following:
- March 26, 2025, at 21:59 p.m., 64/47 mmHG (unit of measurement), BP-low;
- March 27, 2025, at 00:11 a.m., 94/56 mmHg, BP (low_; and
- March 27, 2025, at 00:42 a.m., 106/59 mmHg, BP (low.)
A review of Resident 4 ' s Nurse ' s Note, dated March 27, 2025, indicated, Vital signs for resent (sic) rechecked due to CNA advising this writer that resident had a low blood pressure. Using an arm cuff blood pressure rechecked at 0042 with BP reading 106/59 .
On May 29, 2025, at 11:30 a.m., during a concurrent interview and record review with the RN, the RN stated Resident 4 ' s blood pressure of 106/59 on March 27, 2025, was low and there was no evidence of documentation of change of condition and the physician was not notified. The RN further stated if a physician would not be notified of the change of condition of a resident, it could result to conditions such as alteration of mental state, shock (life threatening condition where the body experiences insufficient blood flow) and could passed out.
On June 2, 2025, at 2:45 p.m., during an interview with the DON, the DON stated she expected all the nurses to follow the facility ' s policy and procedure for a resident ' s change of condition and blood pressure management. The DON stated a physician should have been notified of Resident 4 ' s change of condition. The DON further stated if physician was not notified and no COC, Resident 4 ' s could potentially increase her health deterioration.
On June 3, 2025, at 8:56 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 4 ' s blood pressure was low when he manually rechecked it with blood pressure cuff on March 27, 2025, at 00:42 in the morning. LVN 1 stated Resident 4 ' s change of condition was not relayed to the attending physician. LVN 1 stated Resident 4 ' s low blood pressure should have been identified as COC and should have been reported to a physician. LVN 1 further stated if COC not reported to a physician, resident could deteriorate and declined health condition.
A review of the facility's policy and procedure titled, Blood Pressure, Measuring, dated September 2010, indicated, .The purpose of this procedure is to measure the pressure exerted by the circulating volume of blood .Hypotension is defined as blood pressure less than 100/60 mm/Hg .Hypotension should be reported to the physician .
A review of the facility's policy and procedure titled, Change in a Resident ' s Condition or Status, dated May 2017, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident ' s medical/mental condition and/or status .Prior to notifying the Physician .the nurse will make detailed observations and gather relevant and pertinent information .including (for example) information prompted by the Interact SBAR Communication Form .
5. On May 29, 2025, Resident 4 ' s record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), encephalopathy (condition where brain function is impaired), gastro-esophageal reflux disease (stomach acid flows back and cause heartburn) and muscle wasting.
A review of Resident 3's Minimum Data Set (MDS - an resident assessment tool), dated March 7, 2025, indicated the following:
- Resident 3 had a Brief Interview for Mental Status (BIMS - a cognitive assessment) score of 06 (severe cognitive impairment);
- Resident 3 required totally dependent with oral hygiene; and
- Resident 3 would hold food in her cheeks after a meal, and had difficulty swallowing food.
A review of Resident 3's Physician Orders, dated March 1, 2025, indicated Resident 3 had an appointment to a pain clinic on March 27, 2025, at 9:30 a.m.
A review of Resident 3's care plan, dated March 6, 2025, indicated, .ADL (Activities of Daily Living) functioning with self-care deficit .requires total assistance in personal hygiene .dental/oral care PRN (as needed) .:
On May 29, 2025, at 10:20 a.m., an interview was conducted with the RNA. The RNA stated the staffs should be watchful while feeding residents, residents should be fed very slowly, check and feel residents ' cheeks and ensure the residents were able to tolerate the food. The RNA stated oral care must be provided to the residents after each meal and before bed. The RNA stated they used clean cloth dip in warm water to clean all surrounding cheeks, upper and lower lips, and teeth to remove anything that could have been stuck.
On May 29, 2025, at 11:30 a.m., during an interview with the RN, the RN stated the CNAs (Certified Nursing Assistants) do oral care on residents with feeding issues, immediately after meals and before bed.
On May 29, 2025, at 12:57 p.m., an interview and concurrent document review conducted with the Food and Nutritional Service Director (FNSD), the FNSD reviewed menu from March 26 and 27, 2025 and the Cook's spreadsheet. The FNSD stated Resident 4 received dinner March 26, 2025, which included a soft diet with green beans soft, cheese ravioli garlic bread soft, soft ripe and no skin. The FNSD stated for breakfast on March 27, 2025, included egg soft fried, oats softened in milk, and soft hash browns. The FNSD stated Resident 4 was assigned with a 1:1 feeding assistant. The FNSD further stated Resident 4 did have holding of food in mouth and cheeks noted in MDS admission notes.
On May 30, 2025, at 10:06 a.m., during an interview conducted with the CNA, the CNA stated she fed Resident 4 with scrambled eggs and milk for breakfast on March 27, 2025. The CNA stated she was informed Resident 4 was about to get picked up for a scheduled physician appointment that day, so she did not complete the oral care.
On June 2, 2025, at 2:45 p.m., during an interview conducted with the DON, the DON stated Resident 4's family member had called her to informed Resident 4 was transferred to the acute care facility, as green beans and egg had been found in her mouth at the physician ' s office during the appointment. The DON stated the resident should have had oral care after each meal to assure no food residue remained.
A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, indicated, .Residents will be provided with care .residents who are unable to carry out the activities of daily living independently will receive the service .to maintain good .oral hygiene .oral care .appropriate care and services will be provided for residents who are unable to carry out ADL ' s independently .including .oral hygiene .
May 2025
14 deficiencies
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 develop a comprehensive care plan to address the contr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan to address the contractures (shortening and hardening of muscles) of the feet, for one of two residents, (Resident 10).
This failure had the potential for Resident 10 not to receive the appropriate interventions tailored to her needs and further worsening of the contractures of the feet.
Findings:
On April 29, 2025, at 9:37 a.m., during the initial tour of the facility, Resident 10 was observed laying on her bed in her room with both ankles extended in a downward position with no adaptive devices on her feet. Resident 10 was not able to flex both ankles upward.
On April 30, 2025, at 9:41 a.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated Resident 10 had the foot drop for a long time already. CNA 2 stated they only put heel pads to protect her from skin breakdown.
On May 1, 2025, Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain).
A review of Resident 10's History and Physical, dated December 17, 2023, indicated Resident 10 can make needs known but could not make medical decisions.
A review of Resident 10's Progress Notes, from a physician's follow up appointment, dated August 26, 2024, indicated Resident 10 had a contractures of the feet.
A review of Resident 10's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 10 had impairment on both sides of lower extremities (part of the body that includes hip, knee, ankle, foot).
A review of Resident 10's REHAB: JOINT MOBILITY ASSESSMENT (assessment tool evaluating the range and quality of movement at a joint), dated February 11, 2025, indicated Resident 10 had severe joint immobility condition for both ankles.
There was no documented evidence a care plan was initiated to address Resident 10's contractures of both feet.
On April 30, 2025, at 3:47 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 10 had history of stroke and had contractures on both feet. LVN 1 stated Resident 10 had no care plan to address contractures. LVN 1 further stated care plan should have been initiated to prevent worsening of the contractures.
On April 30, 2025, at 4:33 p.m., during a concurrent interview and record review with the Director of Nursing (DON). The DON stated there was no care plan initiated or in placed to manage the contractures of the feet for Resident 10. The DON stated a care plan should have been initiated or in placed to manage the contractures of Resident 10's feet. The DON further stated without a care plan, Resident 10 would not receive functional needs and services that maintain physical well-being.
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person- Centered, dated December 2026, indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will .Described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .Aid in preventing or reducing decline in the resident's functional status and/or functional levels .Enhance the optimal functioning of the resident by focusing on a rehabilitative program .
A review of the facility's policy and procedure titled, Resident Mobility and Range of Motion, dated July 2017, indicated, .The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed .The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 appropriate care and treatment to manage cont...
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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 appropriate care and treatment to manage contractures, for one of one resident reviewed for range of motion (ROM-the full movement potential of a joint) (Resident 10).
This failure had the potential for Resident 10 to have further worsening of the feet contractures and contribute to pain and discomfort.
Findings:
On April 30, 2025, at 9:47 a.m., Resident 10 was observed laying on her bed with both feet extended in a downward position. Resident 10 was wearing soft blue foam heel pads to cover the ankles.
On April 30, 2025, at 9:41 a.m., during an interview with Certified Nursing Assistant (CNA) 2, she stated Resident 10 had the foot drop for a long time already. CNA 2 stated they only put heel pads to protect her from skin breakdown.
On April 30, 2025, at 10:35 a.m., during an interview with Certified Restorative Nursing Assistant (CRNA) 1, CRNA 1 stated she would provide ROM exercises to the residents after she received the order from the licensed nurse or rehab staff. CRNA 1 stated there was no order for ROM exercises for Resident 10, so she did not provide any ROM treatment/exercises to the resident. CRNA 1 stated Resident 10 had contractures on her feet and should have been included in the list for RNA exercises.
On April 30, 2025, Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (disrupted blood flow to the brain).
A review of Resident 10's History and Physical, dated December 17, 2023, indicated Resident 10 can make needs known but cannot make medical decisions.
A review of Resident 10's REHAB: JOINT MOBILITY ASSESSMENT (assessment tool evaluating the range and quality of movement at a joint), dated August 2, 2023, and February 11, 2025, indicated Resident 10 had severe joint immobility on both ankles.
A review of Resident 10's Physical Therapy PT Discharge Summary, dated January 9, 2024, indicated, .Discharge Instructions .RNA program (program to restore care, helps patient to regain or maintain functional abilities) for ROM .
A review of Resident 10's Progress Notes, from a physician's follow up appointment dated August 26, 2024, indicated Resident 10 had contracture on both feet.
A review of Resident 10's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 10 had impairment on both sides of lower extremities (part of the body that includes hip, knee, ankle, foot).
On April 30, 2025, at 3:47 p.m., during a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 10 had both feet contracted and were using a heel pad to protect the heels from skin breakdown. LVN 1 stated there was no indicated physician order that would maintain or prevent further contractures of Resident 10's feet. LVN 1 further stated Resident 10 should have been referred to the physical therapist for a device and a therapy program to prevent further contractures and to prevent foot drop.
On April 30, 2025, at 4:33 p.m., during an interview with the Director of Nursing (DON), the DON stated she expected the nurses and the rehabilitation therapists to follow the facility's policy and procedure to address residents contractures. The DON further stated Resident 10 should have been placed in the contracture management program and should have received device that prevent further worsening of the contractures.
On May 1, 2025, at 3:20 p.m., during an interview with the Physical Therapist (PT), the PT stated Resident 10 condition was called ankle dorsiflex contracture (joint was limited in its ability to bend upward) and the resident was not wearing a proper device to manage or maintain the structure of the joints. The PT stated Resident 10 should have been recommended to wear a device to maintain the proper alignment of the joints. The PT stated Resident 10 should have received the proper contracture management and should have been picked up for rehab therapy and continue RNA maintenance program to avoid further decline of joint contractures and possible foot drop. The PT further stated, She would be a good candidate.
A review of the facility's policy and procedure titled, Resident Mobility and Range of Motion, dated July 2017, indicated, .Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM .Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility .
A review of the facility's policy and procedure titled, Restorative Nursing Program, dated May 2023, indicated, .It is the policy to assist each and every resident to achieve the highest level of self-care possible. The concept of self-care is an integral part of the daily nursing care and includes at least the following .Proper positioning and body alignment .passive range of motion exercises .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was free from unnecessary medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 19) when:
1.Quetiapine (medication used to treat mental illness characterized by disordered thinking, hallucination) was administered without implementing resident-centered non pharmacological interventions prior to administration of the medication; and
2. There was no attempt for gradual dose reduction (GDR - process of slowly and systematically decreasing the dosage of a medication, particularly psychotic medication) with the use of quetiapine.
These failures had the potential to result in ineffective behavior management for Resident 19 which increased the potential for unidentified risks associated with the use of medication such as sedation, respiratory depression, and memory loss.
Findings:
On May 1, 2025, at 12:40 a.m., during a concurrent observation and interview with a Certified Nursing Assistant (CNA) 4, Resident 19 was observed to be sleepy and slow to respond while CNA 4 was feeding the resident. CNA 4 stated Resident 9 did not exhibit any disruptive behaviors while care was being provided to the resident.
On May 1, 2025, Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and psychosis (a mental disorder characterized by a disconnection from reality).
A review of Resident 19's History and Physical, dated April 3, 2024, indicated Resident 19 was mentally incapable of understanding.
A review of Resident 19's Nurses Note, dated April 2, 2024, indicated, .Resident noted with saying I go repeatedly, tearful at times .
A review of Resident 19's IDT NOTES, dated April 17, 2024, indicated, .Continued episodes of saying/raising her voice saying, I go, I go home continued .
A review of Resident 19's, Order Summary Report, dated April 25, 2024, indicated, .Quetiapine Fumarate Tablet 25 MG (milligram - unit of measurement) Give 1 tablet by mouth two times a day for PSYCHOSIS MANIFESTED BY VISUAL HALLUCINATION (a perception of having seen, heard, touched, tasted, or smelled something that was not actually there) .
A review of Resident 19's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 19 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognition) score of 02 which indicated severe cognitive impairment.
Further review of Resident 19's record indicated there was no documented evidence in Resident 19's medical record non-pharmacological interventions were implemented prior to initiating quetiapine.
A review of Resident 19's MDS Section E- Behavior-indicators for psychosis, indicated the following:
- September 3, 2024, no indications of hallucinations;
- November 22, 2024, no indications of hallucinations; and
- February 10, 2025, no indications of hallucinations.
A review of Resident 19's Medication Administration Record (MAR), indicated episodes of visual hallucination as follows:
- January 2025; no behavior of visual hallucination;
- February 2025; no behavior of visual hallucination;
- March 2025; 14 episodes of visual hallucination; and
- April 2025; three episodes of visual hallucination.
A review of Resident 19's Medication Regimen Review, dated January 7, 2025, indicated, .This resident continues on Seroquel 25 mg BID (twice a day) from 4/25/2024 (April 25, 2024). The Federal nursing facility require that a gradual dose reduction (GDR) be attempted in two separate quarters .
Further review of Resident 19's record indicated there was no gradual dose reduction attempted after the pharmacy consultant recommended GDR related to the use of quetiapine.
On May 1, 2025, at 12:50 p.m., during a concurrent interview and record review with the MDS Nurse (MDSN), the MDSN stated, MDS behavior assessment indicated there were no hallucinations on September 3, 2024, November 22, 2024, and February 10, 2025. The MDSN stated the behavior monitoring in Resident 19's MAR indicated there were no manifestations of visual hallucination for the months of January 2025 and February 2025. The MDSN further stated, The GDR should have been attempted.
On May 1, 2025, at 1 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 5. LVN 5 stated she had taken cared of Resident 19 and had not observed Resident 19 to have disruptive behavior. LVN 5 stated, .she is quiet lady and sleeps most of the time .
On May 1, 2025, at 1:10 p.m., an interview was conducted with LVN 2. LVN 2 stated Resident 19 was receiving quetiapine since she was admitted for psychosis manifested by visual hallucination, and she did not had a behavior of visual hallucination.
On May 1, 2025, at 1:20 p.m., during a concurrent interview and record review with Registered Nurse (RN) 1, RN 1 stated Resident 19 had no disruptive behavior such as visual hallucination that could affect herself and other residents. RN 1 stated there was no evidence of non-pharmacological intervention implemented prior to quetiapine medication administration. RN 1 stated non-pharmacologic intervention should have been implemented prior to administration of any psychotropic medications. RN 1 further stated if non-pharmacologic intervention was not attempted, medication would be inappropriate and could place Resident 19 at risks of sedation and respiratory depression.
On May 1, 2025, at 4:16 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON stated she expected all nursing staff would follow the facility's policy and procedure of antipsychotic (medication to treat mental illness) medication use. The DON confirmed there was no documentation in Resident 19's medical record of non-pharmacological interventions implemented prior to the initiation or during the use of quetiapine and acknowledged there should have been. The DON stated that the visual hallucination was identified during admission and confirmed that there was no documentation in Resident 19's medical record of harm resulted from visual hallucination. The DON stated it was important to use antipsychotic medications as indicated to ensure residents were medicated properly and had clinical reasons to have continued the medication. The DON further stated, GDR should have been implemented.
A review of the facility's policy and procedure titled, Medication Regimen Review (Monthly Report) Unnecessary Medications, dated August 2019, indicated, .Each resident must receive and the Facility must provide the necessary care and services to attain or maintain the highest practicable physical , mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care .Each resident's medication regimen must be free from unnecessary drugs .An unnecessary drug is any used .Without adequate indications for its use .The consultant pharmacist will identify medications that may be considered unnecessary .Residents who use anti-psychotic drugs receive gradual dose reductions, and behavioral interventions .in an effort to discontinue these drugs .
A review of the facility's policy and procedure titled, Antipsychotic Medication Use, dated December 2016, indicated, .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .Diagnoses alone do not warrant the use of antipsychotic medication .antipsychotic medications will generally only be considered if the following conditions are also met .The behavioral symptoms present a danger to the resident or others .Behavioral interventions have been attempted and included in the plan of care .medications will not be used unless behavioral symptoms are .Not sufficiently relieved by non-pharmacological interventions .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
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 one resident reviewed for dental (...
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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 one resident reviewed for dental (Resident 22), a dental consultation was provided for the resident.
This failure had the potential to result in Resident 23 not receiving the dental services needed to maintain her highest practicable level of well-being.
Findings:
On April 29, 2025, at 4:07 p.m., Resident 22 was observed missing some upper and lower teeth. In a concurrent interview with Resident 22, he stated he could chew well, I don't have postiza (denture- artificial teeth), and had not seen the dentist.
On May 1, 2025, Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty in swallowing).
A review of Resident 22's Order Summary, included the following physician's order:
- Dental Health Services as needed, date ordered July 3, 2021; and
- .Dysphagia Mechanical Soft Texture (texture of food to make them easier to chew and swallow) ., date ordered February 5, 2025.
A review of Resident 22's Dental Hygiene Progress notes, dated November 18, 2024, indicated Resident 22 had no dentures and was edentulous (no teeth).
A review of Resident 22's Minimum Data Set (MDS - a resident assessment tool), dated May January 23, 2025, indicated Resident 22 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognition) score of 05 which indicated severe cognitive impairment.
On May 1, 2025, at 10:25 a.m., during a concurrent interview and record review with the Social Service Director (SSD), the SSD stated there was no documentation Resident 22 was seen by the dentist since last year. The SSD stated Resident 22 should have been seen by the dentist. The SSD further stated Resident 22 would not be able to eat properly and could lead to weight loss if Resident 22 would not provide dental services.
On May 1, 2025, at 3:35 p.m., the Director of Nursing (DON) was interviewed. The DON stated she expected the nurses and SSD to follow facility's policy and procedure for dental services. The DON stated the resident should have been seen by the dentist. The DON further stated Resident 22 had the potential not to eat the food and could lead to weight loss if dental issues would not be addressed.
A review of the facility's policy and procedure titled, Dental Services, dated December 2016, indicated, .Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care .Social services representatives will assists residents with appointments, transportation arrangements .
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 observation, interview, and record review, the facility failed to ensure resident's information was protected from unau...
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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 resident's information was protected from unauthorized use, for one of five residents observed during medication administration (Resident 161), when the electronic health record of Resident 161 was left open and unattended by the licensed nurse.
This failure had the potential for Resident 161's record to be disclosed to other people not authorized in the provision of care and treatment.
Findings:
On May 1, 2025, 08:06 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed to leave the computer open and unattended with Resident 161's resident information viewable to persons not directly related to the resident's care.
Resident 161's record was reviewed. Resident 161's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break) of left femur (thigh bone), difficulty walking, diabetes (too much sugar in the blood), and hypertension (high blood pressure).
Resident 161's Minimum Data Set (MDS - a resident assessment tool), dated May 3, 2025, indicated Resident 161 had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact).
On May 1, 2025, at 2:35 p.m., during a concurrent interview and record review with LVN 3, LVN 3 acknowledged she left the computer open and unattended which was a Health Insurance Portability and Accountability Act (HIPPA - law to protect patient sensitive health information) violation. LVN 3 stated the facility's policy was for the staff to close or lock the computer monitor when leaving the medication cart. LVN 3 stated she should have closed her laptop. LVN 3 further stated there was a possibility resident information could get stolen, which violates the resident's privacy.
On May 1, 2025, at 3:44 p.m., during an interview with the Director of Nursing (DON), the DON stated her expectation staff should lock their screen before going into a patient room. Stated the concern was a violation of HIPPA. The DON also stated resident information was risk and available to person who was not involved with Resident 161's care. The DON further stated the expectation was for the resident's personal information and health information to be maintained.
A review of the facility's undated policy and procedure titled, HIPPA COMPLIANCE, indicated, .It is the intent of the facility to adhere to the Omnibus Health Insurance Portability and Accountability Act (HIPPA) Privacy, Security, Enforcement and Breach Notification Rules .It is our intent to assure that policies, procedures and practices are developed, implemented, staff trained breaches avoided and compliance monitored .
A review of the facility's policy and procedure titled, Dignity, revised February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .and feelings of self-worth and self-esteem .Staff protect confidential clinical information .Staff promote, maintain and protect resident privacy, including bodily privacy .during treatment procedures .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure heater equipment in the resident's room was maintained in a safe operating condition, for one of 55 residents (Residen...
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Based on observation, interview, and record review, the facility failed to ensure heater equipment in the resident's room was maintained in a safe operating condition, for one of 55 residents (Resident 52), when one baseboard heater cover was observed open, detached and laying on the floor.
This failure had the potential to cause a fire and hazardous environment for the residents, staff and visitors.
Findings:
1. On April 29, 2025, at 2:30 p.m., during a concurrent observation and interview with Resident 52 inside her room, Resident 52 was observed sitting in a wheelchair looking at the baseboard heater below the window panel. The baseboard heater cover was observed open and detached and laying on the floor. Resident 52 stated her she could feel the warm breeze directly coming from the baseboard heater. Resident 52 stated she could not pass directly because she was afraid that she might burn from the heater.
On April 29, 2025, at 2:43 p.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated the baseboard heater cover was damaged and was detached from the main base of the heater. The MS stated the baseboard cover of the heater should have been fixed to prevent further damage and prevent someone getting burned. The MS further stated, It should have been repaired as soon as possible.
On April 29, 2025, at 2:50 p.m., an interview was conducted with the Administrator (ADM). The ADM stated he expected the maintenance staff to repair any damaged devices and make sure residents and staff were free from hazards. The ADM further stated any broken equipment should have been repaired to provide a safe and functional environment for the residents.
A review of the facility's policy and procedure titled, Maintenance Service, dated December 2009, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of maintenance personnel include .Maintaining the building in a compliance with current federal, state, and local laws, regulations, and guidelines .Maintaining the building in good repair and free from hazards .maintaining the heat/cooling system .in good working order .Maintenance personnel shall follow established safely regulations to ensure that safety and well-being of all concerned .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 treat residents with respect and dignity when:
1. 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 treat residents with respect and dignity when:
1. For Resident 19, Certified Nursing Assistant (CNA) did not fully close the privacy curtain to cover resident's body while providing care;
2. For Resident 47, the staff did not answer call lights in a timely manner, and;
3. For Resident 55, the staff did not respond to resident's requests to provide care.
These failures resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative physical or psychosocial outcomes, such as embarrassment, or changes in mood and/or behavior.
Findings:
1. On April 29, 2025, at 10:21 a.m., during a concurrent observation and interview with CNA 1, CNA 1 was observed providing care to Resident 19 in her room. CNA 1 was changing Resident 19's clothes and the privacy curtain was observed half drawn and Resident 19's body was exposed. CNA 1 stated she was in a hurry because the therapy told her Resident 19 would be next for treatment. CNA 1 further stated, I forgot to fully close the curtain.
On May 1, 2025, Resident 19's record was reviewed. Resident 19 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss).
A review of Resident 19's Minimum Data Set (MDS - a tool for assessment), dated February 10, 2025, indicated Resident 19 had a BIMS (Brief Interview for Mental Status - a tool used to assess cognition) score of 02 which indicated severe cognitive impairment.
On May 1, 2025, at 10:32 a.m., during interview with Registered Nurse (RN) 1, RN 1 stated privacy was important and CNA1 should have fully closed the curtain and should not expose Resident 19's body while providing care. RN 1 stated she would feel embarrassed if someone would saw her body. RN 1 further stated, It's a dignity issue.
On May 1, 2025, at 3:32 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated she expected all staff to always treat residents with respect and dignity. The DON stated the CNA 1 should have drawn the privacy curtains while providing care to residents.
A review of the facility's policy and procedure titled, Dignity, dated February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .
3. On April 29, 2025, at 10:14 a.m., during an interview with Resident 55, Resident 55 stated he turned on the call light to request for assistance to transfer from wheelchair to bed, on the night of April 24, 2025. Resident 55 stated he waited for at least 15- 20 minutes and no staff came, then his roommate (Resident 48) went to get help.
On April 29, 2025, at 10:34 a.m., during an interview with Resident 48, Resident 48 confirmed the incident alleged by Resident 55 on April 24, 2025. Resident 48 stated he used his call light for staff assistance and they never came. Resident 48 stated he got out of his bed and went to get help for Resident 55 after 20 minutes had passed and no staff responded to their call light.
On May 2, 2025, at 3:40 p.m., during an interview with the DON, the DON stated the call lights should be answered timely. The DON stated it was every staffs responsibility to answer the lights. The DON stated the concern was resident's needs would not be met timely and there was a potential for resident falls.
A review of the facility's policy and procedure titled, Dignity, dated February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited .Staff are expected to promote dignity and assist residents; for example; promptly responding to a resident's request for toileting assistance .
A review of the facility's policy and procedure titled, Answering The Call Light, dated September 2022, indicated, .to ensure timely responses to resident's requests and needs .answer the resident call system immediately .answering an auditory request for assistance .if resident needs assistance indicate approximate time it will take for you to respond .if you can not fulfill the resident's request .ask the nurse supervisor for help .
2. On May 1, 2025, at 2:35 p.m., an observation of the call lights and nurse response during change of day shift (7 a.m. to 3 p.m.) to evening shift (3 p.m. to 11 p.m.) was conducted. The CNAs were observed standing near the central nurse station talking to each other while the call lights in two rooms were observed on. The call lights were were answered with an average time of 5 -10 minutes.
On May 1, 2025, at 3:40 p.m., an interview with Resident 47 was conducted. Resident 47 stated the call lights were not being answered timely especially during the day and evening shift. Resident 47 stated he could not do many things for himself after his stroke and several times his roommate had to go into the hallway to find a nurse to help him. Resident 47 further stated he felt disrespected and unimportant when he had to wait for the nurse for a prolonged time.
A review of Resident 47's medical record indicated Resident 47 was admitted to the facility on [DATE], with the diagnoses which included cerebral infarction (when blood flow to the brain is blocked causing brain tissue to die) and hemiplegia (paralysis or severe weakness on one side of the body).
Resident 47's Minimum Data Set (MDS - an assessment tool), dated April 1, 2025, indicated Resident 47 had a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact).
On May 2, 2025, at 3:40 p.m., an interview was conducted with Director of Nursing (DON). The DON stated her expectation was for the nurses to answer lights as soon as possible, and if unable to assist immediately inform the residents of their return time. The DON stated the resident's sense of well-being or self-worth were not being promoted when call lights are not being answered as soon as possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for seven of 16 residents reviewed for Advanced Directive (AD - a written statement of an ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for seven of 16 residents reviewed for Advanced Directive (AD - a written statement of an individual's wishes regarding his/her medical treatment) the facility failed to ensure a copy of the AD was readily available in the resident's records when:
1. For Resident 9, the facility did not follow up with resident representative (RR) to obtain a copy of the resident's AD. This failure had the potential for Resident 9's wishes regarding his medical treatment would not be honored;
2. For Residents 29, 30, 39, 55, 160 and 209, a written information regarding formulating an AD was not provided to the resident or RR. This failure had the potential for Residents 29, 30, 39, 55, 160 and 209 to not be aware of how to formulate an AD.
Findings:
1. On May 1, 2025, Resident 9's record was reviewed . Resident 9 was admitted on [DATE], with diagnoses which included acute kidney failure (a condition in which kidneys suddenly can not filter waste from the blood).
A review of Resident 9's Advance Directive Acknowledgement dated February 5, 2024, indicated Resident 9 had executed an AD.
A review of Resident 9's Minimum Data Set (MDS - an assessment tool), indicated Resident 9 had BIMS (Brief Interview for Mental Status) score of 12 (moderate cognitive impairment).
Further review of Resident 9's record indicated there was no AD readily available for review in Resident 9's chart.
On May 1, 2025, at 9:56 a.m., an interview was conducted with the Social Service Director (SSD). The SSD stated the residents were inquired regarding information if they have an AD or not. The SSD stated if the resident have an AD, it should be in the resident's electronic file or a hard copy in the resident's chart. The SSD stated it was important for a physical copy of the AD to be readily available in the resident's chart so that the facility staff and the physician would be aware of the wishes of the resident and to honor their wishes. The SSD stated a copy of Resident 9's AD was not uploaded in the resident's electronic record as well as in the paper chart, and was not readily available for the facility when needed. The SSD stated Resident 9's AD should have been followed up from the resident's family member.
2. On May 1, 2025, Resident 29 's record was reviewed. Resident 29 was admitted to the facility on [DATE], with diagnoses that which included cerebral vascular accident (CVA - a condition where blood flow to the brain is interrupted, causing brain tissue damage).
Further review of Resident 29's record indicated there was no documented evidence written information regarding formulating an AD being given to Resident 29.
3. On May 1, 2025, a review Resident 39's record indicated Resident 39 was admitted on [DATE], with diagnoses which included fracture (break) of the right and left tibia (the shinbone) and mandible (the lower jawbone).
A further review of Resident 39's record indicated there was no documented evidence written information regarding formulating an AD was provided to Resident 39.
4. On May 1, 2025, Resident 209's record was reviewed. Resident 209 was admitted to the facility on [DATE], with diagnoses which included urinary tract infection, inflammatory polyarthropathy (joint swelling and pain affecting five or more joints).
A review of Resident 209's Advance Directive Acknowledgement, dated April 24, 2025, indicated Resident 209 did not have an AD, and there was no documentation the resident was provided written information regarding formulating an AD.
5. On April 30, 2025, Resident 30's record was reviewed. Resident 30 was admitted on [DATE], with diagnoses which included hemiplegia/hemiparesis (partial paralysis on one side of the body), slurred speech, facial weakness, difficulty walking, dysphagia (difficulty swallowing), and hypertension.
A review of Resident 30's History and Physical, dated March 24, 2025, indicated Resident 30 had the capacity to make decisions.
A review of Resident 30's Advance Directive Acknowledgement, dated _____, indicated Resident 30's did not have an AD, and there was no documentation the resident was provided written information regarding formulating an AD.
6. On April 29, 2025, Resident 55's record was reviewed. Resident 55 was admitted to the facility on [DATE], with diagnoses which included fusion of the spine (procedure joining two or more vertebrae of the spine), cauda equina syndrome (damaged to bundle of nerves at the end of the spinal cord), and difficulty walking.
A review of Resident 55's History and Physical, dated April 15, 2025, indicated Resident 55 had the capacity to make medical decisions.
A review of Resident 55's Minimum Data Set (MDS - a resident assessment tool), dated April 18, 2025, indicated Resident 55 had a BIMS score of 13 (cognitively intact).
A review of Resident 55's Advance Directive Acknowledgement, dated _____, indicated Resident 30's did not have an AD, and there was no documentation the resident was provided written information regarding formulating an AD.
7. On April 30, 2025, Resident 160's record was reviewed. Resident 160 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (blood flow to the brain is blocked), hemiplegia (weakness on one side of the body), difficulty walking, dysphagia (difficulty swallowing), and diabetes mellitus (too much sugar in the blood).
A review of Resident 160's History and Physical, dated February 27, 2025, indicated Resident 160 did not have the capacity to understand and make decisions.
A review of Resident 160's MDS, dated March 4, 2025, indicated Resident 160 had a BIMS score of 6 (severe cognitive impairment).
A review of Resident 30's Advance Directive Acknowledgement, dated _____, indicated Resident 160's did not have an AD, and there was no documentation the resident's representative was provided written information regarding formulating an AD.
On May 1, 2025, at 9:56 a.m., during an interview with the SSD, the SSD stated she was not providing written information to the resident or RR regarding formulating an AD. The SSD stated there was no documentation a written information regarding formulating an AD was provided to the resident or RR. The SSD stated Residents 9, 29, 30, 39, 55, 160, and 209 should have been provided written information regarding formulating an AD.
A review of the facility's policy and procedure titled, Advance Directives, dated December 2016, indicated, .Advance Directives will be respected in accordance with state law and facility policy .Upon admission, the resident will be provided with written information concerning the right .to formulate an advance directive if he or she chooses to do so .Written information will include a description of the facility's policies to implement advance directives .If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative .Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his legal representative, about the existence of any written advance directives .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .If a resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
On May 2, 2025, at 10:10 a.m., an interview was conducted with the MS. The MS stated he was aware of the condition of the pa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.
On May 2, 2025, at 10:10 a.m., an interview was conducted with the MS. The MS stated he was aware of the condition of the painted walls. The MS further stated the damaged painted walls should have been fix and repainted.
On May 2, 2025, at 10:20 a.m., an interview was conducted with the Administrator ADM. The FA stated he expected maintenance to check and fix any damaged wall or surfaces in the rooms. The FA further stated the walls should have been fix and the facility should have a homelike environment feeling for all residents.
A review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean sanitary and orderly environment .
Based on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for two of four residents reviewed for environment (Residents 37 and 14), when the peeled painted walls were observed damaged behind the resident's headboard. In addition, peeled painted walls were observed in rooms [ROOM NUMBER].
This failure had the potential for residents not to experience comfortable and pleasant stay in the facility.
Findings:
1. On April 29, 2025, at 9:30 a.m., Resident 37 was observed sleeping in her bed. Multiple peeled painted walls were observed damaged behind the headboard of Resident 37's bed.
On April 30, 2025 at 9:20 a.m., the walls behind Resident 14's headboard was observed to have peeled paint.
In addition, on April 30, 2025 at 1:29 p.m., multiple peeled painted wall was observed behind residents headboard in rooms 9B and 22.
On May 2, 2025, at 10:10 a.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated he was aware of the condition of the painted walls. The MS further stated the damaged painted walls should have been fix and repainted.
On May 2, 2025, at 10:20 a.m., an interview was conducted with the Administrator (ADM). The ADM stated he expected maintenance to check and fix any damaged wall or surfaces in the rooms. The ADM further stated the walls should have been fixed and the facility should have a homelike environment feeling for all the residents.
A review of the facility's policy and procedure titled, Homelike Environment, dated February 2021, indicated, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean sanitary and orderly environment .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure professional standards of practice during medic...
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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 professional standards of practice during medication administration and the facility's policy and procedure were implemented, for three of 10 residents observed during medication administration (Residents 48, 55, 31, and 161), when:
1. Resident 48's medication was placed on a shelf next to Resident 55, readily available for use. This failure had the potential for Resident 48's medication be administered to Resident 55;
2. The identification of Resident 31 was not verified prior to administering the medications. This failure had the potential for the medications to be administered to the wrong resident; and
3. Resident 161 was not provided privacy while administering the medications. This failure had the potential to affect Resident 161's psychosocial and mental status.
Findings:
1. May 1, 2024, at 7:44 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) LVN 3, LVN 3 was observed to have 1 open packet of Lidocaine Patch 5% (topical medication for pain relief) labeled for Resident 48 sitting on a shelf next to Resident 55.
Resident 55's record was reviewed. Resident 55's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fusion of the spine (procedure joining two or more vertebrae of the spine), cauda equina syndrome (damaged to bundle of nerves at the end of the spinal cord), and difficulty walking.
Resident 55's Minimum Data Set (MDS- an assessment tool), indicated Resident 55 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact).
A review of Resident 55's physician's orders, dated April 16, 2025, indicated, .Lidocaine Patch 4% Lidocaine, Apply to bilateral knee pain topically one time a day for bilateral knee pain and remover per schedule .
On May 1, 2025, at 2:33 p.m., during an interview with LVN 3 , LVN 3 confirmed she left 1 Lidocaine Packet 5% belonging to Resident 48 open and readily available for use on the shelf by Resident 55. LVN 3 stated the medication belonged to Resident 48. LVN 3 stated she did not put the medication back into the cart nor discarded it and she should have. LVN 3 stated she should not have had another resident's medication out while administering to a different resident. LVN 3 stated the resident could have used the medication and could have adverse effect from the medication.
On May 1, 2025, at 3:48 p.m., during an interview with the Director of Nursing (DON), the DON stated open medication should not be open and left unattended in the presence of another resident. The DON stated the expectation was staff should handle one resident medication at a time to decrease the risk for any medication errors. The DON stated potential concerns was if the resident was confused and used the medicine, there was a possibility of adverse side effects.
A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated .Medications are administered in a safe and timely manner, and as prescribed .Medications ordered for a particular resident may not be administered to another resident .
2. On May 1, 2025, at 8 a.m., during a medication pass observation with LVN 3, LVN 3 was observed administering medication to Resident 31 without verifying the resident's identity.
Resident 31's record was reviewed. Resident 31's admission Record, indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included fracture (break) of right wrist and hand, bradycardia (slow heart rate), and difficulty walking.
Resident 31's History and Physical, dated April 13, 2025, indicated Resident 31 had the capacity to understand and make decisions.
Resident 31's Minimum Data Set (MDS - a resident assessment tool), indicated Resident 31 had a BIMS score of 15 (cognitively intact).
A review of Resident 31's Medication Administration Record, indicated a physician's order which indicated, Sodium Chloride Oral Tablet (Sodium Chloride) Give 0.5 tablet by mouth three times a day for hyponatremia (low sodium levels) by mouth three times a day.
On May 1, 2025, at 2:33 p.m., during a concurrent interview and record review with LVN 3. LVN 3 acknowledged she did not verify the resident before administering the medication to Resident 31. LVN 3 stated the facility's process was for the licensed nurse to check every single resident identification by confirming the name and date of birth of the resident before she administers the medication to make sure she did not give the medication to the wrong resident.
On May 1, 2025, at 3:39 p.m., during an interview with the DON, the DON stated her expectation was licensed staff nurses was to identify resident typically with their identification wrist band to verify they have the right resident. The DON stated licensed nurses was expected to follow the medication administration guidelines and verify all residents prior to administration. The DON further stated some consequences was the possibility of adverse reactions, abnormal vitals signs, hospitalization depending on reactions or even death.
On May 1, 2025, at 4:20 p.m., during an interview with LVN 4, LVN 4 stated the facility's process during medication administration was the licensed nurse introduced themselves and verify the resident by their wrist band and/or ask the resident their name and date of birth . LVN 4 stated residents change rooms all the time and the outside name plaque on the door may not be updated. LVN 4 stated the licensed nurse need to verify the resident to prevent administering the wrong medicine to the wrong patient. LVN 4 further stated if you do not verify the resident and give the wrong medicine to a resident there was a possibility of an allergic reaction or possible death.
A review of the facility's policy and procedure titled, Administering Medications, revised April 2019, indicated .Medications are administered in a safe and timely manner, and as prescribed .The individual administering medications verifies the resident's identity before giving the resident his/her medications .Methods of identifying .include .a. Checking identification band .The individual administering the medication check the label THREE (3) times to verify the right resident .before giving the medication .
3. During a medication pass observation on May 1, 2025, 08:06 a.m., with LVN 3, LVN 3 was observed not providing privacy during medication administration to Resident 161.
Resident 161's record was reviewed. Resident 161's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included fracture (break) of left femur (thigh bone), difficulty walking, diabetes (too much sugar in the blood), and hypertension (high blood pressure).
Resident 161's MDS, dated May 3, 2025, indicated Resident 161 had a BIMS score of 13 (cognitively intact).
On May 1, 2025, at 2:43 p.m., during a concurrent interview and record review with LVN 3. LVN 3 acknowledged she did not provide privacy while administering medications to Resident 161. LVN 3 stated she should always provide privacy and dignity when administering medication because it was their right. LVN 3 stated she should have pulled the curtain or closed the door when administering Resident 161 medications.
On May 1, 2025, at 3:52 p.m., during an interview with the DON, the DON stated resident the licensed nurse should have provided privacy when administering medications to the resident. The DON stated staff should have pulled the curtain or closed the door.
On May 1, 2025, at 5:51 p.m., during a follow-up interview with the DON, the DON stated residents needed privacy during medication administration. The DON also stated the resident could feel embarrassed or exposed. The DON further stated the expectation was licensed staff should provide privacy for the resident during medication administration.
A review of the facility's policy and procedure titled, Dignity, revised February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being .Residents are treated with dignity and respect at all times Staff promote, maintain and protect resident privacy, including bodily privacy .during treatment procedures
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the nee...
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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 sufficient staff were provided to meet the needs of the residents when:
1. For five of 55 residents (Residents 55, 48, 31, 163, and ) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and
2. The facility did not meet the required minimum of Actual Total CNA Direct Care Service Hours the actual CNA DHPPD of 2.4 hours for the month of March 2025, for 16 out of 31 days reviewed, and for the month of April 2025, for 11 out 30 days reviewed.
These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents.
Findings:
1a. On April 29, 2025, at 11:09 a.m., during an interview with Resident 55, Resident 55 stated he was sliding off his bed and used his call light and yelled out for the nurse aound late night of April 24, 2025. Resident 55 stated he yelled out for over 15 to 20 minutes, and no staff came. Resident 55 stated his roommate got up and pulled his call light and the staff still did not come.
Resident 55's record was reviewed. Resident 55's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included fusion of the spine (procedure joining two or more vertebrae of the spine), cauda equina syndrome (damaged to bundle of nerves at the end of the spinal cord), and difficulty walking.
Resident 55's Minimum Data Set, (MDS - a resident assessment tool), dated April 18, 2025, indicated Resident 55 had a BIMS (Brief Interview for Mental Status) score of 13 (cognitively intact).
1b. On April 29, 2025, at 10:34 a.m. during an interview with Resident 48, he acknowledged and confirmed that Resident 55 waited for his call light too long. Resident 48 stated he used his call light and staff never came. Resident 48 stated he had to go to the nurse station to get help. Resident 48 stated his light was on for at least 20 minutes. Resident 48 also stated staff would take forever to answer the call light and it happened more than once and sometimes the wait was over 30 minutes.
Resident 48's record was reviewed. Resident 48's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included disorders of kidney and ureter (problems filtering urine), pulmonary nodule (mass in the lungs), muscle wasting and difficulty walking.
Resident 48's MDS, dated March 6, 2025, indicated Resident 48 had a BIMS score of 15 (cognitively intact) and uses a wheelchair as primary mode of locomotion.
1c. On April 30, 2025, at 1:37 p.m., during an interview with Resident 31, Resident 31 stated staff would take a long time to answer the call light about over 30 minutes. Resident 31 stated it was mostly in the evening that the staff would respond to the call light.
Resident 31's record was reviewed. Resident 31's admission Record indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included a fracture (break) of right wrist and hand, bradycardia (slow heart rate), and difficulty walking.
Resident 31's History and Physical, dated April 13, 2025, indicated Resident 31 had the capacity to understand and make decisions.
Resident 31's MDS, dated April 17, 2025, indicated Resident 31 had a BIMS score of 15 (cognitively intact).
1d. On May 2, 2025, at 3:43 p.m. during an interview with Resident 163, Resident 163 stated the staff does not look at the call light. Resident 163 stated she waited up to an hour at night waiting for pain medicine. Resident 163 stated she was wet and waited for over 30 minutes.
Resident 163's record was reviewed. Resident 163's admission Record, indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included saddle embolus of pulmonary artery (condition where large blood clot lodges in main lung artery), muscle wasting, and difficulty walking,
Resident 163's History and Physical, dated April 13, 2025, indicated Resident 163 had the capacity to make medical decisions.
Resident 163's MDS, dated May 3, 2025, indicated Resident 163 had a BIMS score of 15 (cognitively intact).
1e. On May 2, 2025, at 3:51 p.m., during an interview with Resident 162, Resident 162 stated it would take staff over an hour to answer the call light. Resident 162 stated she was left soiled and wet.
Resident 162's record was reviewed. Resident 162's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included respiratory failure with hypoxia (lungs not able to deliver enough oxygen), congestive heart failure (heart does not pump blood well), difficulty walking, obesity (too much body fat), and muscle wasting.
Resident 162's MDS, dated April 30, 2025, indicated Resident 162 had a BIMS score of 13 (cognitively intact) and required assistance with bathing, dressing, and using the toilet.
2. On May 2, 2025, at 11:22 a.m., a concurrent interview and record review of the facility's Census and Direct Care Service Hours Per Patient Day, (DHPPD - measures the number of hours of direct care given to patients in skilled nursing facilities) with the Director of Staff Development (DSD) was conducted. The DSD acknowledged and confirmed records for multiple days in March 2025, and April 2025, indicated the Actual Total CNA Direct Care Service Hours were below the required minimum of 2.4 hours for 16 of the 31 days reviewed for March 2025, and eleven (11) of 30 days reviewed for April 2025.
The Actual Total DCSH hours were below 2.4 hours (hrs,) on the following dates:
- March 1, 2025 (Saturday): 2.3 hrs. (CNA DCSH);
- March 3, 2025 (Monday): 2.31 hrs. (CNA DCSH);
- March 9, 2025 (Sunday): 2.29 hrs. (CNA DCSH);
- March 10, 2025 (Monday): 2.39 hrs. (CNA DCSH);
- March 15, 2025, (Saturday): 2.38 hrs. (CNA DCSH);
- March 16, 2025 (Sunday): 2.10 hrs. (CNA DCSH);
- March 17, 2025 (Monday): 2.34 hrs. (CNA DCSH);
- March 18, 2025 (Tuesday): 2.38 hrs. (CNA DCSH);
- March 19, 2025 (Wednesday): 2.39 hrs. (CNA DCSH);
- March 21, 2025 (Friday): 2.30 hrs. (CNA DCSH);
- March 22, 2025 (Saturday): 2.34 hrs. (CNA DCSH);
- March 23, 2025 (Sunday): 2.28 hrs. (CNA DCSH);
- March 24, 2025 (Monday): 2.24 hrs. (CNA DCSH);
- March 29, 2025 (Saturday): 1.96 hrs. (CNA DCSH)
- March 30, 2025 (Sunday): 2.30 hrs. (CNA DCSH);
- March 31, 2025 (Monday): 2.21 hrs. (CNA DCSH).
- April 5, 2025 (Saturday): 2.33 hrs. (CNA DCSH);
- April 6, 2025 (Sunday): 2.11 hrs. (CNA DCSH);
- April 7, 2025 (Monday): 2.34 hrs. (CNA DCSH);
- April 9, 2025 (Wednesday): 2.32 hrs. (CNA DCSH);
- April 11, 2025, (Friday): 2.37 hrs. (CNA DCSH);
- April 12, 2025 (Saturday): 2.28 hrs. (CNA DCSH);
- April 13, 2025 (Sunday): 2.30 hrs. (CNA DCSH);
- April 15, 2025 (Tuesday): 2.39 hrs. (CNA DCSH);
- April 19, 2025 (Saturday): 2.18 hrs. (CNA DCSH);
- April 20, 2025 (Sunday): 2.24 hrs. (CNA DCSH) and
- April 28, 2025 (Monday): 2.36 hrs. (CNA DCSH).
On May 5, 2025, at 2:27 p.m., during an interview with the DSD, the DSD stated normally there should be seven CNAs and one Restorative Nurse Assistant (RNA) on the day (AM - 6:30 a.m. to 2:30 p.m.) shift, six CNAs on the PM (2:30 p.m. to 10:30 p.m.) shift and four CNAs on the Night (NOC - 10:30 p.m. to 6:30 a.m.). A concurrent record review and interview with the DSD of the Nursing Staffing Assignment and Sign-In Sheet, for the mentioned dates indicated CNA staffing was not met according to Facility Assessment Projections. Facility CNA staffing was less than projected number per shift on the following dates:
- March 1, 2025 (Saturday): AM shift - 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each);
- March 3, 2025 (Monday): AM shift - PM shift 5 CNAs (11 residents each);
- March 5, 2025 (Wednesday): AM shift - 6 CNAs (9 residents each);
- March 10, 2025 (Monday): PM shift 5 CNA's (11 residents each);
- March 16, 2025 (Sunday): PM shift 4 CNAs (14 residents each);
- March 17, 2025 (Monday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each);
- March 18, 2025 (Sunday): AM shift 6 CNAs (9 residents each); NOC shift 3 CNAs (18 residents each);
- March 21, 2025 (Friday): AM shift 6 CNAs (10 residents each);
- March 22, 2025 (Saturday): PM shift 5 CNAs (11 residents each);
- March 24, 2025 (Monday): AM shift 6 CNAs (10 residents each); PM shift 4 CNAs (14 residents each);
- March 29, 2025 (Saturday): AM shift 5 CNAs (11 residents each); PM shift 5 CNAs- 11 residents each;
- March 30, 2025 (Sunday): AM shift 7 CNAs -8 residents each; PM shift 5 CNAs- 11 residents each; NOC shift 4 CNAs -14 residents each and
- March 31, 2025 (Sunday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each);
- April 5, 2025 (Saturday): AM shift 5 CNAs (11 residents each); PM shift 5 CNAs (11 residents each); NOC shift 3 CNAs (18 residents each);
- April 6, 2025 (Sunday): AM shift 5 CNAs (11 residents each);
- April 7, 2025 (Monday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11residents each);
- April 9, 2025 (Wednesday): PM shift 5 CNAs (11 residents each);
- April 11, 2025 (Friday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each);
- April 12, 2025 (Saturday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (11 residents each);
- April 13, 2025 (Sunday): AM shift 6 CNAs (9 residents each);
- April 15, 2025 (Tuesday): AM shift 6 CNAs (9 residents each; PM shift 5 CNAs (11 residents each);
- April 19, 2025 (Saturday): AM shift 6 CNAs (9 residents each); PM shift 4 CNAs (13 residents each); NOC shift 3 CNAs (17 residents each).
- April 20, 2025 (Sunday): PM shift 5 CNAs (10 residents each); NOC shift 3 CNAs (17 residents each); and
- April 28, 2025 (Monday): AM shift 6 CNAs (9 residents each); PM shift 5 CNAs (10 residents each); NOC shift 3 CNAs (13 residents each).
The facility did not meet the expected assigned number of staffing ratio for CNA's as indicated in the Facility Assessment Projections, for staff ratio on the following dates:
- March 18, 2025 (Sunday): NOC shift 3 CNAs -18 residents
- April 5, 2025 (Saturday): NOC shift 3 CNAs -18 residents each.
- April 19, 2025 (Saturday): NOC shift 3 CNAs -17 residents each.
- April 20, 2025 (Sunday): NOC shift 3 CNAs -17 residents each and
- April 28, 2025 (Monday): NOC shift 3 CNAs -13 residents each.
On May 2, 2025, at 3:01 p.m. during an interview with the DSD, the DSD stated it was hard for 3 CNAs to cover 17 residents on a shift where indicated. The DSD stated the Actual Total CNA Direct Care Service Hours were not met on documented dates reviewed. The DSD also stated it was not enough CNAs to provide residents safe, efficient, and adequate care. The DSD stated it was a higher risk for resident falls and residents not getting help to the restrooms. The DSD also stated low staffing affects resident falls and she was working on staffing for the NOC shift. The DSD stated her expectation was to meet the correct number of staffing to provide adequate care for residents to meet their needs. The DSD further stated based on the numbers outlined staffing care was not adequate and she addressed the concern with administration.
On May 2, 2025, at 6:22 p.m. during a concurrent interview and record review with the Director of Nursing (DON), the DON stated call lights should be answered. The DON stated all staff were responsible for answering the call lights. The DON stated the concern was a potential for falls and her expectation was that staff answer call lights timely. The DON further stated the Actual Total CNA Direct Are Service Hours were not met on documented dates reviewed and should be 2.4 hours and above. The DON also stated not having the required hours met, meant less staff available to provide care. The DON stated with delays care could be affected. The DON further stated some possible concerns were impaired skin integrity if residents were left soiled in urine and a potential for falls. The DON stated her expectation was staff provide adequate care. The DON stated based on the dates reviewed the facility was not able to meet the required DHPPD hours for the CNAs.
A review of the facility's policy and procedure titled, Certified Nursing Assistant, indicated, .The primary purpose of this position is to provide residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and as directed by supervisor .Assist residents in accordance to their needs ranging from minimal assistance to total dependent care on activities of daily living (ADLs).
A review of the facility's policy and procedure titled, Staffing, dated October 2017, indicated, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all resident in accordance with resident care plans and the facility assessment .
A review of the facility's policy and procedure titled, Answering the Call Light, dated September 2022, indicated, .The purpose of this procedure is to ensure timely responses to the resident's requests ans needs .Answer the resident call system immediately .If the resident needs assistance, indicate the approcimate time it will take for you to respond .
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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 serve foods under safe and sanitary conditions when the staff placed a four-ounce (unit of measurement) s...
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Based on observation, interview, and record review, the facility failed to store, prepare, and serve foods under safe and sanitary conditions when the staff placed a four-ounce (unit of measurement) soup ladle directly on the table instead of the clean container in between serving of the soup for the residents, for .
This failure had the potential to put the vulnerable residents at risk for foodborne illnesses.
Findings:
On April 29, 2025, at 12:15 p.m., during the dining room observation, the Certified Restorative Nurse Assistant (CRNA) was observed to use the four-ounce ladle to serve soup into a bowl and then placed the ladle on the tablecloth instead of the clean container.
On April 29, 2025, at 12:25 p.m., an interview with the CRNA was conducted. The CRNA stated she placed the ladle on the tablecloth in between serving of the soup to the residents. The CRNA stated she had been trained to place the used soup ladle on the clean tray. The CRNA further stated she should not have placed the ladle on the tablecloth as it might cause cross-contamination and illness in the residents.
On April 29, 2025, at 12:55 p.m., an interview with the Director of Food and Dietary (DND) was conducted. The DND stated the CRNA had been trained in how to serve the crockpot soup of the day by the DND and the ladle should not have been placed on the table in between serving residents. The DND further stated the concern of illness for residents from the risk of cross-contamination was possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On April 29, 2025, at 3:23 p.m., during an observation, Resident 5 was observed lying in a geri-chair (geriatric chair - a sp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On April 29, 2025, at 3:23 p.m., during an observation, Resident 5 was observed lying in a geri-chair (geriatric chair - a specialized cushioned and reclineable chair) being assisted to her room by CNA 5 . CNA 5 was observed sniffling (drawing air through nose to keep mucus from running) with a runny nose and was not wearing a mask.
A review of Resident 5's record indicated, Resident 5 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (lung diseases that block airflow makes it difficult to breathe) and diabetes mellitus (too much sugar in the blood).
A review of Resident 5's History and Physical, dated November 25, 2024, indicated Resident 5 was dependent on supplemental oxygen.
A review of Resident 5's Minimum Data Set (MDS- assessment tool), indicated Resident 5 had a BIMS (Brief Interview for Mental Status) score of 10 (moderate cognitive impairment).
On April 29, 2025, at 3:29 p.m., during a concurrent observation and interview with CNA 5, CNA 5 was observed to be sniffling with a runny nose. CNA 5 stated she started feeling sick about 1 ½ hours ago. CNA 5 stated she did not report to her supervisor she was ill. CNA 5 stated she should have put on a mask while providing care to the residents. CNA 5 further stated she could possibly get the residents sick and that was critical for the vulnerable residents.
On April 30, 2025, at 4:01 p.m., during an interview with the Director of Staff Development (DSD), the DSD stated if staff become sick while on duty, they should notify DSD, their direct Charge Nurse (CN) or the Infection Preventionist (IP) so symptoms could be verified. The DSD stated staff would be sent home if they are sick. The DSD stated staff should not have worked sick without using a mask. The DSD also stated the risk of staff working while sick was the possibility to expose and spread infection to residents and other staff. The DSD further stated there was a high risk of vulnerable residents to further decline.
On April 30, 2025, at 4:17 p.m., during an interview with the DON, the DON stated the facility process was staff should let the IP and immediate supervisor know they were sick. The DON stated if staff was exhibiting symptoms of a runny nose and sniffling staff should have worn a mask. The DON stated if staff report they are ill with a runny nose and still worked they should wear a mask. The DON also stated symptoms should be contained to protect others. The DON further stated the concerns of staff not wearing a mask was the possibility of spreading infection or worse to others.
A review of the facility's policy and procedure titled, Employee Infection and Vaccination Status, revised August 2013, indicated, .Reportable Conditions .Employees must report the following conditions to the Infection Preventionist (or designee) .Acute Respiratory Infection (URI) or influenza .The Medical Director and Infection Preventionist will collaborate to determine the significance of any employee health condition in relation to job responsibility and the employees' restrictions regarding direct resident contact .
Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:
1. Two used diapers were found on top of resident cabinet drawer in room [ROOM NUMBER];
2. One direct care staff was observed wearing long artificial finger nails while providing care to the residents;
3. The Certified Restorative Nursing Assistant (CRNA) did not wear personal protective equipment (PPE- equipment used to protect against infection or illness) when providing care to a resident with an active of Methicillin-Resistant Staphylococcus Aureus (MRSA - a bacteria resistant to many antibiotics [medication used to treat infections]) wound infection;
4. The CRNA did not clean and disinfect (use of chemicals to reduce the number of germs or virus particles on surfaces) the Hoyer lift (mechanical device use for lifting) after resident use;
5. The CRNA did not conduct proper handwashing after providing care to a resident with active infections of MRSA of the wound; and
6. The Certified Nursing Assistant (CNA) was observed not wearing a mask during resident care while exhibiting cold symptoms.
These failures had the potential to increase the spread of pathogens (germs) and infections from staff to residents which could lead to serious illness.
Findings:
1. On April 29, 2025, at 9:38 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3, two used white diapers were found on top of the resident cabinet drawer in room [ROOM NUMBER]. LVN 3 stated used diapers should have been tossed into the trash bin and should have not been placed on top of the resident's cabinet drawer. LVN 3 further stated soiled diapers would contaminate the surface of the cabinet and would cause spread of germs and infection.
On May 1, 2025, at 2:58 p.m., an interview was conducted with the Infection Preventionist (IP). The IP stated all soiled materials such as diapers should have been placed in the trash bins. The IP stated soiled diapers would contaminate the surface and would spread infections.
On May 1, 2025, at 4:53 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she expected all nurses to follow the facility's policy and procedure for infection control program. The DON stated soiled materials such as diapers should have been discarded to prevent contamination and spread of infections.
A review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated October 2018, indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .
2. On April 29, 2025, at 10:57 a.m., an observation was conducted with the Director of Staff Development (DSD). The DSD was observed to have long artificial nails when providing care to the residents.
On April 29, 2025, at 11:35 a.m., an interview was conducted with the DSD. The DSD stated she was involved in the care of residents and I am considered as direct care staff handling residents. The DSD stated she was capable of helping residents in their care, passing food trays in residents' rooms, oral care, and helping to feed residents. The DSD stated that she had artificial nails made of acrylic, that were attached and extended to her natural fingernails (DSD's finger nails were measured to be approximately 1.8 centimeter in length from the tip of the fingers). The DSD further stated long artificial nails should have not been worn because it could harbor germs underneath the artificial nails and would spread germs and infection.
On May 1, 2025, at 2:58 p.m., an interview was conducted with the IP. The IP stated the facility's policy indicated nails must have appropriate length, and the nails should not be too long specially for direct care staff. The IP further stated if staff had long nails, these could potentially scratch the skin of the residents, which could lead to skin breakdown and cause infection.
According to the web article titled, Guideline for Hand Hygiene in Health-care Settings published by the Centers for Disease Control and Prevention (CDC - a leading national public health institute in the United States), dated 2002, iindicated, .even after careful handwashing, HCWs (health care workers) often harbor substantial numbers of potential pathogens (disease causing viruses, fungi, and bacteria) in the subungual (under the nails) spaces .HCWs who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing .
According to the web article titled, WHO (World Health Organization) Guidelines on Hand Hygiene in Health Care, published by the World Health Organization in 2009, indicated .Long, sharp fingernails, either natural or artificial, can puncture gloves easily .Each health-care facility should develop policies on the wearing of .artificial fingernails or nail polish by HCWs. These policies should take into account the risks of transmission of infection to patients .recommendations are that HCWs do not wear artificial fingernails or extenders when having direct contact with patients .
A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated, .Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents .The Infection Preventionist maintains the right to request the removal of artificial fingernails at any time if he or she determines that they present an unusual infection control risk .
3. On April 30, 2025, at 9:20 a.m., Resident 33's room was observed to have a sign by the door indicating instructions to wear appropriate PPE (gown and gloves) before entering the room. The CRNA was observed entering Resident 33's room and provided care to the resident who was in the bathroom without wearing a gown. In a concurrent interview with the CRNA, she stated she forgot to wear PPE. The CRNA further stated she should have worn PPE when she provided care to Resident 33 to prevent the spread of germs and protect the other residents from infection.
A review of Resident 33's Order Summary, indicated the following:
- .Isolation with .CONTACT precautions related to MRSA/WOUND . date ordered April 28, 2025; and
- .EBP .Enhanced Barrier Precautions due to (High contact resident care activities with colonized or infected MDRO (multidrug-resistant organisms), increased risk of MDRO acquisition due to presence of wounds or indwelling medical devices ., date ordered April 29, 2025.
On May 1, 2025, at 3:06 p.m., during an interview with the IP, the IP stated Resident 33 had a history of MDRO and had active infection of the wound and was placed on enhanced barrier precaution. The IP further stated the CRNA should have worn PPE before providing care to Resident 33 to prevent the spread of infection to other residents.
A review of the facility's policy and procedure titled, Personal Protective Equipment, dated October 2018, indicated, .Personal protective equipment appropriate to specific task requirements is available at all times .The type of PPE required for a task is based on .The type of transmission-based precaution .
A review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated June 2024, indicated, .To provide guidance and recommendations for implementing Enhanced Barrier Precautions (EBP) to include the use of glove and gown during high-contact care activities for residents .High-Contact Resident Care Activities include activities such as .Changing briefs or assisting with toileting .
4. On April 30, 2025, at 9:27 a.m., during a concurrent observation and interview with the CRNA, the CRNA was observed coming out of Resident 33's room with the Hoyer lift. The CRNA used the Hoyer lift to transfer Resident 33 to her bed. The CRNA transported the Hoyer lift into the facility hallway then parked the Hoyer lift to the corner of the facility's dining room and did not clean or disinfect the Hoyer lift. The CRNA further stated, I forgot to disinfect the Hoyer lift, and she should have cleaned and disinfected the Hoyer lift to prevent the spread of infection to other residents who will use it.
On May 1, 2025, at 3:06 p.m., during an interview with the IP, the IP stated Resident 33 was on enhanced barrier precaution for MRSA of the wound. The IP stated the CRNA should have disinfected or sanitized all medical equipment such as the Hoyer lift before and after use between residents.
A review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, indicated, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA (occupational safety and health administration) Bloodborne Pathogens Standard .
5. On April 30, 2025, at 9:35 a.m., during concurrent observation and interview with the CRNA, the CRNA was observed providing care in the bathroom to Resident 33 and did not perform hand hygiene after care. The CRNA stated, I forgot to wash my hands. The CRNA further stated she should wash her hands after providing care to the residents to prevent the spread of infection.
On May 1, 2025, at 3:06 p.m., the IP was interviewed. The IP stated, staff should wash their hands before and after providing care procedure. The IP further stated infection could spread if staff did not wash hands.
A review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated, .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide a safe, functional and comfortable environment, when the lint trap of dryer 3 was observed damaged and the lint trap ...
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Based on observation, interview, and record review, the facility failed to provide a safe, functional and comfortable environment, when the lint trap of dryer 3 was observed damaged and the lint trap was not cleaned.
This failure to maintain a functional environment had the potential to compromise resident safety.
Findings:
On May 2, 2025, at 9:24 a.m., during a concurrent observation and interview with the Laundry Staff (LS). The lint trap located at the bottom of dryer 3 was observed damaged with an opening at the corner towards the middle of the edge of the screen and filled with thick, soft lint that was collected from the clothes. The LS stated lint trap in dryer 3 was damaged and laundry staff still used it. The LS stated the lint trap was not collected since yesterday and was not cleaned by the laundry staff. The LS further stated the lint trap should have been cleaned and the damaged lint trap of dryer number 3 should have not been used because it could result to fire.
A review of record titled, DRYER'S LINT TRAP CLEANING LOG, indicated the lint trap was not cleaned at 12 noon of May 1, 2025 to May 2, 2025 at 8 a.m.
In addition, a review of document titled, DAILY STAND UP/CLINICAL MEETING, dated April 28, 2025, indicated the dryer 3 was identified with safety concerns.
On May 2, 2025, at 9:45 a.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated the lint trap of dryer 3 was torn with the screen was ripped off. The MS stated the lint trap 3 should have been fixed, replaced and should have been cleaned per facility policy to prevent hazards such as fire. The MS further stated, It should have been repaired or replaced as soon as possible.
On May 2, 2025, at 9:49 a.m., an interview was conducted with the Administrator (ADM). The ADM stated he expected the maintenance staff to repair any damaged equipment and make sure they worked properly. The ADM further stated the damaged equipment should have been replaced or repaired to provide a safe and functional environment for the residents.
A review of the facility's policy and procedure titled, Maintenance Service, dated December 2009, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of maintenance personnel include .Maintaining the building in a compliance with current federal, state, and local laws, regulations, and guidelines .Maintaining the building in good repair and free from hazards .
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safeguard residents ' privacy and confidentiality, fo...
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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 safeguard residents ' privacy and confidentiality, for two of two residents (Residents 1 and 2), when the residents were filmed by a staff member and posted on to social media without the residents or resident representative's consent.
The deficient practice had the potential to affect the resident psychosocial well being.
Findings:
On April 1, 2025, at 9 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding resident's rights.
1. On April 1, 2025, at 11:05 a.m., a concurrent observation and interview with Resident 1 was conducted. Resident 1 was observed alert and was sitting in a wheelchair in the activity room. Resident 1 stated she did not dance anymore and pointed to the wheelchair. Resident 1 further stated she had bad memory and did not remember dancing with the Social Service Director (SSD) or gave permission to post her video on social media.
On April 1, 2025, a review of Resident 1's record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included major depressive disease(a persistent feeling of hopelessness, sadness and loss of interest), dementia (a mental disease that interferes with daily functioning) and anxiety (excessive worry, fear or nervousness).
A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated January 31, 2025, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 04 (severe cognitive impairment).
Further review of Resident 1's record indicated there was no documented evidence Resident 1 or Resident 1's representative gave permission for the facility staff to get a video of the resident and post a video on social media.
2. On April 1, 2025, at 11:15 a.m., a concurrent observation and interview with Resident 2 was conducted. Resident 2 was observed alert and sitting in a wheelchair singing with the music videos in the activity room. Resident 2 further stated he did not remember dancing with the SSD or gave permission for the SSD to post the video.
On April 1, 2025, a review of Resident 2's record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia, anxiety, and malignant neoplasm of the prostate (cancer of the gland below the urinary bladder).
A review of Resident 2's History and Physical, dated January 20, 2025, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 2's MDS, dated February 12, 2025, indicated a BIMS score of 10 (moderate cognitive impairment).
Further review of Resident 2's record indicated there was no documented evidence Resident 2 or Resident 2's representative gave permission for the facility staff to get a video of the resident and post a video on social media.
On April 1, 2025, at 11:25 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated she had a close relationship with both Residents 1 and 2 and often joined the sing along in the activity room. The SSD stated Residents 1 and 2 agreed when asked if the SSD could make a video of them and also understood the residents had short term memory loss. The SSD stated she had not thought of requesting permission from the resident ' s representative to make or post the video on social media.
On April 1, 2025, at 2:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the residents ' representatives were not notified before the SSD made and posted the video on social media. The DON stated the resident's representative should have been asked permission to film and post a video of the residents on social media. The DON further stated the residents ' privacy and rights had been violated by not seeking permission.
A review of the facility ' s policy and procedure titled, Resident Rights, dated December 2016, indicated, .Employees shall treat all residents with .respect .Federal and state laws guarantee certain basic rights .these rights include .privacy and confidentiality .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oral care after meals was provided, 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 oral care after meals was provided, for one of three sampled residents (Resident 3).
This failure had the potential to cause serious health issues and could affect the residents psychosocial well being.
Findings:
On April 1, 2025, at 9 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care.
On April 1, 2025, a review of Resident 3's record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included major depressive disease (a persistent feeling of hopelessness, sadness and loss of interest), dementia (a mental disease that interferes with daily functioning), encephalopathy (condition where brain function is impaired), sepsis (infection damages the body ' s tissues and organ) and muscle wasting.
A review of Resident 3's History and Physical, dated March 2, 2025, indicated the resident did not have the capacity to understand and make decisions.
A review of Resident 3's Minimum Data Set (MDS - ar resident assessment tool), dated March 7, 2025, indicated the following:
- Resident 3 had a Brief Interview for Mental Status (BIMS - a cognitive assessment) score of 06 (severe cognitive impairment);
- Resident 3 required totally dependent with oral hygiene; and
- Resident 3 would hold food in her cheeks after a meal, and had difficulty swallowing food.
A review of Resident 3's Physician Orders, dated March 1, 2025, indicated Resident 3 had an appointment to a pain clinic on March 27, 2025, at 9:30 a.m.
A review of Resident 3's care plan, dated March 6, 2025, indicated, .ADL (Activities of Daily Living) functioning with self-care deficit .requires total assistance in personal hygiene .dental/oral care PRN (as needed) .:
On April 1, 2025, at 12:10 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated the CNAs (Certified Nursing Assistants) do oral care on residents with feeding issues, immediately after meals and before bed.
On April 1, 2025, at 12:20 p.m., an interview was conducted with CNA 2. CNA 2 stated oral care should be provided to the resident after every meal and before bed.
On April 1, 2025, at 1:55 p.m., an interview was conducted with CNA 3. CNA 3 stated the CNA should be observant while feeding residents, need to feed the residents very slowly, feel for plumpness in their cheeks and ensure the residents were able to tolerate the thickness of the fluids. CNA 3 stated oral care must be provided to the residents after each meal and before bed. CNA 3 stated they use sponges on stick for oral care, dips it in water and clean all round cheeks, lips, and teeth to remove anything that could have been stucked.
On April 1, 2025, at 2:25 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 3's family member had called the DON to say the resident was being transferred to the acute care facility, as green beans and egg had been found in her mouth at the physician ' s office during the appointment. The DON stated the resident should have had oral care after each meal to assure no food remnants remained.
On April 2, 2025, at 10:05 a.m., a phone interview was conducted with CNA 1. CNA 1 stated she fed Resident 3 scrambled eggs and milk for breakfast on March 27, 2025. CNA 1 stated she was informed Resident 3 was about to get picked up for a scheduled physician visit that day. CNA 1 stated she and another CNA, took the resident to her room to clean her and change her clothes, into a pair of black sweatpants and a sweater. CNA 1 stated she did not see any coughing or choking with swallowing her milk or eggs or any sign when her teeth were cleaned prior to transport.
On April 2, 2025, at 11:11 a.m., an interview and concurrent document review was conducted with the Nutritional Service Director (NSD). The NSD reviewed menu from March 26 and 27, 2025 and the [NAME] ' s spreadsheet. The NSD stated Resident 3 received dinner March 26, 2025, which included a soft diet with green beans soft, cheese ravioli garlic bread soft , soft ripe and no skin. The NSD stated for breakfast on March 27, 2025, included egg soft fried, oats softened in milk, and soft hash browns. The NSD stated Resident 3 was alert with a 1:1 feeding assistant. The NSD stated Resident 3 did have pocketing of food noted in admission notes.
A review of the facility ' s policy and procedure titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, indicated, .residents will be provided with care .residents who are unable to carry out the activities of daily living independently will receive the service .to maintain good .oral hygiene .oral care .appropriate care and services will be provided for residents who are unable to carry out ADL ' s independently .including .oral hygiene .
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate staff assistance was provided during transfer ac...
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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 appropriate staff assistance was provided during transfer according to the plan of care, for one of five residents (Resident A).
This failure resulted to Resident A to experience physical pain and had the potential for the residents to sustain injury.
Findings:
On December 17, 2024, at 9:45 a.m., an unannounced visit was conducted at the facility to investigate a complaint of quality of care and a facility reported allegation of abuse.
On December 17, 2024, at 11:40 a.m., an interview and concurrent record review was conducted with the Rehabilitation Program Manager (RPM). The RPM stated Resident A had weakness and flaccid (no strength) on the left side. The RPM stated Resident A required moderate to maximum assistance with transfers, and the recommendation was to have two person assist with all transfers, and a mechanical lift being the safest option. The RPM stated Resident A had left sided pain since her stroke, her left arm and leg were sensitive. The RPM reviewed Resident A ' s therapy notes and stated if Resident A complained of right shoulder pain and left hip pain, she would have been turned on her left side, if the right arm was pulled over, by turning the resident onto her weakened side, this could have cause her the discomfort she complained about.
On December 17, 2024, at 1:20 p.m., an interview was conducted with Resident A. Resident A stated she was still having right shoulder pain and pain was being managed. Resident A stated CNA 1 came inside Resident A's room to give the resident a shower. Resident A stated she told CNA 1 she was going to need more than one person to transfer her to the shower chair. Resident 1 stated CNA 1 grabbed her right arm, and left leg and dragged her to the edge of the bed, she began to fall out of the bed, as she was falling. Resident A stated CNA 1 left her to get two staff members to help. Resident A stated a male CNA helped CNA 1, and finally got her back to bed. Resident A stated CNA 1 should have arranged help before moving her, and she did not use the mechanical lift. Resident A stated she had leg pain after the incident, and CNA 1 kept pushing on her hip to get her from the bed to the chair. Resident A stated CNA 1should have moved her legs off the bed first, then pivot her before trying to stand her up.
On December 17, 2024, at 3:30 p.m., Resident A ' s medical record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (a blood vessel to the brain is blocked), hemiplegia (muscle weakness or partial paralysis on one side of the body) and hemiparesis (muscle weakness or paralysis affecting one side of the body the arm, leg, and facial muscles) left non-dominant side.
A review of Resident A's care plan, revised on July 16, 2024, indicated, .Resident requires assistance from staff for bed mobility related to weakness and decreased strength. Unable to turn and reposition self in bed without physical assistance from staff .
A review of Resident A ' s Minimal Data Set (MDS- a federally mandated resident assessment tool), dated November 11, 2024, indicated, .Functional Abilities-sit to stand, chair/bed to chair transfer, and tub/shower transfer all .Dependent-helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity .
A review of Resident A ' s Progress Note, dated December 8, 2024, at 4 p.m., indicated, .patient reported to attending .she is experiencing pain over rt. (right) shoulder area .also reported pain over left hip area .per patient ' s account the pain started after staff member moved her on the edge of the bed grabbing her rt (right) shoulder and moving her left lower extremity (leg) forcibly over the edge of the bed on 12-6-24 (December 6, 2024) at night time .
On December 17, 2024, at 4:29 p.m., an interview was conducted with the DON. The DON stated according to CNA 1, she was trying to get Resident A from the bed to the shower chair, was unable to get Resident A up, and provided bed bath instead. The DON stated the police spoke with all three CNAs on shift the night of the incident on December 6, 2024, the CNAs told the police CNA 1 did not ask for help with Resident A during the evening shift, and CNA 1 stated she did not use the mechanical lift for Resident A.
On December 18, 2024, at 8:50 a.m., an interview was conducted with the RN. The RN stated it is best to get two persons to assist for safety when transferring a resident. The DSD stated it is always best to consult the chart and/or the therapy department for recommendations if a resident ' s transfer ability is not known. The RN stated Resident A needed two person assistance to get up.
On December 2024, at 10:25 a.m., an interview was conducted with the Director of Staff Development (DSD). The DSD stated she encourages the CNAs to walk room to room and give report, if a staff member does not know how to transfer a resident, they should ask a nurse or another CNA who has had the resident before, residents do not always know what their true ability is. The DSD stated she requires the nursing staff to have a partner when using the mechanical lift in transferring the resident for safety.
On December 18, 2024, at 11:40 a.m., an interview was conducted with CNA 2. CNA 2 stated she was working the PM shift (3 p.m. to 11 p.m.) on December 6, 2024, and she did not have Resident A that evening. CNA 2 stated CNA 1 was assigned to Resident A, and CNA 1 did not ask for help to move or transfer Resident A. CNA 2 stated she has been Resident A ' s CNA before and she always gets someone to assist her if she needs to move or transfer the resident, she does not think Resident A is able to stand very well, and when moving Resident A she uses the mechanical lift for the most part. CNA 2 stated she is small and because of her size she was not able to move Resident A without assistance. CNA 2 stated Resident A had a lot of weakness on her one side, and for the safety of the resident two people are needed.
A review of the facility ' s policy titled Activities of Daily Living (ADLs), Supporting, dated March 2018, indicated .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .appropriate support and assistance with .Mobility (transfer and ambulation .A resident ' s ability to perform ADLs will be measured using clinical tools, including the MDS .Interventions to improve or minimize a resident ' s functional abilities will be in accordance with the resident ' s assessed needs, preference, stated goals and recognized standards of practice .
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 ensure one of three residents' (Resident 1) medication (Hydralazine-...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of three residents' (Resident 1) medication (Hydralazine-used to treat high blood pressure) was administered in accordance with the physician order. The medication was not held for systolic blood pressure (SBP-force of blood pumped out of the heart) below 110 per order.
This failure had the potential for Resident 1 to have low blood pressure requiring medical attention.
Findings:
On November 18, 2024, at 9:15 a.m., an unannounced visit was conducted to investigate a complaint on quality-of-care issue.
On November 18, 2024, Resident 1 ' s record was reviewed. The record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included fusion of spine in lumbar (lower back) region, spinal stenosis (spaces inside the bones of the spine get too small), end stage renal disease (permanent condition that occurs when the kidneys stop functioning), dependence on renal dialysis (treatment that removes waste and excess fluid from the blood when kidneys are no longer functioning) and hypertensive heart disease (group of heart conditions that develop over time due to high blood pressure).
A review of Resident 1 ' s Physician Orders dated October 10, 2024, indicated Hydralazine tablet, give one tablet by mouth three times a day for hypertension (condition in which the force of blood against the artery walls is too high), hold if SBP below 110 and heart rate below 60.
A review of Resident 1 ' s Electronic Medication Administration Record (EMAR) indicated Hydralazine was administered on October 15, 2024, with a blood pressure (BP) of 101/78.
On November 18, 2024, at 12:46 p.m., during an interview, Licensed Vocational Nurse (LVN)1 stated before administering blood pressure medications, the licensed nurse had to check the blood pressure of the resident. LVN 1 stated it was very important to follow parameters ordered by the physician to prevent any harm to the resident.
On November 18, 2024, at 1:11 p.m., during an interview, LVN 2 stated the nurse had to check the BP before administering BP medication to a resident, especially if they had parameters ordered. LVN 2 stated it was important to follow orders for resident ' s safety.
On November 18, 2024, at 1:30 p.m., during an interview, the Director of Nursing (DON) stated the facility policy indicated a medication should be administered as ordered. The DON stated not following orders for BP medication, resident could be at risk of having low blood pressure and could become a safety issue.
A review of the facility policy and procedure titled Administering Medications revision date April 2019 indicated, .Medications are administered in accordance with prescriber orders, including any required time frame .Factors that are considered include: Enhancing optimal therapeutic effect of the medication .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .The following information is checked/verified for each resident prior to administering medications: .vital signs, if necessary .
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
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 transfer was appropriate and necessary for one out of th...
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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 transfer was appropriate and necessary for one out of three sampled residents (Resident 1), when Resident 1 was transferred to the general acute care hospital (GACH) without documented justification on how needs could not be met at the facility.
This failure has the potential to negatively affect resident's needs due to unnecessary transfer.
Findings:
A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including fracture (a break or a crack in a bone) of unspecified parts of lumbosacral spine (lower part of the spine) and pelvis (the bones between the lower abdomen and upper thighs).
A review of Resident 1's Notice of Transfer/ Discharge Form, dated, September 6, 2024, indicated, .The transfer or discharge is necessary for your welfare and your needs cannot be met in the facility .
A review of Resident 1 ' s Interact Transfer Form V5, dated September 6, 2024, indicated, .transfer to hospital per MD order for proper placement .
A review of progress notes did not indicate any documented evidence from the resident's physician of the rationale on why Resident 1's need could not be met at the facility, and the rationale on why resident was transferred to the hospital for proper placement.
A review of the progress notes titled Interdisciplinary Team (IDT) Notes, dated September 6, 2024, indicated, .Resident is awake and alert, verbally responsive and able to make needs known .Psychotropic regimen of Fluoxetine continued as ordered; no adverse reactions or complications to note. Resident was admitted with pelvic surgical incision, right hip surgical site and skin discoloration to left torso and left lateral knee and left ankle monitor .
On September 10, 2024, at 12:10 p.m., during an interview with the Director of Nursing (DON), the DON stated the resident mentioned to the Administrator that he felt not mentally stable, and he needed help. The DON stated the resident was admitted with pelvic fracture and rib fractures but was transferred to the GACH due to the resident verbalizing he needed help.
On September 10,2024, at 12:43 p.m., during an interview, the Administrator (Admin) stated Resident 1 informed him that he had some mental health things that he was dealing with and needed help. The Admin stated the physician gave an order to transfer the resident to the GACH.
A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated, dated October 2022, indicated, .Once admitted to the facility, residents have the right to remain in the facility, and not be transferred or discharged unless .the transfer or discharge is necessary for the resident's welfare and the resident's need cannot be met in this facility .the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility .Facility -initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation .Documentation of Facility-Initiated Transfer or Discharge. 1. When the resident is transferred or discharged from the facility, the following information is documented in the medical record: a. The basis for the transfer or discharge; (1) If the resident is being transferred or discharged because his or her needs cannot be met at the facility, documentation will include: a) the specific resident needs that cannot be met; b.) this facility's attempt to meet those needs; and c.) the receiving facility's service (s) that are available to meet those needs .Should the resident be transferred or discharged for nay of the following reasons, the basis for the transfer or discharge is documented in the resident's clinical record by the resident's attending physician .the transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility .
Aug 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a comfortable environment, for five of 13 samp...
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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 a comfortable environment, for five of 13 sampled residents (Residents 4, 5, 6, 7, and 8) when the airconditioning (AC) unit was not working and the resident's room temperatures exceeded 81degrees Fahrenheit. In addition, the facility failed to report an unusual occurrence of disruption of services when the facility's airconditioning unit was not working.
These failures resulted in discomfort for Residents 4, 5, 6, 7, and 8 and had the potential to for the residents to experience dehydration (loss of body fluids), heat stress (condition where the body is under stress from overheating), and heat stroke (when the body cannot control its temperature);
Findings:
On August 6, 2024, at 9:55 a.m., during the initial tour, standing narrow fans were moving from side to side both in the hallways and in the resident's rooms. Large and small stationary fans were observed placed in the resident rooms and in the hallways.
On August 6, 2024, at 10:02 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the facility has an HVAC (outdoor air conditioning unit that houses a compressor [supplies clean air] that pumps refrigerant [chemical that absorbs heat and transfers it to cool air] to an evaporator system [removes heat from the area] for cooling the facility), which she was not very familiar with how it works. The DON stated that some rooms were more affected than others.
On August 6, 2024, at 10:48 a.m. an interview was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 stated rooms [ROOM NUMBERS] have been hot lately.
On August 6, 2024, at 11:13 a.m., an interview was conducted with the Maintenance Director (MD). The MD stated they were waiting for fuses on some air conditioning units to be fixed, the rooms most affected were rooms 15, 17, 22, and 30. The MD stated he had not been tracking temperatures in the resident rooms while the AC was not functioning.
On August 6, 2024, at 11:45 a.m., an interview was conducted with Resident 7. Resident 7 stated the room would get hot and they have a fan on the floor but it doesn't cool off the room enough, she would stay in the T.V. (television) room or activities due to her room getting so hot. Resident 7 stated there were fans, but with the oxygen concentrators it would stay hot.
A review of Resident 7's admission Record - (clinical record with demographic information), indicated Resident 7 was admitted to the facility on [DATE], with a diagnosis of peripheral vascular disease (narrowed blood vessels reduce blood follow to limbs), cellulitis of left lower limb (bacterial skin infection), malignant neoplasm of ovary (cancer of ovary).
On August 6, 2024, at 11:49 a.m., an interview was conducted with Resident 6. Resident 6 stated she would stay in the T.V. room or dining room due her room being hot.
A review of Resident 6's admission Record, indicated, Resident 6 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD -lung disease making it difficult to breathe), malignant neoplasm of the bronchus/lung (cancer of the lung), and respiratory failure (not enough oxygen in you body).
On August 6, 2024, at 12 p.m., an interview was conducted with Resident 8. Resident 8 stated, my room gets the morning and afternoon sun, it does get hot, the fan helps, but it would still be warm.
A review of Resident 8's admission Record, indicated Resident 8 was admitted to the facility on [DATE], with a diagnosis of fractures of ribs (cracks to the rib cage), heart failure (the heart does not pump blood as well as it should), and kidney failure (lose the ability to remove waste).
On August 6, 2024, at 12:14 p.m., an interview was conducted with the DON. The DON stated she had requested a temperature gun (a non-contact device that measures the temperature of an object) from the MD. The MD cannot find the facility temperature gun.
On August 6, 2024, at 12:22 p.m., an interview was conducted with the DON. The DON was unable to answer when asked how were they checking the temperatures in the hallways and in the resident's rooms when the wall thermosats were not working and the facility did not have a temperature gun.
On August 6, 2024, at 1:15 p.m., an interview was conducted with the Administrator (ADMIN). The ADMIN stated he heard there was a complaint about the increased heat in a resident ' s room. The ADMIN stated the AC units supplying the four rooms 15, 17, 22, and 30 needed fuses. The ADMIN was asked if he reported the issue with the air conditioner to CDPH, the ADMIN stated, I probably could have done that.
On August 6, 2024, at 2:00 p.m., an interview was conducted with the DON, she was asked if the issue with the air conditioning should be reported to CDPH. The DON stated, I don't know, the administrator deals with the air conditioning.
On August 6, 2024, at 3:20 p.m., a concurrent observation and interview was conducted with the DON. rooms [ROOM NUMBER] had portable air conditioners placed in the rooms with temperature readings as follows:
- room [ROOM NUMBER] was 79 degrees Fahrenheit (F - unit of measurement);
- room [ROOM NUMBER] was 77 degrees Fahrenheit; and
- room [ROOM NUMBER] did not have portable air conditioner turned on at this time with room temperature at 80.3 degrees F.
On August 6, 2024, at 3:20 p.m., the following rooms were observed with the following temperatures conducted with the DON.
- room [ROOM NUMBER]; 85.4 degrees F; and
- room [ROOM NUMBER]; 85.5 degrees F.
A review of the policy and procedure titled, Homelike Environment, revised February 2021 indicated, .and safe temperatures (71-degree F - 81-degree F) .
A review of the undated policy and procedure titled, Extreme Weather - Heat or Cold, indicated, .with local emergency management and state survey agencies regarding nursing home situation status, critical issues, and resource requests .distribute appropriate comfort equipment throughout the nursing home (e.g., portable fans and blankets), as needed .provide increased hydration and implement cooling or warming measures as indicated .
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 two (Resident A and Resident B) of three sampled residents w...
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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 two (Resident A and Resident B) of three sampled residents was assessed properly for bladder and bowel continence.
This failure resulted in Resident A and Resident B not being identified, assessed and provided appropriate treatment and services to improve or restore as much bladder and bowel function as possible.
Findings:
On July 5, 2024, at 12:30 p.m., an unannounced visit to the facility was conducted to investigate a complaint for quality of care.
1. On July 5, 2024, a review of Resident A's medical record indicated Resident A was admitted to the facility on [DATE], with diagnoses which included intracerebral hemorrhage (bleeding inside the brain) and epileptic syndrome (a group of symptoms causing seizures).
Resident A's Minimum Data Set (MDS - a resident assessment tool), dated June 2, 2024, indicated Resident A was always continent (ability to control) for urinary and bowel function continence.
Resident A's Documentation Survey Report, dated June 2024, indicated Resident a had episodes of bladder incontinence and was placed on adult brief from June 2 to 7, 2024.
Resident A's eINTERACT Transfer Form, dated June 8, 2024, at 1:05 p.m., indicated .bladder function: incontinent .
Further review of Resident A's medical record indicated there was no documented evidence an assessment was initiated when there was a change in bladder function from being continent to episodes of incontinence. There was no documented evidence a plan of care was developed to address bladder incontinence.
On July 8, 2024, at 1:10 p.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident A was incontinent in bladder.
On July 8, 2024, t 1:30 p.m., CNA 2 was interviewed. CNA 2 stated Resident A was mostly incontinent and wore an adult brief.
On July 8, 2024, at 1:50 p.m., a concurrent interview and record review was conducted with the MDS coordinator. The MDS Coordinator stated residents were to be monitored for bowel and bladder function for three days upon admission. He stated he would then appropriate bladder and bowel program were to be developed for the resident's bladder and bowel function review. He stated the bladder and bowel program would be re-evaluated after 14 days. The MDS stated Resident A was continent of bladder and bowel and went to the restroom and did not need bowel or bladder program upon admission. The MDS stated Resident A had bladder incontinence episodes in June, and a change of condition should have been initiated and be assessed for another three days and place Resident A in a bladder program. He stated a plan of care to address periods of incontinence should have been developed to address periods of incontinence to regain continent bladder function
2. On July 5, 2024, at 3:45 p.m., an interview was conducted with Resident B. Resident B stated she was incontinent of bladder and bowel and wears a brief at all times. Resident B stated she does not get out of bed to use the toilet; her brief was being changed when she is soiled.
On July 5, 2024, a review of Resident B's medical record indicated Resident B was admitted to the facility on [DATE], with diagnoses which included cystitis (infection of the lower urinary tract and the bladder) and sepsis (infection in the blood).
Resident B's Order Summary Report, dated May 31, 2024, indicated to check and change brief every two hours x 14 days, then re-evaluate.
Resident B's MDS, dated June 2, 2024, Resident B was frequently incontinent with bowel and bladder.
Resident B's Daily Skilled Documentation, dated June 30 2024 and July 1 through July 4, 2024, indicated .pt (patient) incontinent of bowel and bladder .
There was no documented evidence a care plan to address bowel and bladder incontinence for Resident B.
On July 8, 2024, at 1:50 p.m., a concurrent interview and record review was conducted with the MDS coordinator. The MDS Coordinator stated Resident B should have been placed on a bowel and bladder program for 14 days following her 4th day of incontinence, the nurses should have developed a care plan with interventions to support Resident B. The MDS stated no care plan was initiated, and no interventions were put in place to help Resident B re-gain some bowel and bladder control.
A review of the facility's policy titled Change in a Resident's Condition or Status, dated May 2017, indicated, .A 'significant change' of condition requires interdisciplinary review and/or revision to the care plan .the nurse will make detailed observations and gather relevant and pertinent information for the .SBAR Communication Form .if a significant change in the resident's physical condition occurs, a comprehensive assessment of the resident's condition will be conducted .any noted changes will be reported to the director of nursing services to ensure information is changed in the resident's medical record .
A review of the facility's policy titled Bowel and Bladder Protocol, dated April 5, 2022, indicated, .to improve and/or restore the resident's bowel and bladder function to the extent possible and prevent possible urinary tract infections .Residents who exhibit an improvement or decline in bowel and bladder function will be assessed .upon resident's admission to the facility, start 72-hour bowel and bladder observation .CNA will document in the 72-hour bowel and bladder observation diary .Licensed Nurses will collect and review the data from the 72-hour bowel and bladder observation diary and complete the Bowel and Bladder Program Screen-V2 Form . based on the . score, the licensed nurse or IDT (interdisciplinary team) will determine resident's ability to participate in .bowel and bladder incontinence behavior program .
A review of the facility's in-service training record, dated December 29, 2023, indicated .Topic of Inservice COC (change in condition) documentation .include a progress note at the beginning of your shift when documenting COC's .
May 2024
5 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
Based on interview, record review, and facility policy review, the facility failed to provide advance directive information to 1 (Resident #57) of 5 residents reviewed for advance directives.
Findings...
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Based on interview, record review, and facility policy review, the facility failed to provide advance directive information to 1 (Resident #57) of 5 residents reviewed for advance directives.
Findings included:
A facility policy titled, Advance Directives, revised in 12/2016, indicated, Advance Directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law.
An admission Record revealed the facility admitted Resident #57 on 04/20/2024.
Resident #57's Physician Orders for Life-Sustaining Treatment (POLST), prepared on 04/20/2024, revealed the section addressing advance directives was not completed.
Resident #57's Consents form, dated 04/20/2024, revealed the Advance Directives section was incomplete. This section of the form was not signed to indicate the facility had offered the resident information about advance directives or the facility's policy on advance directives and did not indicate if the resident had executed an advance directive.
During an interview on 05/07/2024 at 12:11 PM, the Director of Nursing (DON) stated she was not able to locate an advance directive, acknowledgement, or documentation of discussions regarding advance directives with Resident #57. The DON stated the process of determining whether the resident had an advance directive and providing information on advance directives should have started at the time of the resident's admission to the facility.
During an interview on 05/08/2024 at 2:44 PM, the Social Services Director (SSD) stated residents were asked during their care conference if they had an advance directive or if they would like information about advance directives. She stated this discussion was documented in a care conference note; however, the SSD said she was on vacation when Resident #57 was admitted , so the Social Services Assistant (SSA) participated in the care conference meeting. The SSD reviewed Resident #57's care conference meeting notes and stated that a discussion about advance directives was not documented, but it should have been.
During an interview on 05/09/2024 at 8:00 AM, the DON stated social services should provide information to residents regarding advance directives. She stated she was not sure why Resident #57 was not provided advance directive information.
During an interview on 05/09/2024 at 8:20 AM, the Administrator stated that usually social services discussed advance directives with the residents during the care conference and documented the conversation in the care conference note.
During an interview on 05/09/2024 at 8:52 AM, the SSA stated she helped the SSD, and they both offered advance directives to residents. The SSA said if a resident wanted to execute an advance directive, they reached out to the Ombudsman to come in and complete the form. She stated she documented conversations about advance directives in the care conference notes but stated recently they had not been documenting it, but she did not know why. She stated she did remember the care conference with Resident #57 but could not say if advance directives were discussed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility policy review, the facility failed to ensure privacy was provided during resident care for 1 (Resident #46) 1 resident reviewed for privacy.
Findings inc...
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Based on observation, interview, and facility policy review, the facility failed to ensure privacy was provided during resident care for 1 (Resident #46) 1 resident reviewed for privacy.
Findings included:
A facility policy titled, Dignity, revised in 02/2021, indicated, 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
An admission Record revealed the facility admitted Resident #46 on 02/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of quadriplegia and muscle wasting and atrophy.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had a functional limitation in range of motion on both sides of their upper and lower extremities, was dependent on staff for toileting hygiene, and was always incontinent of urine and bowel.
Resident #46's comprehensive care plan revealed a Focus area, initiated on 03/01/2024, that indicated the resident demonstrated decreased strength and balance for safe bed mobility, transfers, and gait. Another Focus area, initiated on 03/01/2024, indicated the resident was at risk for skin breakdown and included an intervention dated 03/01/2024 that directed staff to assist with toileting needs if needed.
During an observation on 05/06/2024 beginning at 12:01 PM, Certified Nurse Assistant (CNA) #4 and CNA #3 transferred Resident #46 from a geriatric chair to their bed using a mechanical lift. There was no privacy curtain in the room, the window blinds were open, and Resident #46's roommate was seated on their bed watching the transfer. At 12:13 PM, after Resident #46 asked to be changed because of an incontinent episode, CNA #4 gathered the necessary supplies, pulled Resident #46's gown up to the top of their brief, and unfastened both sides of the resident's brief while their roommate was watching. After initiating incontinence care, CNA #4 informed the resident they would need to wait to finish the care until their privacy curtain was hung back up, so that they could have privacy during the care.
During an interview on 05/07/2024 at 2:59 PM, CNA #4 stated staff pulled the privacy curtain completely around the resident during resident care to ensure privacy but said they did not do that on 05/06/2024, because Resident #46's privacy curtain was removed from their room for cleaning.
During an interview on 05/08/2024 at 10:03 AM, CNA #3 stated staff pulled the privacy curtain and closed the blinds during resident care. CNA #3 stated Resident #46's privacy curtains were in laundry being cleaned. She indicated they should not have transferred the resident to their bed for care until they could provide the resident with privacy.
During an interview on 05/08/2024 at 11:11 AM, the Director of Nursing (DON) said she expected residents to be provided privacy during a mechanical lift transfer. She also said the aides should have come to one of the administrative staff to intervene and should not have proceeded until they could ensure the resident's privacy during care.
During an interview on 05/09/2024 at 8:25 AM, the Administrator stated that he expected staff to provide residents with privacy during any resident care tasks.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was developed to address smoking for 1 (Resident #32) of 1 sampled resident review...
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Based on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was developed to address smoking for 1 (Resident #32) of 1 sampled resident reviewed for smoking and failed to ensure the care plan reflected the level of assistance required with activities of daily living (ADLs) for 1 (Resident #46) of 2 sampled residents reviewed for ADLs.
Findings included:
An undated facility policy titled, Goals and Objectives, Care Plans, indicated, 3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and: a. Are resident oriented; b. Are behaviorally stated; c. Are measurable; and d. Contain timetables to meet the resident's needs in accordance with the comprehensive assessment. 4. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.
1. An admission Record indicated the facility admitted Resident #32 on 04/22/2024.
Resident #32's Smoking-Safety Screen, dated 04/22/2024, indicated the resident was a smoker or user of tobacco products two to five times per day. Per the Smoking- Safety Screen, the resident could light their own cigarettes and required a smoking apron, a cigarette holder, supervision, and one-on-one assistance.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2024, revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident used tobacco at the time of the assessment.
Resident #32's comprehensive care plan revealed it did not address the resident's smoking status or the assessed needs of the resident related to smoking.
Observation on 05/07/2024 at 8:45 AM revealed Resident #32 was outside smoking in the designated smoking area with staff supervision .
During an interview on 05/08/2024 at 1:44 PM, the MDS Coordinator stated if a resident smoked, they needed a care plan that indicated what type of supervision they required, what adaptive equipment was needed, and other safety interventions such as putting cigarettes out in the proper disposal areas.
During an interview on 05/08/2024 at 2:55 PM, Licensed Vocational Nurse (LVN) #6 stated a resident that smoked should have a care plan that addressed smoking supervision and any needed equipment.
During an interview on 05/09/2024 at 8:00 AM, the Director of Nursing (DON) stated if a resident smoked, they should have a care plan that reflected safety and cessation interventions and any adaptive equipment the resident required.
During an interview on 05/09/2024 at 8:20 AM, the Administrator stated if a resident smoked, their care plan should address smoking, including information on safety, the resident's compliance, and any needed supervision.
2. An admission Record revealed the facility admitted Resident #46 on 02/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of quadriplegia and muscle wasting and atrophy.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had a functional limitation in range of motion on both sides of their upper and lower extremities and was dependent on staff for all ADLs.
Resident #46's comprehensive care plan revealed a Focus area, initiated on 12/26/2023, that indicated the resident had impaired ADL function and required assistance with ADLs; however, the care plan did not address the level of assistance the resident required. A Focus area, initiated on 03/01/2024, indicated the resident demonstrated decreased strength and balance for safe bed mobility, transfers, and gait. Another Focus area, initiated on 03/01/2024, indicated the resident was at risk for skin breakdown and included an intervention dated 03/01/2024 that directed staff to assist with toileting needs if needed. Resident #46' care plan did not specify the level of assistance the resident required from staff with the performance of ADLs.
During an interview on 05/08/2024 at 2:06 PM, the MDS Coordinator stated it was important for care plans to address ADLs, so staff know how to care for the residents. After reviewing Resident #46's care plan, the MDS Coordinator confirmed the resident's care plan did not address the level of assistance they required with ADLs.
During an interview on 05/09/2024 at 8:02 AM, the Director of Nursing (DON) stated if a resident was dependent on staff for their ADLs, the level of assistance required with their ADLs should be reflected on their care plan, so staff knew how to care for them. The DON confirmed Resident #46 was dependent on staff for all ADLs and indicated the resident's care plan should address the level of assistance the resident required.
During an interview on 05/09/2024 at 8:23 AM, the Administrator stated if a resident was dependent on staff for ADLs, the level of assistance required with ADLs should be reflected on their care plan. He said care plans should reflect how to take care of the residents. The Administrator said the importance of care planning was so that staff knew what level of assistance and care the residents needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review, and facility policy review, the facility failed to ensure staff provided assistance with activities of daily living (ADLs) for 2 (Resident #44 and Resident #46) of...
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Based on observation, record review, and facility policy review, the facility failed to ensure staff provided assistance with activities of daily living (ADLs) for 2 (Resident #44 and Resident #46) of 2 residents reviewed for ADLs.
Findings included:
A facility policy titled, Activities of Daily Living (ADLs), Supporting, revised in 03/2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The policy further indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).
1. An admission Record revealed the facility admitted Resident #44 on 12/26/2023. According to the admission Record, the resident had a medical history that included diagnoses of transient cerebral ischemic attack (a brief stroke-like attack) and muscle wasting and atrophy.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2024, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for personal hygiene, including combing their hair.
Resident #44's comprehensive care plan included a Focus area, initiated on 12/26/2023, that indicated the resident had impaired ADL function and required assistance with ADLs.
On 05/06/2024 at 10:02 AM, Resident # 44 was observed lying in bed with their hair very disheveled.
On 05/07/2024 at 9:12 AM, Resident #44 was observed lying in bed and their hair was again disheveled.
During an interview on 05/08/2024 at 10:45 AM, the Director of Nursing (DON) stated she expected staff to provide ADL care during morning care. After observing Resident #44, she confirmed Resident #44 needed their hair groomed and said she would get their aide to take care of it.
During an interview on 05/08/2024 at 11:27 AM, Certified Nurse Assistant (CNA) #5 stated that once staff got residents dressed, they then brushed their teeth and hair. She indicated she usually got Resident #44 dressed after breakfast, then brushed their hair. She further said that on the morning of 05/08/2024, she dressed Resident #44 after breakfast but did not brush the resident's hair because she forgot.
During an interview on 05/09/2024 at 8:23 AM, the Administrator said Resident #44 was dependent on staff for hair care and their hair needed to be groomed daily.
2. An admission Record revealed the facility admitted Resident #46 on 02/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of quadriplegia and muscle wasting and atrophy.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2024, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had a functional limitation in range of motion on both sides of their upper and lower extremities and was dependent on staff for personal hygiene.
Resident #46's comprehensive care plan included a Focus area, initiated on 03/01/2024, that indicated the resident had a potential for decline in self-care skills. The Goal indicated Resident #46 would demonstrate grooming and personal hygiene with moderate assistance by staff, with a target ate of 05/29/2024. The interventions indicated the resident was receiving occupational therapy five times per week for four weeks but did not reflect the level of assistance the resident currently required from staff for grooming and personal hygiene. In addition, the comprehensive care plan did not address the resident's need for routine nail care.
On 05/06/2024 at 12:20 PM, Resident #46's fingernails and toenails were observed. The resident's fingernails were long, jagged, and extended approximately an eighth of an inch past the pads of their fingers. The resident's toenails were thick, discolored, and long.
On 05/08/2024 at 8:16 AM, Resident #46's fingernails were observed, and they remained long and jagged and had a brown substance under them. Licensed Vocational Nurse (LVN) #1 and Certified Nurse Assistant (CNA) #2, who were providing care to the resident at the time, were asked who was responsible for providing nail care for Resident #46. LVN #1 stated they had an in-house podiatrist that did residents' toenails, and the aides did their fingernails. After observing Resident #46's nails, LVN #1 and CNA #2 agreed the resident's nails needed to be addressed. Resident #46 said their nails had not been trimmed since they were admitted to the facility and stated they would like for them to be trimmed.
During an interview on 05/08/2024 at 10:19 AM, CNA #3 stated that the aides provided the residents' nail care. She indicated the aides provided nail care when they noticed they needed to be done. She further indicated she had never done Resident #46's nails.
During an interview on 05/09/2024 at 8:02 AM, the Director of Nursing (DON) stated Resident #46 was dependent on staff for all their ADLs, and the resident's nails should be cleaned and trimmed as needed.
During an interview on 05/09/2024 at 8:23 AM, the Administrator stated Resident #46 was dependent on staff for nail care and indicated the resident's nails should have been addressed by staff prior to a surveyor pointing out the concern.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An admission Record indicated the facility admitted Resident #16 on 03/09/2024.
Resident #16's Physician Orders for Life-Sus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. An admission Record indicated the facility admitted Resident #16 on 03/09/2024.
Resident #16's Physician Orders for Life-Sustaining Treatment (POLST), prepared on 03/09/2024, revealed in the event the resident was found with no pulse and not breathing, the resident elected Do Not Attempt Resuscitation/DNR (Allow Natural Death). The POLST reflected this information was discussed with the resident, and the resident had No Advance Directive; however, the section of the form for the physician, nurse practitioner, or physician assistant signature was not signed.
An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2024, revealed the MDS reflected that Resident #16 had a POLST form in their chart that was signed by a physician, nurse practitioner, or physician assistant. The MDS further indicated that the section of the POLST addressing advance directives was discussed with the resident's legally recognized decision maker and was not completed, as opposed to reflecting the resident did not have an advance directive as indicated on their POLST.
During an interview on 05/08/2024 at 1:44 PM, the MDS Coordinator reviewed Resident #16's MDS and POLST and confirmed the resident's MDS was not accurate. The MDS Coordinator said the resident's POLST was not signed by a physician, nurse practitioner, or physician assistant, so he should not have coded the MDS to reflect that it was signed. The MDS Coordinator further stated the section of the MDS related to advance directives was not accurate.
During an interview on 05/09/2024 at 8:00 AM, the Director of Nursing (DON) stated she expected the information on the MDS to be accurate. The DON stated the MDS should accurately reflect POLST information and confirmed that Resident #16's MDS was not accurate.
During an interview on 05/09/2024 at 8:20 AM, the Administrator stated he expected the MDS to be accurate. The Administrator stated the MDS should accurately reflect POLST information and confirmed that Resident #16's MDS was not accurate.
4. An admission Record indicated the facility admitted Resident #30 on 01/11/2022.
Resident #30's Physician Orders for Life-Sustaining Treatment (POLST), prepared on 01/31/2024, revealed in the event the resident was found with no pulse and not breathing, the resident elected Attempt Resuscitation. The POLST reflected this information was discussed with the resident, and the resident had an advance directive dated 01/30/2024; however, the section of the form for the physician, nurse practitioner, or physician assistant signature was not signed.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/03/2024, revealed the MDS reflected that Resident #30 had a POLST form in their chart that was signed by a physician, nurse practitioner, or physician assistant. The MDS further indicated that the section of the POLST addressing advance directives was discussed with the resident and was not completed, as opposed to reflecting the resident did have an advance directive as indicated on their POLST.
During an interview on 05/08/2024 at 1:44 PM, the MDS Coordinator reviewed Resident #30's MDS and POLST and confirmed the resident's MDS was not accurate. The MDS Coordinator said the resident's POLST was not signed by a physician, nurse practitioner, or physician assistant, so he should not have coded the MDS to reflect that it was signed. The MDS Coordinator further stated the section of the MDS related to advance directives was not accurate.
During an interview on 05/09/2024 at 8:00 AM, the Director of Nursing (DON) stated she expected the information on the MDS to be accurate. The DON stated the MDS should accurately reflect POLST information and confirmed that Resident #30's MDS was not accurate.
During an interview on 05/09/2024 at 8:20 AM, the Administrator stated he expected the MDS to be accurate. The Administrator stated the MDS should accurately reflect POLST information and confirmed that Resident #30's MDS was not accurate.
Based on interview, record review, and facility document and policy review, the facility failed to accurately code Minimum Data Set (MDS) assessments for 4 (Residents #34, #61, #16, and #30) of 17 residents reviewed for MDS accuracy.
Findings included:
A facility policy titled, Certifying Accuracy of the Resident Assessment, revised in 11/2019, indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy further indicated, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment.
1. An admission Record revealed the facility admitted Resident #34 on 05/03/2023. According to the admission Record, the resident had a medical history that included diagnoses of idiopathic peripheral autonomic neuropathy (disorder of the nerves that regulate body processes), Alzheimer's disease, and dysphagia (swallowing disorder).
Resident #34's Order Summary Report, listing active orders as of 05/07/2024, revealed an order, dated 12/30/2023, to admit Resident #34 to hospice on 12/30/2023 with a diagnosis of senile degeneration of the brain.
Resident #34's Hospice Plan of Care, certified from 12/29/2023 through 03/27/3034, indicated hospice services started on 12/29/2023.
Resident #34's quarterly MDS, with an Assessment Reference Date (ARD) of 03/19/2024, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 1, indicating the resident had severe cognitive impairment. However, the MDS did not reflect the resident received hospice care while a resident of the facility or within the 14 days prior to the assessment.
During an interview on 05/08/2024 at 1:53 PM, the MDS Coordinator acknowledged Resident #34's quarterly MDS dated [DATE] was not accurate and should have been coded to reflect the resident received hospice services while a resident of the facility.
During an interview on 05/09/2024 at 8:00 AM, the Director of Nursing (DON) stated Resident #34's quarterly MDS dated [DATE] should have reflected the resident received hospice services while a resident of the facility.
During an interview on 05/09/2024 at 8:20 AM, the Administrator stated he expected a resident's MDS to accurately reflect if they were receiving hospice services while a resident of the facility.
2. An admission Record revealed the facility admitted Resident #61 on 12/28/2023. According to the admission Record, the facility discharged the resident on 03/02/2024 to a Board and care/assisted living/group home.
Resident #61's Order Summary Report, listing active orders as of 03/08/2024, revealed an order dated 02/28/2024 that directed staff to discharge the resident to an assisted living facility on 03/02/2024.
Resident #61's Progress Notes revealed the following entries:
- a note dated 02/29/2024 at 10:23 AM that indicated the resident was going to be discharged to an assisted living facility in two days; and
- a note dated 03/02/2024 at 12:06 PM, that indicated the resident was discharged home via private transportation.
Resident #61's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/02/2024, indicated Resident #61 was discharged to a Short-Term General Hospital, instead of Home/Community. Per the MDS, Home/Community was the appropriate discharge status for residents who were discharged to a private home or apartment, assisted living facility, group home, or other residential care arrangement.
During an interview on 05/08/2024 at 2:10 PM, the MDS Coordinator stated Resident #61's discharge MDS was coded to reflect the resident was discharged to a hospital but should have been coded to reflect the resident was discharged home.
During an interview on 05/09/2024 at 7:59 AM, the Director of Nursing (DON) confirmed Resident #61's discharge assessment was inaccurate, because the MDS should have reflected the resident was discharged home, not to a hospital.
During an interview on 05/09/2024 at 8:20 AM, the Administrator stated if a resident was discharged home, their MDS should be coded to reflect they were discharged home, not to a hospital.
Nov 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to Establish and maintain safe resident smoking practices...
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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 Establish and maintain safe resident smoking practices, per the facility's Policy & Procedure (P&P) Smoking Policy-Resident, as two residents (Residents1&2) were observed smoking on the patio, without staff supervision.
This failure could have resulted in injuries to Residents1&2, while smoking without staff supervision.
Findings:
On October 27, 2023, at 11:15 a.m., an unannounced revisit was conducted at the facility for a Quality-of-Care issue.
On October 27, 2023, an interview was conducted with the Director of Nursing (DON), who indicated, Smoking Patio hours are at designated times. Residents can go out on patio at anytime but must be monitored by staff when smoking. DON further stated, the activities staff are responsible to hand out the smoking paraphenalia (Cigarettes & lighters), and monitor the smoke breaks, then staff collect the cigarettes and lighters until the next smoke break.
On October 27, 2023, at 11:45 a.m., a concurrent observation of the smoking patio, and interview with the DON was conducted. A sign on the smoking patio indicated the daily smoke breaktimes. The next smoke break time was observed to be .12:00 – 12:10 (p.m.) . Outside on the smoking patio, 2 residents (Resident1&2) were observed smoking, unsupervised by staff. Resident 1 was observed in possession of 1 cigarette box and 1 lighter. DON verified, residents Shouldn't be on the patio smoking without being monitored by staff. DON stated, Staff should be out here watching them (Smoke), and (Residents) shouldn't have their cigareetes and lighters without staff.
On October 27, 2023, at 12:06 p.m., a concurrent interview with the Acitivity Assistant (AA), and observation of smoking patio was conducted. Residents 1&2 were observed smoking on the patio being monitored by AA. AA stated she had been employeed at the facility for One week, and she is responsible to take residents out to smoke during smoke breaks, monitor residents smoking, then collect their lighter and cigarettes. Residents are to come to her to get their lighter and cigarettes and she will take then out to smoke. AA verified, she did not know Resident1 had his cigarettes and lighter in his possession, or how he got them prior to smoke break. AA stated, I collected them (Resident1's light and cigarettes).
On October 27, 2023, a review of Resident1's medical records was conducted. Residents Face sheet, indicated he was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease (A disease that causes contriction of the airway and difficulty breathing) and Asthma (Spasms in the lungs, causing difficulty breathing). Resident1's BIMS (Brief Interview of Mental Status – a test of mental cognition) score was 15, indicating cognitive intactness. Resident1's Smoking Safety Screen, dated August 24, 2023, indicated, resident .May smoke with supervision . requiring, .Adaptive equipment (of) 1. Smoking Apron . Review of Resident1's Care Plans indicated; no care plan was developed for smoking.
On October 27, 2023, at 2:10 p.m., an interview was conducted with Resident1. Resident1 verified he was smoking on the patio, unsupervised earlier in the day (at 11:45 a.m.). Resident1 stated, staff Usually, monitor smoking breaks on the patio, and collect his cigarettes and lighter, when smoking break is over, but Sometimes (staff) forget (to collect cigarettes and lighter). Resident1 further stated, he Couldn't remember, how he had his cigarettes and lighter with him, during his unsupervised smoking break. Resident1 further verified, staff do ask him to wear a smoking apron when he goes out to smoke, and he refuses to wear it, stating, I don't like it, It's too hot and heavy, and I don't need.
On October 27, 2023, a review of Resident2's medical records was conducted. Resident2's Face Sheet, indicated, he was admitted to the facility on [DATE], with a diagnosis of traumatic brain injury and right-sided hemiplegia (paralysis of one side of the body), with a BIMS score was 01, indicating severe cognitive impairments. Resident2's Smoking Safety Screen, dated July 7, 2023, indicated, . Resident is a smoker . requiring .Supervision . while smoking. Review of Resident2's Care Plans, indicated, resident did have a care plan developed for smoking, stating, .(Resident2) is a smoker . requires SUPERVISION while smoking .
On November 7, 2023, at 10:53 a.m., an interview was conducted with the Activity Director (AD). AD stated activity staff are responsible for taking the residents out and monitoring them during the designated smoke breaks. AD and her assistant (AA) will go out to the smoking patio and monitor smoking residents for the duration of the smoke break. The nursing staff will assess new residents for Smoking safety, during the admission process, and she will print a copy of the residents smoking safety assessment, and put it in the Smoking binder, so special needs of the smoking residents are easily accessed. If is a resident is assessed for the need of a smoking apron for safety, then the apron is handed to the resident during the smoking break. AD further stated, she will orient new residents to the facility's Smoking policy and safety rules, which includes smoking requirements and use of smoking aprons, then resident will sign (a copy of documents reviewed). AD verified, she does not have a copy of Resident1&2's Smoking safety, documents, as Both residents discharged , and I threw the documents away. AD further stated, Resident1 Often refused (to wear) the smoking aprons, and she notifies nursing staff, if a resident repeatedly refused to wear their smoking apron, but she could not Remember, if nursing staff was notified of Resident1 refusing to wear the smoking aprons.
On November 7, 2023, at 1:15 p.m., an interview was conducted with the DON. The DON verified Resident 1 was a smoker, and a Smoking, care plan was missing from the resident's medical records. DON stated, a smoking care plan for Resident 1, should have been developed within 14 days of admission on [DATE], after being identified as a smoker. DON further verified, Resident1 was not wearing a smoking apron, and should have been, when observed smoking on the patio, unmonitored by staff, on October 27, 2023, at 11:45 a.m. DON stated, if a resident refuses to wear a smoking apron, then the resident can smoke if monitored by staff, then the resident should then be re-assessed by nursing staff, for smoking safety without an Apron, and the care plan should also be updated. DON verified Resident 1 was not re-assessed for Smoking safety, after refusing to wear a smoking apron.
A facility Policy & Procedure, titled, SMOKING POLICY-RESIDENT, updated, 3/06/2023, indicated, .This facility shall establish and maintain safe resident smoking practices . d. Ability to smoke safely with or without supervision (per a completed Smoking Safety Screen) . 8. A resident's ability to smoke safely will be re-evaluated . as determined by staff . 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervison of a staff member, family member, visitor or volunteer worker at all times while smoking . 12. Residents with or without independent smoking privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession including lighters or matches.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure Resident 1 was free from significant medication errors on October 27, 2023, as Licensed Vocational Nurse 1 (LVN1) did n...
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Based on observation, interview and record review, the facility failed to ensure Resident 1 was free from significant medication errors on October 27, 2023, as Licensed Vocational Nurse 1 (LVN1) did not follow the facility's Policy & Procedure (P&P), Administering Medications, as she left Resident 1's medications in his hand, and exited resident's room, before witnessing Resident 1 take his medications.
This failure resulted in Resident 1 missing his 8:00 a.m. dose of medications, including Metocarbonal and Cyclobenzaprine (Muscle relaxers, used to relieve muscle spasms).
Findings:
On October 27, 2023, at 11:15 a.m., an unannounced Quality-of-Care issue was conducted.
During an observation on October 27, 2023, at 11:55 a.m., of Resident 1 in his bedroom, resident was observed lying flat in bed, reaching to the right of his bed, for 2 orange-colored pills on his bedside table; An empty medication cup and several pills were observed on Resident 1's mattress next to him, and one pill observed on resident's shoulder. Resident 1 was further observed moving his mouth, making inaudible noises, as he was reaching for the pills on his bedside table, unresponsive to questions regarding his medications.
On October 27, 2023, at 12:10 p.m., a concurrent observation and interview with LVN 1, at Resident 1's bedside, LVN 1 stated she is the nurse responsible for administering Resident 1's daytime medications. LVN 1 observed Resident 1 lying in bed, and stated, Oh no, you didn't take your pills. Resident 1 did not verbally respond, he was observed mouthing inaudible words and reaching for his bedside table with medications on it. LVN 1 was observed picking medications off Resident 1's mattress, his gown (shoulder) and bedside table. LVN 1 began to review the medications she was picking up, with Resident 1, stating, This is your flexeril (Muscle relaxer), your metocarbonal (Muscle relaxer), your calcium (Mineral supplement). Resident 1 did not respond verbally. Observed LVN 1 pick up 8 pills and place in the medication cup that was on the bedside table.
On October 27, 2023, at 12:15 p.m. an interview with LVN1 was conducted. LVN1 stated, The (Facility's medication administration) policy is, We always have to make sure patients swallow their pills before we leave the room. LVN1 verified, I left (Resident1's) pills in a medication cup, in his hand, and did not wait for him to swallow them, and I did not come back to make sure (Resident1) took all of (his medications). LVN1 further verified, Resident 1 does not have doctor's (Dr's) to self-administer his own medications.
A review of Resident 1's October 27, 2023, MAR, and concurrent interview with LVN 1 was conducted. LVN 1 reviewed Resident 1's MAR, against the 8 pills recovered from his room, stating, Oh some of these (Medications) are from this morning (8:00 & 9:00 a.m. dose). LVN 1 verified, Residen t1 did not receive his 8:00 a.m. dose of Ferrous Sulfate (Iron supplement), 9:00 a.m. doses of Cyclobenzaprine (Muscle relaxer) 5 mg (Milligrams, a unit of measure), Methocarbonal (Muscle relaxer) 500mg, Colace 100 mg, and Calcium (mineral supplement) 500mg, and 12:00 p.m. doses of Metocarbonal 500 mg, Colace 100 mg and Calcium 500mg. Further review of Resident1's MAR, dated, October 27, 2023, indicated, all of Resident1's 8:00 & 9:00 a.m. medications were initialed by LVN1, indicating the medications were administered by LVN1, and taken by Resident1.
Review of Resident1's admission medical records was conducted. Resident1's face sheet, indicated, resident was admitted to the facility May 7, 2020, with a diagnosis of lower leg muscle contracture (When muscles tighten or shorten causing pain, loss of movement to joints, and deformity). Resident1's Brief Interview for Mental Status (BIMS) score was 12 (Moderate cognitive impairment).
Review of Resident1 Dr's orders, verified, resident has no orders to self-administer his medications. Further review indicated, Resident 1 has the following medication orders:
Cyclobenzaprine 5 mg tablet, three times per day (9:00 a.m., 1:00 & 5:00 p.m.);
Methocarbamol 500 mg tablet, three times per day (9:00 a.m., 1:00 & 9:00 p.m.);
Ferrous Sulfate, 65 mg tablet, with meals, (8:00 a.m., 12:00 & 5:00 p.m.);
Calcium 500-200 tablet, two times per day, (9:00 a.m. & 5:00 p.m.);
Senokot (Colace) 8.6-50 mg, two times per day (9:00 a.m. & 5:00 p.m.).
On October 27, 2023, at 1:01 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, The facility's procedure for passing medications is to stand with the resident until the medications are swallowed, and verify the medications are taken before (the nurse) leaves the room. The DON verified, (LVN1) did not follow proper facility procedure by Not waiting to see if (Resident1) took his medications before leaving (Resident1's) room. The DON further verified, a resident must be assessed by the Interdisciplinary Team (IDT), and the doctor for the cognitive ability to self-administer their medications, and Resident1 has not been assessed by the IDT or doctor to self-administer his medications.
During a review of the facility's policy and procedure titled, Admistering Medications, revised December 2012, indicated, .Medications shall be administered in a safe and timely manner, and as prescribed . 4. Medications must be administered in accordance with the orders . 24. Residents may self-administer their own medications only if the Attending Physician, in conjuction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely .
Oct 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 one of two residents, (Resident 2)'s call ligh...
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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 two residents, (Resident 2)'s call light was within reach. This failure had the potential for Resident 1 to have unmet needs.
On October 30, 2023, at 3:05 p.m., observed Resident 2 in her room, sitting in a wheelchair on the right side of her bed. Resident 2's call light was wrapped around the upper right siderail and was dangling onto the floor, outside of Resident 2's reach.
On October 30, 2023, at 3:05 p.m., an interview was conducted with Resident 2. Resident 2 asked if she could be assisted to the restroom and back to bed. Resident 2 was asked if she knew where her call light was located, Resident 2 stated no . Resident 2 was asked if she could reach her call light, Resident 2 answered no .
On October 30, 2023, at 3:06 p.m., an interview was conducted with the Medical Records Director, (MRD). The MRD stated the Resident 2's call light was not within reach.
On October 30, 2023, at 4:14 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that the call light should be within reach, even if the resident is confused.
A review of Resident 2's medical records indicted she was admitted on [DATE], with diagnosis of hip fracture, (broken hip bone), fall, osteoporosis, (causes bones to become weak and brittle), with pathological fracture, (broken bone caused by disease), left ankle and foot, depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest), and 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).
A review of Resident 2's History and Physical dated October 20, 2023, indicated she could make needs known, but could not make medical decisions.
A review of the facility's policy and procedure titled Answering the Call Light undated, indicated .The purpose of this procedure is to ensure timely responses to the resident's requests and needs .5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor .
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
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 provide medication and treatment to address one of three residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide medication and treatment to address one of three residents' (Resident 1)'s multiple episodes of diarrhea when:
1. Loperamide HCL (medication for diarrhea) was not provided every four hours in accordance with the physician order; and
2. Docusate sodium tablet (medication for constipation) was administered on four occasions when Resident 1 was having loose stools.
Findings:
On August 8, 2023, at 2:56 p.m., an unannounced visit to the facility was conducted to investigate quality care issue.
A review of Resident 1's medical records indicated she was admitted to the facility on [DATE], and discharged on May 13, 2022, with diagnoses which included dehydration, (a harmful loss of the amount of water in the body), constipation, (difficulty in emptying the bowel leading to hard feces), stroke, and chronic kidney disease, (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood).
A review of Resident 1's History and Physical dated indicated she had the capacity to understand and make decisions.
A review of Resident 1's Order Summary Report dated May 1, 2022, at 9 a.m., indicated the following:
a. On May 1, 2022, Docusate Sodium Tablet 100 MG Give 1 tablet by mouth two times a day for constipation hold for loose stools; and
b. On May 6, 2022, at 10:15 a.m., Loperamide HCl Tablet 2 MG Give 2 mg by mouth every 4 hours as needed for LOOSE STOOL
A review of Resident 1's Change in Condition dated May 2, 2022, at 7:43 a.m., indicated . resident alert and able to verbalize needs. breathing even and non-labored. no acute distress present. resident present with loose stools with foul odor .
A review of Resident 1's Bowel Output indicated the following episodes of diarrhea:
May 2, 2022, at 5:59 a.m., Incontinent, (having no or insufficient voluntary control over defecation), Large Loose/Diarrhea
May 2, 2022, at 1:26 p.m., Incontinent, Medium, Loose/Diarrhea
May 4, 2022, at 1:59 p.m., Incontinent, Large, Loose/Diarrhea
May 5, 2022, at 5:59 a.m., Incontinent, Large, Loose/Diarrhea
May 5, 2022, at 5:26 p.m., Incontinent, Large, Loose/Diarrhea
May 5, 2022, at 9:59 p.m., Incontinent, Large, Loose/Diarrhea
May 5, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 12:22 p.m., Incontinent, Large, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Large, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 11:26 p.m., Incontinent, Small, Loose/Diarrhea
May 7, 2022, at 5:59 a.m., Incontinent, Small, Loose/Diarrhea
May 7, 2022, at 1:59 p.m., Incontinent, Large, Loose/Diarrhea
May 8, 2022, at 5:59 a.m., Incontinent, Large, Loose/Diarrhea
May 8, 2022, at 11:23 a.m., Incontinent, Large, Loose/Diarrhea
May 8, 2022, at 7:21 p.m., Incontinent, Large, Loose/Diarrhea
A review of Resident 1's Medication Administration Record for May 2022 indicated the following:
a. May 1, 2022, at 9 a.m., hold from May 2, 2022, at 5:08 p.m., to May 5, 2022, 5:07 p.m., Docusate Sodium Tablet 100 MG Give one tablet by mouth two times a day for constipation hold for loose stools.
The MAR indicated the medication was given on May 2, 2022, at 9 a.m., May 5, 2022, at 6 p.m., May 6, 2022, at 6 p.m., and May 7, 2022, at 9 a.m.
b. May 6, 2022, at 10:15 a.m., Loperamide HCl Tablet 2 MG Give 2 MG by mouth every four hours as needed for loose stool.
The MAR indicated the medication was given on May 8, 2022, at 10:16 a.m.; May 9, 2022, at 10:17 a.m., and May 11, 2022, at 11:32 a.m.
On August 8, 2023, at 4:11 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated if a resident was having diarrhea, she would notify the charge nurse and document episodes of diarrhea in the residents' medical record.
On August 8, 2023, at 4:32 p.m., an interview was conducted with the Registered Nurse, (RN). The RN stated if resident had a new onset of diarrhea, she would notify the doctor and follow new orders. The RN stated that if residents had an order for Docusate Sodium and were having diarrhea, she would hold the medication.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was free fr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was free from unnecessary medication when Docusate Sodium Tablet (medication used for constipation and or a stool softener) was given on four occasions when Resident 1 was having multiple episodes of diarrhea.
This failure had the potential for Resident 1 to suffer prolonged diarrhea.
Findings:
On August 8, 2023, at 2:56 p.m., an unannounced visit to the facility was conducted to investigate quality care issue.
A review of Resident 1's medical records indicated she was admitted to the facility on [DATE], and discharged on May 13, 2022, with diagnoses which included dehydration, (a harmful loss of the amount of water in the body), constipation, (difficulty in emptying the bowel leading to hard feces), stroke, and chronic kidney disease, (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood).
A review of Resident 1's History and Physical dated indicated she had the capacity to understand and make decisions.
A review of Resident 1's Order Summary Report dated May 1, 2022, at 9 a.m., indicated, Docusate Sodium Tablet 100 MG Give 1 tablet by mouth two times a day for constipation hold for loose stools.
A review of Resident 1's Change in Condition dated May 2, 2022, at 7:43 a.m., indicated . resident alert and able to verbalize needs. breathing even and non-labored. no acute distress present. resident present with loose stools with foul odor .
A review of Resident 1's Medication Administration Record for May 2022, indicated the following:
a. May 1, 2022, at 9 a.m., hold from May 2, 2022, at 5:08 p.m., to May 5, 2022, 5:07 p.m., Docusate Sodium Tablet 100 MG Give one tablet by mouth two times a day for constipation hold for loose stools.
b. The medication was given on May 2, 2022, at 9 a.m., May 5, 2022, at 6 p.m., May 6, 2022, at 6 p.m., and May 7, 2022, at 9 a.m.
A review of Resident 1's Bowel Output indicated the following episodes of diarrhea:
May 2, 2022, at 5:59 a.m., Incontinent, (having no or insufficient voluntary control over defecation), Large Loose/Diarrhea
May 2, 2022, at 1:26 p.m., Incontinent, Medium, Loose/Diarrhea
May 5, 2022, at 5:59 a.m., Incontinent, Large, Loose/Diarrhea
May 5, 2022, at 5:26 p.m., Incontinent, Large, Loose/Diarrhea
May 5, 2022, at 9:59 p.m., Incontinent, Large, Loose/Diarrhea
May 5, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 12:22 p.m., Incontinent, Large, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Large, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 9:59 p.m., Incontinent, Medium, Loose/Diarrhea
May 6, 2022, at 11:26 p.m., Incontinent, Small, Loose/Diarrhea
May 7, 2022, at 5:59 a.m., Incontinent, Small, Loose/Diarrhea
May 7, 2022, at 1:59 p.m., Incontinent, Large, Loose/Diarrhea
On August 8, 2023, at 4:11 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated if a resident was having diarrhea, she would notify the charge nurse and document episodes in the residents' medical record.
On August 8, 2023, at 4:32 p.m., an interview was conducted with the Registered Nurse, (RN). The RN stated if resident had a new onset of diarrhea, she would notify the doctor and follow new orders. The RN stated that if residents were on Docusate Sodium and have diarrhea, she would hold the medication.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, for four (Resident 1, 2, 3, and 4) of six residents, the facility failed to ensure necessary care and services were completed as scheduled on June 1...
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Based on observation, interview, and record review, for four (Resident 1, 2, 3, and 4) of six residents, the facility failed to ensure necessary care and services were completed as scheduled on June 12, 2023, when the Restorative Nursing Assistant (RNA) failed to conduct Restorative Nursing Therapy (RNT) as ordered.
As a result, the facility failed to promote the resident's abilities in the performance of their activity of daily living when the RNA failed to conduct the RNTs as ordered on June 12, 2023.
Findings:
On June 29, 2023, at 11:00 a.m., an unannounced visit was conducted to investigate an allegation RNT services were not provided as ordered.
On June 29, 2023, at 11:45 a.m., the facility's June 2023 staffing schedule was reviewed with the Administrator (ADM). The record indicated RNA 1 was marked R (Request Off) on June 12, 2023. ADM stated RNA 1 worked on the floor as a Certified Nursing Assistant (CNA) coverage that day.
On June 29, 2023, the Staffing Schedule and Signature Sheet , dated June 12, 2023, was reviewed. The record indicated RNA 1 did not work as an RNA but covered a CNA assignment for 10:00 p.m. – 6:30 a.m., on June 12, 2023. The AM Shift, 6:00 a.m. – 2:30 p.m., was left blank indicating no RNA was assigned to work that day.
On June 29, 2023, at 1:45 p.m., RNA 1 was interviewed and resident's RNT records were reviewed. RNA 1 stated that on June 12, 2023, she was off daytime, came 10 p.m., and stayed the next day until 2 p.m. RNA 1 stated she made a mistake and signed off the RNT program that RNT services were completed and provided that day. RNA 1 stated there was nobody assigned to work for RNA on 06/12/2023 and RNT was not done.
On June 29, 2023, RNT's resident records were reviewed. The records indicated:
Resident 1's RNA Program: Sit to stand exercises QD (every day) 5x/week as tolerated , was documented RNA 1 spent 15 minutes with the resident on June 12, 2023, at 1:59 p.m. The Audit trail indicated the RNA 1 documented the therapy on June 14, 2023, at 11:47 a.m.;
Resident 2's RNA QD 5 days/week for arm/leg bike , was documented RNA 1 spent 15 minutes with the resident on June 12, 2023, at 1:59 p.m. The Audit trail indicated the RNA 1 documented the therapy on June 14, 2023, at 11:46 a.m.;
Resident 3's RNA Program: RNA exercises of PROM (Passive Range of Motion) exercises to BLE (Bilateral Lower Extremity) QD 5X/Week and RNA Program: RNA exercises of PROM exercises to BUE (Bilateral Upper Extremity) QD 5X/Week , were both documented RNA 1 spent 15 minutes with the resident on June 12, 2023, at 1:59 p.m. The Audit trail indicated the RNA 1 documented the therapy on June 14, 2023, at 11:50 a.m.; and
Resident 4's NURSING REHAB/RESTORATIVE: Ambulation with Front Wheel [NAME] Program qd x 90days , was documented RNA 1 spent 15 minutes with the resident on June 12, 2023, at 1:59 p.m. The Audit trail indicated the RNA 1 documented the therapy on June 14, 2023, at 11:47 a.m.
On June 29, 2023, at 2:37 p.m., CNA 1 and 2 were interviewed regarding accurate and timely documentation of services provided. Both CNA's stated they document only on RNA Feeder's Program and never on Range of Motion (ROM) exercises or Sit and Stand . Both CNA's stated they will never document on days that they were not around.
On June 29, 2023, at 2:45 p.m., a concurrent interview and record review were conducted with Director of Nursing (DON) and ADM. DON stated an RNT should have been conducted on June 12, 2023. DON and ADM acknowledged this is a learning opportunity and will make sure RNA Programs will be provided as ordered.
A review of the facility policy titled, RESTORATIVE NURSING PROGRAM, dated May 1, 2023, indicated, POLICY: It is the policy to assist each and every resident to achieve the highest level of selfcare possible .and includes .1. Proper positioning and body alignment; 2. Residents up and out of bed; 3. Active and passive range of motion exercises; 4. Assistance and training in activities of daily living (eating, bathing, dressing, grooming and toiletry); 5. Walking or wheelchair mobility; 6. Transfer mobility (sit to stand); 7. Bowel and bladder management; 8. Weight Management; and 9. Self-Feeding .
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure on abus...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the facility's policy and procedure on abuse prohibition when an alleged staff member was not removed from resident care while investigation was being conducted, for one of two residents reviewed (Resident A).
This failure resulted for the alleged perpetrator (abuser) to continue to provide care for residents in the facility while an abuse investigation was in progress in which potentially placed Resident A and other residents at risk for harm or further abuse.
Findings:
On June 7, 2022, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse.
On June 7, 2022, Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included skin infection.
A review of the Minimum Data Set (MDS - an assessment tool), dated May 28, 2022, indicated Resident A had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact).
The document titled, eINTERACT Change of Condition Evaluation ., dated May 25, 2022, at 11:04 p.m., was reviewed. The document indicated, .pt (patient) stated to social service assistant that a female morning shift CNA smacked her hand after trying to lift her up in bed .
On June 7, 2022, at 9:50 a.m., an interview with the Social Service Director (SSD) was conducted. She stated Resident A reported to the Social Service Assistant (SSA) on the evening of May 25, 2022, that Certified Nursing Assistant (CNA) 1 smacked her right hand on May 25, 2022, at 6:40 a.m.
On June 7, 2022, at 10:20 a.m., an interview and concurrent record review with the Director of Staff Development (DSD) was conducted. She stated CNA 1 had finished her shift (6:30 a.m. to 3 p.m.) on May 25, 2022, by the time abuse allegation was reported. She stated CNA 1 worked several hours on May 26, 2022 (morning shift - a day after abuse allegation was reported) until she was sent home the same day.
CNA 1's timesheet was concurrently reviewed with the DSD. The timesheet indicated CNA 1 clocked-in for work from 6:31 a.m. to 11:31 a.m., on May 26, 2022.
In a concurrent interview with the DSD, she stated CNA 1 was not notified timely that she was suspended until later in the morning of May 26, 2022, after she had already worked for several hours providing care for residents. The DSD stated per facility abuse protocol, a staff involved in abuse allegation should be removed from all patient care until investigation is completed.
On June 7, 2022, at 12:15 p.m., an interview with RN Supervisor (RNS) 1 was conducted. She stated when she worked the morning of May 26, 2022, she was not aware CNA 1 should be suspended pending abuse investigation until she received a call from the SSD in the morning of May 26, 2022. She stated CNA 1 was sent home later that morning after she had worked for several hours providing care for residents.
On June 7, 2022, at 4;53 p.m., an interview with RNS 2 was conducted. She stated she was the RNS on May 25, 2022. She stated the SSA reported the abuse allegation to her in the evening of May 25, 2022.
On October 12, 2022, at 3:50 p.m., an interview with CNA 1 was conducted. She stated she worked several hours providing patient care for residents in the morning of May 26, 2022, until she was sent home later that morning. She stated she was sent home because there was a pending abuse allegation made towards her from Resident A that occurred the morning of May 25, 2022. She stated on May 26, 2022, was the first time she was notified by RNS 1 that she was suspended pending investigation of an abuse allegation reported by Resident A.
The facility's policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, was reviewed. The policy indicated, .Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation .The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented .
Jun 2021
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for two of two residents reviewed for dignity ...
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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 two of two residents reviewed for dignity (Residents 69 and 223), were treated with respect and dignity that promotes maintenance or enhancement of their quality of life; when:
1. Resident 69 was not assisted to get up from bed before breakfast as requested; and
2. Resident 223 was not dressed in his preferred clothes.
These failures had the potential to result in decline in residents' self-worth and self-esteem.
Findings:
1. On June 22, 2021, at 10:54 a.m., Resident 69 was interviewed with the family member (FM). The FM stated that during the visit, the resident (Resident 69) complained that he was still in bed, and was upset. The FM stated the resident wanted to get up from bed at 7:30 a.m., and had mentioned the request to the staff. However, the resident was not assisted in getting up until 11:30 a.m.
On June 24, 2021, at 10:22 a.m., during an interview with Resident 69, who was still in bed, the resident stated he did not know why he was not up yet. Resident 69 stated, I have been waiting.
On June 24, 2021, at 1:29 p.m., during interview, Licensed Vocational Nurse (LVN) 1 stated during the start of shift, the CNAs were expected to get up the residents from bed and be ready for breakfast. She stated the residents should be up in the wheelchair.
On June 25, 2021, at 7:39 a.m., during an interview, the Director of Staff Development (DSD) stated the staff had a schedule to get up the residents who had requested. The DSD stated the CNA should ask the residents who requested, and get up these resident from bed before breakfast.
Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), right dominant side and contracture (stiffening or shortening) of the muscle, right hand and mild cognitive impairment.
The document titled, Order Summary Report, for the month of June 2021, indicated, .Functional Status: OOB (out of bed) as tolerated with assist .Order date .5/31/2021 (May 31, 2021) .
The Minimum Data Set (an assessment tool) dated June 5, 2021, indicated, Resident 69 required limited to extensive assistance with activities of daily living (a term used to refer to people's daily self-care activities).
2. On June 23, 2021, at 9:29 a.m., Resident 223 was interviewed. Resident 223 stated he was dressed with this big thing (a facility gown). He stated he had his own shirts and was not sure why he was dressed with the facility gown.
On June 23, 2021, at 9:31 a.m., during interview, Certified Nursing Assistant (CNA) 2 stated Resident 223 was alert and oriented. CNA 2 stated Resident 223 was wearing a facility gown, and she stated residents wear facility gown at night. In addition, she stated Resident 223 had his own shirts and shorts.
In a concurrently interview, Resident 223 stated he used whatever the staff put on, even if it was something he did not prefer to wear. Resident 223 stated he preferred to wear a shirt and shorts at night.
On June 23, 2021, at 10:12 a.m., during an interview, the Director of Staff Development (DSD) stated the resident should be asked what to wear, and should be wearing home clothes which provided a homelike setting. The DSD stated the residents should not be wearing a facility gown.
A review of the facility policy and procedure titled, Quality of Life - Dignity, dated February 2020, indicated, .Each resident shall be cared for in a manner that promotes and enhance his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem .Residents are treated with dignity and respect at all times .The facility culture is one that supports and encourages humanitarian and individuation of residents, and honors resident choices, preferences, values and beliefs .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call lights were within reach for three 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 the call lights were within reach for three of sixteen residents (Residents 69, 173, and 224). This failure had the potential to result in residents' needs not met.
Findings:
1. On June 21, 2021, at 10:59 a.m., Resident 173 was observed in a wheelchair. Resident 173's call light was observed behind the resident on top of the night stand, away from the resident.
In a concurrent interview with Resident 173, she stated she did not know where the call light was. Resident 173 stated she would press the call light button when she needed assistance.
On June 21, 2021, at 11:04 a.m., Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated Resident 173 used the call light for assistance. CNA 3 stated the resident's call light was not within reach. CNA 3 stated the call light should be close to the resident.
Resident 173's record was reviewed. Resident 173 was admitted to the facility on [DATE], with diagnoses which included left hip dislocation s/p (status post) fall. Resident 173 has the capacity to understand and make decisions.
The Minimum Data Set (an assessment tool) dated June 22, 2021, indicated Resident 173 required limited assistance with her activities of daily living.
Resident 173's care plan initiated on June 8, 2021, indicated, At risk for falls/injury due to .fall risk assessment score: 22 . (10 and above .high risk) balance problem .Interventions .call light within reach .
2. On June 22, 2021, at 11:15 a.m., Resident 224 was observed in bed. Resident 224's call light was observed tucked underneath his pillow.
In a concurrent interview with Resident 224, Resident 224 stated he would press the call light button for help. Resident 224 was observed looking for his call light and stated he had the call light button somewhere.
Resident 224's record was reviewed. Resident 224 was admitted to the facility on [DATE], with diagnoses which included difficulty in walking and repeated falls.
Resident 224's care plan initiated on June 18, 2021, indicated, At risk for falls/injury due to .Fall risk assessment score: 16 . (10 and above high risk) balance problem .Interventions .call light within reach .
On June 23, 2021, at 8:30 a.m., during an interview, Certified Nursing Assistant (CNA) 7 stated she was familiar with Resident 224. CNA 7 stated Resident 224 required limited assistance. CNA 7 stated the purpose of the call light was for the resident to be able to notify the staff that the resident needed assistance.
3. On June 21, 2021, at 2:47 p.m., Resident 69 was observed in bed. Resident 69's call light was observed hanging on the right side of the bed.
On June 24, 2021, at 10:24 a.m., Resident 69 was observed in bed with CNA 1. CNA 1 stated Resident 69's call light was stuck in between the side rail and the mattress. CNA 1 stated the call light should be within reach of the resident.
Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemiparesis (weakness of one side of the body) and hemiplegia (paralysis of one side of the body), right dominant side and contracture (stiffening or shortening) of the muscle, right hand and mild cognitive impairment.
Resident 69's care plan dated May 31, 2021, indicated, .At risk for falls/injury due to: fall risk assessment score: 24 . (10 and above high risk) balance problem .Interventions .call light within reach .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written Skilled Nursing Beneficiary Notice (SNF ABN- a no...
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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 a written Skilled Nursing Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving skilled services that may not be paid by Medicare and assume financial responsibility) for two of three residents reviewed for SNF ABN (Residents 6 and 25).
This failure resulted in not informing Residents 6 and 25 or their responsible party (RP) of the potential liability for payment in non-covered Medicare Part A services in writing.
Findings:
1. A review of record indicated Resident 6 was admitted to the facility on [DATE]. The form titled, SNF Beneficiary Protection Notification Review, indicated, Medicare Part A Skilled Services Episode Start Date: 1/19/21 . Last covered day of Part A Services: 3/15/21.
There was no documented evidence the resident or resident representative received a written SNF ABN.
2. A review of record indicated Resident 25 was admitted to the facility on [DATE]. The form titled, SNF Beneficiary Protection Notification Review, indicated, Medicare Part A Skilled Services Episode Start Date: January 19, 2021. Last covered day of Part A Services: March 31, 2021. There was no documented evidence the resident/beneficiary received a written SNF ABN.
On June 23, 2021, at 10:48 a.m., in a concurrent interview and record review with the Administrator (ADM), the ADM confirmed the SNF Beneficiary Protection Notification was not provided in writing to the residents or resident's representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 resident or representative was provided information on b...
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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 resident or representative was provided information on bed hold (holding or reserving a resident's bed while the resident was absent from the facility during hospitalization or therapeutic leave) opportunity for one of three residents reviewed for closed records (Resident 44).
This failure had the potential to result in the family member not to be given the opportunity to ensure facility bed would remain available for Resident 44's return to receive services needed.
Findings:
A review of Resident 44's record indicated he was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (kidney infection) and cancer of the bladder.
A review of the history and physical indicated the resident has the capacity to understand and make decisions.
A review of the progress notes, dated June 14, 2021, indicated Resident 44 was transferred to the acute hospital due to blood infection.
There was no documented evidence a notice of bedhold was provided during the acute care transfer on June 14, 2021.
On June 23, 2021, at 9:27 a.m., during interview with the Business office Manager (BOM), the BOM stated the nursing staff is responsible in the completion of bed hold notification during hospital transfer.
On June 23, 2021, at 9: 35 a.m., during concurrent interview and record review with Licensed Vocational Nurse (LVN) 2. LVN 2 confirmed that there was no documented evidence that the resident or the representative was notified about the bed hold rights when the resident was transferred June 14, 2021.
A review of the facility policy and procedure titled, Bed-Holds and Returns, dated March 2017, indicated, Prior to transfer and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
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 care and services for one of two residents 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 provide care and services for one of two residents reviewed for activities of daily living (ADL- a term used to refer to people's daily self-care activities) (Resident 69), when the physician order for one on one feeding was not followed. This failure had the potential to result in the decline in the resident's ADLs which could lead to a decrease in oral intake and weight loss.
Findings:
On June 21, 2021, at 12:52 p.m., A staff (Certified Nursing Assistant/CNA) was observed serving tray to Resident 69, and left. Resident 69 was observed eating using his left hand, and there was no staff observed with the resident.
Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), right dominant side and contracture (stiffening or shortening) of the muscle, right hand.
The document titled Order Summary Report, for the month of June, 2021, indicated, .1:1 FEEDING .Order date .6/1/2021 (June 1, 2021) .
Resident 69's care plan dated June 2, 2021, indicated, NUTRITIONAL RISK DUE TO: Mech. (Mechanical) Altered Diet, Swallowing difficulty .Therapeutic diet, Weight Loss .Interventions .provide 1:1 meal assist .
The Nutritional Risk assessment dated [DATE], indicated, .Eating ability .Limited assistance .Nutritional Risk Related to .Current PO (per oral) intake does not always meet estimated needs .
The Speech Therapy Plan of Care dated June 2, 2021, indicated, .Reason for Referral .referred to skilled st (speech therapy) d/t (due to) decline in safety swallow skills, aspiration risk, safety swallow trg (training), diet texture mgt. (management) .
On June 24, 2021, at 9:34 a.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated when a resident had an order for 1:1 feeding, the resident should be on a RNA (restorative nursing assistant) program.
On June 24, 2021, at 9:41 a.m., the RNA was interviewed. The RNA stated she was not aware Resident 69 required a 1:1 feeding. She stated the RNA or the CNA should assist the resident with feeding. The RNA stated Resident 69 was not included in the RNA feeding program.
On June 24, 2021, at 10:57 a.m., RNS 1 was interviewed. She stated the doctor ordered for 1:1 feeding so the staff could assist the resident due to the contracture of Resident 69's right hand. RNS 1 stated if the doctor ordered for 1:1 feeding, the physician's order should be followed.
A review of the facility policy and procedure titled, Activities of Daily Living (ADL's), Supporting, dated March 2018, indicated, .Residents will provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living .Interventions to improve or minimize a resident's assessed need, preferences, stated goals and recognized standards of practice .The resident's response to interventions will be monitored, evaluated and revised as appropriate .
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** Based on interview and record review, the facility failed to assess and evaluate the episodes of increased in heart rate for one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and evaluate the episodes of increased in heart rate for one of three residents reviewed for closed records (Resident 70). In addition, the physician was not notified of the resident's change in condition.
These failure had the potential to result in worsening of the resident's medical condition.
Findings:
1. Resident 70's record was reviewed. Resident 70 was admitted to the facility on [DATE], with diagnoses which included chronic respiratory failure, chronic atrial fibrillation (irregular heart rate), and diabetes mellitus (abnormal blood sugar).
Resident 70's progress notes titled, Nurse's Note, indicated the following:
- Dated [DATE], at 12:57 p.m., .resident noted to be pale, no chest rise observed. resident assessed; eyes fixed, no pulse palpated, no breath sounds auscultated. unable to obtain vital signs .
- Dated [DATE], at 9:50 a.m., .episode of groaning and moaning noted. resident noted to be gurgling, oral secretions suctioned .
Resident 70's Weights and Vitals Summary, indicated the following:
- [DATE] ([DATE]) .140 bpm (beats per minute) (Irregular - new onset) High of 100.0 exceeded .
- [DATE] ([DATE]) .120 bpm (Irregular - new onset) High of 100.0 exceeded .
- [DATE] ([DATE]) .107 bpm (Regular) High of 100.0 exceeded .
- [DATE], at 9:06 (a.m.) 109 bpm (Regular) High of 100.0 exceeded .
There was no documentation Resident 70's physician was notified of the resident's change of condition.
On [DATE], at 2:40 p.m., Registered Nurse Supervisor (RNS) 1 was interviewed. RNS 1 stated for a change of condition, the practice was to complete an assessment, notify the physician, and monitor for 72 hours. RNS 1 stated a resident had a change of condition when a resident was different from the normal.
In a concurrent review of Resident 70's record with RNS 1, she stated the resident had episodes of heart rate above 100 in the month of [DATE]. She stated Resident 70 had no secretions for the past two months. RNS 1 stated Resident 70 had a change of condition and there was no documentation that the resident was assessed and the physician was notified of the changes in the resident's condition.
On [DATE], at 3:45 p.m., Certified Nursing Assistant (CNA) 4 was interviewed. She stated a heart rate above 100 is an abnormal heart rate. She stated when a resident had a heart rate above 100, she would refer to the charge nurse right away.
On [DATE], at 7:35 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated she was in-charge of Resident 70 when the resident expired. LVN 3 stated she was not aware Resident 70 had an increase heart rate of 109. She stated the CNA should have informed her, and she would have rechecked the heart rate and reassessed the resident. LVN 3 stated she would inform the physician of the abnormal heart rate.
On [DATE], at 1:49 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 70 had episodes of high heart rate for [DATE], and the licensed nurse should have rechecked the heart rate, assessed the resident, and notified the doctor.
A review of the facility policy and procedure titled Change in a Resident's Condition or Status, dated [DATE], indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending physician or physician on call when there has been a(an) .significant change in the resident's physical/emotional/mental condition .
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, and record review, the facility failed to implement the physician's order for range of motion (ROM) exercises for one of seven residents reviewed for limited ROM (Resi...
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Based on observation, interview, and record review, the facility failed to implement the physician's order for range of motion (ROM) exercises for one of seven residents reviewed for limited ROM (Resident 63).
This failure had the potential to result in decline in the ROM of Resident 63's right wrist.
Findings:
On June 21, 2021, at 10:45 a.m., Resident 63 was observed in his room, with a right wrist drop. He stated he had the wrist drop (paralysis of the muscles which normally raise the hand at the wrist and extend the fingers, typically caused by nerve damage) after he got his COVID 19 vaccine injection in February 2021, given in the facility.
Resident 63's record was reviewed. Resident 63 was admitted to the facility August 24, 2020, with diagnoses which included, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and diabetes (disease in which the blood glucose, or blood sugar, levels are too high).
Resident 63's History and Physical Examination (H & P), dated August 24, 2020, indicated, .Has the capacity to understand and make decisions .
Resident 63's Order Summary Report, dated March 16, 2021, indicated, RNA (Restorative Nurse Assistant) TO ADD PROM(passive range of motion) FOR WRIST EXTENSION (movement of the hand backwards towards the posterior side of the forearm) , PRONATION (when palm is faced down) , AND SUPINATION (when palm is faced up) .
Resident 63's care plan dated March 12, 2021, indicated.Focus: rt (right) wrist drop .revise new exercise plan to rt hand /wrist .
On June 23, 2021, at 11:50 a.m., the Physical Therapy Coordinator (PTC) was interviewed. He stated he assessed Resident 63 two months ago. He recommended splint and ROM exercises for the right wrist.
On June 23, 2021, at 2:58 p.m., a RNA was interviewed. She stated she was the only RNA in the facility, and she verified the ROM exercises on Resident 63, was not done.
On June 23, 2021, at 3:03 p.m., Resident 63 was interviewed with the RNA at bedside. Resident 63 stated no one provided him exercises for his right wrist. Resident 63 stated They ignored it .
The facility policy and procedure, titled, Restorative Nursing Services, dated July 2017, was reviewed. The policy indicated, .Resident will receive restorative nursing care as needed to help promote optimal safety and independence .
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 the care plan for fall was implemented for one...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan for fall was implemented for one of one resident reviewed for falls (Resident 69), when resident's bed was not placed in the lowest position and the call light was not within reach.
This failure had the potential for further falls and injuries.
Findings:
On June 21, 2021, at 2:47 p.m., Resident 69 was observed in bed, the bed was not in the lowest position. Resident 69's call light was observed hanging on the right side of the bed, not within reach of Resident 69.
On June 24, 2021, at 10:22 a.m., Resident 69 was in bed. Resident 69's bed was observed not in the lowest position. The call light was not visible, and observed in between the mattress and the side rail.
Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), right dominant side and difficulty in walking.
Resident 69's document titled, Progress notes, dated June 23, 2021, indicated, .S/P (status post) FALL .PT (patient) SLID DOWN FROM WHEELCHAIR TO FLOOR .
Resident 69's document titled, FALL RISK ASSESSMENT, dated May 31, 2021, indicated, .Score: 24 .Category: High Risk .
Resident 69's care plan dated May 31, 2021, indicated, .At risk for falls/injury due to: fall risk assessment score: 24 .(10 and above high risk) balance problem .Interventions .Utilize low bed .call light within reach .
On June 24, 2021, at 10:24 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 69 was not a fall risk. She stated Resident 69 was alert.
In a concurrent observation of Resident 69 with CNA 1, CNA 1 stated Resident 69's bed was not in the lowest position. CNA 1 stated the call light was in between the bed rail and the mattress. CNA 1 stated the call light was not within reach of the resident.
On June 24, 2021, at 1:29 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated she was familiar with Resident 69. LVN 1 stated Resident 69 was a fall risk. She stated the CNA should make sure the bed is in low position and the call light should be within reach, next to the resident. LVN 1 stated Resident 69's care plan for fall should be implemented.
A review of the policy and procedure titled, Falls and Fall Risk, Managing, dated March 2018, indicated, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the appropriateness and continued use of Foley...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the appropriateness and continued use of Foley catheter ( flexible tube that passes through the urethra and into the bladder to drain urine) for one of one resident reviewed for catheter (Resident 223).
This failure had the potential to predispose Resident 223 to catheter associated urinary tract infection.
Findings:
On June 21, 2021, at 11:22 a.m., during interview, Resident 223, who has a Foley catheter, stated the catheter was inserted while at the hospital, due to his fall injury.
Resident 223's record was reviewed. Resident 223 was admitted to the facility on [DATE], with diagnoses which included right lower rib fracture (broken bone) and generalized weakness.
The document titled HISTORY AND PHYSICAL EXAMINATION, dated June 14, 2021, indicated, .s/p (status post) fall .rib fractures rt (right) 9-12 .
The document titled CUSTOM IDT (Interdisciplinary) CARE CONFERENCE FORM, dated June 15, 2021, indicated .s/p fall weakness multiple rib fx (fracture) .f/c (Foley catheter) in place f/u (follow up) for discontinuance .
On June 24, 2021, 2:10 p.m., Registered Nurse Supervisor (RNS) 1 was interviewed. She stated the practice of the facility was to clarify the use of Foley catheter, with the physician. RNS 1 stated Resident 223's use of Foley catheter was for urinary retention, and was not an adequate indication for the use of Foley catheter. RNS 1 stated if a resident had urinary retention, the licensed nurse would call the physician, discontinue the Foley catheter, complete a bladder training, and monitor for urine output.
In a concurrent review of Resident 223's record with RNS 1, she stated the use of Foley catheter for Resident 223 did not meet the criteria for use of Foley catheter.
A review of the policy and procedure titled, Urinary Continence and Incontinence - Assessment and Management, dated September 2010, indicated, .Indwelling urinary catheters will be used sparingly, for appropriate indications only .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services was provided for adequate pain manage...
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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 services was provided for adequate pain management when referral for pain management was not completed for one of two residents reviewed for pain (Resident 63).
This failure had the potential to result in Resident 63's pain not managed appropriately.
Findings:
On June 21, 2021, at 10:45 a.m., during an interview, Resident 63's stated his knee pain was not controlled. He stated the pain medications he was getting were not effective.
A review of Resident 63's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body) and diabetes (high blood sugar).
Resident 63's History and Physical Examination (H & P), dated August 24, 2020, indicated, .Has the capacity to understand and make decisions .
Resident 63's Order Summary Report, order date of April 1, 2021, indicated, REFER TO PAIN MANAGEMENT RE: PAIN UNCONTROLLED WITH CURRENT REGIMEN .
On June 23, 2021, at 3:45 p.m., in a concurrent interview and record review with RNS 2, she verified the pain management referral was not implemented. She confirmed it should have been done.
On June 24, 2021, at 11:16 a.m., the new case manager was interviewed. She stated she did not know what happened with the appointment. She confirmed the order for the referral was missed.
A review of the facility policy and procedure titled, Pain Assessment and Management, dated March 2020, indicated, .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the dietary preference for one of three residents reviewed ...
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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 the dietary preference for one of three residents reviewed for food preference (Resident 36). This failure had the potential for Resident 36's dietary intake to be inadequate by not making reasonable effort of adjusting resident's food plan and preference.
Findings:
On June 21, 2021, at 2:30 p.m., Resident 36 was interviewed. She stated that she requested for peanut butter and jelly sandwich for her midnight snacks. However, it was not provided. Resident 36 stated she made several request from the facility staff after dinner.
Resident 36 was admitted to the facility on [DATE], with diagnoses which included cellulitis (bacterial infection involving the inner layers of the skin) of Right leg.
The history and physical indicated Resident 36 has the capacity to understand and make decision.
On June 24, 2021, at 9:59 a.m., the Registered Dietician (RD) was interviewed. She stated that the licensed nurse is supposed to communicate to dietary manager that the resident was requesting for peanut butter and jelly sandwich.
On June 24, 2021, at 10:19 a.m., the Dietary Manager (DM) was interviewed. The DM stated she had no knowledge of Resident 36's request of peanut butter and jelly sandwich.
On June 24, 2021, at 10:30 a.m., Certified Nurse Assistant (CNA) 5 was interviewed. She stated Resident 172 requested for a peanut butter jelly sandwich. She stated she notified the licensed nurse about it.
A review of the facility policy and procedure titled, Resident Food Preference, dated July 2017, indicated, .The Food Service Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night.
CONCERN
(D)
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 maintain a complete medical records in accordance to the accepted professional standards and practices, when there was no record of commun...
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Based on interview, and record review, the facility failed to maintain a complete medical records in accordance to the accepted professional standards and practices, when there was no record of communication between the dialysis center and the facility on one of one resident reviewed for dialysis (Resident 172) on June 16, 2021.
This failure had the potential to result in the facility not being aware of any recommendation from the dialysis center for Resident 172, which could affect overall care.
Findings:
A review of Resident 172's record indicated, that the resident was admitted to the facility June 10, 2021, with diagnoses which included end stage renal disease (ESRD- inability of the kidney to make urine and remove waste from the blood).
A review of Resident 172's care plan indicated, Focus .dialysis (process of removing waste from the blood with the use of a machine) .Goal .Resident will adjust and adapt to renal dialysis .Interventions .Check v/s (vital signs- blood pressure, weight) upon return from dialysis .Coordinate resident's care with the dialysis center staff .
On June 23, 2021, at 2:15 p.m., in a concurrent interview and record review with the Registered Nurse Supervisor (RNS) 1, The RNS 1 stated the NOC shift staff will prepare the communication dialysis sheet for the resident going to dialysis the following day. RNS 1 stated the communication sheet would reflect the weight, and the blood pressure before and after dialysis treatment. The communication sheet would reflect any recommendation for the resident from the dialysis center. RNS 1 verified that the communication sheet for June 16, 2021, was not in Resident 172's record. RNS 1 stated if the communication sheet is not in the record, it means no communication between dialysis staff and the facility was recorded on June 16, 2021.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were i...
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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 appropriate infection control practices were implemented when:
1. A staff was observed going inside the room located in the yellow zone (designated for PUI - person under investigation due to unknown COVID-19 status), without donning an isolation gown; and
2. Two staff were observed wearing a surgical mask under the N95 (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles).
These failures had the potential to result in transmission of COVID-19 infection between staff and residents.
Findings:
1. On June 23, 2021, at 8:27 a.m., the Social Service Assistant (SSA) was observed entering room [ROOM NUMBER] (room on quarantined- in the yellow zone) wearing an N95, face shield, and gloves. The SSA was observed not wearing an isolation gown.
On June 23, 2021, at 8:45 a.m., the SSA was interviewed. The SSA stated when inside the yellow room (referring to room under quarantined- in the yellow zone), she should be wearing N95, face shield, an isolation gown, and gloves. The SSA stated she did not don an isolation gown when she entered room [ROOM NUMBER]. The SSA stated she should be wearing an isolation gown when inside a yellow room.
On June 23, 2021, at 9:05 a.m., the Infection Preventionist (IP) was interviewed. She stated staff should be wearing an N95, face shield, isolation gown, and gloves when in a yellow room.
A review of the undated facility mitigation plan indicated, .PERSONAL PROTECTIVE EQUIPMENT (PPE) .Full PPE is to be worn entering the yellow zone or red zone room. This consists of N95, disposable or reusable gown, eye protection (faceshield/goggles), gloves .
A review of the Centers of Disease Control and Prevention (CDC) guidance titled,Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on February 23, 2021, indicated, .Personal Protective Equipment HCP (Healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection .
2. On June 21, 2021, at 2:57 p.m., Certified Nursing Assistant (CNA) 6 was observed entering the yellow room (designated room for PUI-person under investigation due to unknown COVID-19 status) . CNA 6 was observed wearing a surgical mask underneath her N95.
On June 21, 2021, at 3:09 p.m., CNA 6 was interviewed. CNA 6 stated she was wearing an N95 and a surgical mask. CNA 6 stated she should not be wearing a surgical mask underneath the N95.
On June 23, 2021, at 8:30 a.m., CNA 7 was observed entering room [ROOM NUMBER] (a yellow room). CNA 7 was observed wearing a surgical mask underneath an N95.
In a concurrent interview, CNA 7 stated she was wearing a surgical mask under the N95. CNA 7 stated she was not required to wear a surgical mask with the N95.
On June 23, 2021, at 9:05 a.m., the Infection Preventionist was interviewed. The IP stated the staff should not be wearing a surgical mask underneath the N95.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
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 COVID-19 (illness caused by a virus that can be transmitted ...
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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 COVID-19 (illness caused by a virus that can be transmitted person to person) testing was conducted on admission for two of three residents on quarantined (Residents 222 and 224), due to COVID-19.
This failure had the potential to result in transmission of COVID-19 to the staff and residents in the facility.
Findings:
1. Resident 222's record was reviewed. Resident 222 was admitted to the facility on [DATE], with diagnoses which included pneumonia (infection of the lung).
The document Order Summary Report, for the month of June 2021, indicated the following:
- DROPLET AND CONTACT ISOLATION X (for) 14 DAYS FOR COVID19 PRECAUTION .Order Date .June 22, 2021.
- MAY DO COVID TESTING UPON admission AND RETESTING AS PER FACILITY PROTOCOL .Order date .June 16, 2021.
Resident 222's immunization history indicated Resident 222 was vaccinated for COVID-19 on June 15, 2021, with second dose scheduled on July 2021.
There was no documentation Resident 222 was tested for COVID-19 on admission.
On June 24, 2021, at 3:25 p.m., the Infection Preventionist (IP) was interviewed. The IP stated for resident admitted at the facility, not fully vaccinated, will be tested on admission, and placed in the yellow room (designated to residents under quarantined due to unknown COVID-19 status) for 14 days.
In a concurrent review of Resident 222's record, the IP stated there was no documentation the resident was tested on admission for COVID-19.
2. Resident 224's record was reviewed. Resident 224 was admitted to the facility on [DATE], with diagnoses which included cellulitis of the buttock (bacterial infection involving the inner layers of the skin).
The document Order Summary Report, for the month of June, 2021, indicated the following:
DROPLET AND CONTACT ISOLATION X (for) 14 DAYS FOR COVID19 PRECAUTION .Order Date .June 22, 2021.
- MAY DO COVID TESTING UPON admission AND RETESTING AS PER FACILITY PROTOCOL .Order date .June 17, 2021.
There was no documentation Resident 224 was tested on admission for COVID-19.
On June 24, 2021, at 3:25 p.m., the Infection Preventionist (IP) was interviewed. She stated the admitting nurse should test residents for COVID-19. The IP stated Resident 224 had one dose of COVID-19 vaccine and Resident 224 should be tested on admission.
In a concurrent review of Resident 224's record, the IP stated there was no documentation Resident 224 was tested on admission for COVID-19. The IP stated Resident 224 should be tested for COVID-19.
The undated facility mitigation plan indicated, .TESTING AND COHORTING .If no test result from the transferring hospitals are available, resident will be rapid tested upon admission as well as swabbed for (name of laboratory) to test .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure result of the most recent survey of the facility was posted and readily accessible to resident, family members, and re...
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Based on observation, interview, and record review, the facility failed to ensure result of the most recent survey of the facility was posted and readily accessible to resident, family members, and representatives of the residents.
This failure had the potential for residents and family members not to be aware of the survey findings which could affect the decision to stay in the facility.
Findings:
On June 22, 2021, at 10:40 a.m., during the confidential Resident Council meeting multiple residents stated the survey results were not visible and accessible to read.
On June 23, 2021, at 8:13 a.m., the Director of Nursing (DON) was asked where the survey results were kept. The DON was observed looking for the result in the front lobby. The DON verified that the result of the recent survey was kept inside the desk of the receptionist. She stated the survey result should be posted and readily accessible to residents, their family members or representatives to read.
A review of the facility policy and procedure titled, Resident Rights, dated December 2016, indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .examine survey results .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemipleg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 69's record was reviewed. Resident 69 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body), hemiparesis (weakness of one side of the body), right dominant side.
The Physician Orders for Life-Sustaining Treatment (POLST) dated May 31, 2021, indicated Resident 69 had an Advance Directive.
There was no advance directive available in the resident's record.
On June 24, 2021, at 1:43 p.m., in a concurrent interview and review of Resident 69's record, with Social Service Assistant (SSA), she stated she could not find the advance directive in the resident's record. The SSA stated it should be in the resident's record.
A review of the facility policy and procedure titled, Advance Directives, dated December 2016, indicated, .Advance Directives will be respected in accordance with state law and facility policy .Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his legal representative, about the existence of any written advance directives .Information about or whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .
Based on interview and record review, the facility failed to ensure an Advance Directive (AD-written instruction documentation related to the provision of health care when the resident/individual is no longer able to make decisions) was discussed with the resident and or resident representative upon admission to the facility, for four of 12 residents reviewed (Residents 9, 62, 69, and 120). In addition, the AD was not available in the medical record.
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.
Findings:
1. A review of Resident 9's record indicated he was admitted to the facility on [DATE], with diagnoses which included surgery of the digestive system.
A review of Resident 9's Physician orders for Life-Sustaining Treatment (POLST) section D, did not indicate any information related to the resident's advance directives.
2. A review of Resident 62's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included infection.
A review of Resident 62's Physician orders for Life-Sustaining Treatment (POLST) section D, did not indicate an information related to the resident's advance directives.
3. A review of Resident 120's record indicated Resident 120 was admitted to the facility on [DATE], with diagnoses which included motor-vehicle accident, sustaining fractures (a break).
A review of Resident 120's Physician orders for Life-Sustaining Treatment (POLST) section D, did not indicate any information related to the resident's advance directives.
On June 20, 2021, at 11 a.m, an interview was conducted with the Social Services Assistant (SSA), she confirmed the AD section was blank and should be completed by the Social Services Department on admission.
In a concurrent interview with Registered Nurse Supervisor (RNS) 1, she confirmed that the SSD was responsible for ensuring the AD was completed.
A review of the facility Advance Directive Policy, dated revised date of December 2016, indicated the following: Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Written information will include a description of the facility's policies to implement advance directives and applicable state law .Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record .If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when:
1. O...
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Based on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when:
1. One Dietary Aides (DA 1)and one [NAME] (Cook 1) were unable to demonstrate and verbalized the process of manual dishwashing by using three-compartment sink; and
2. One [NAME] (Cook 1) was unable to verbalize the proper cool down procedure of cooked meat.
These failures had the potential to place 55 out of 58 highly susceptible residents who received food from the kitchen at risk for food-borne illness.
Findings:
1. During an interview on June 21, 2021, at 9:52 a.m., DA 1 verbalized and demonstrated the process of manual dishwashing with the three-compartment sink. DA 1 stated the three-compartment sink is usually used in case the dishwashing machine was not functioning. DA 1 stated first step was to scrape off the food into the trash can, put the dishes to wash bin with a detergent, rinse the dishes in the rinse bin, and then immersed the dishes into the sanitizing solution. DA 1 stated she was not sure of the wash and rinse water temperature. In addition, she did not know the immersion time for the dishes in the sanitizing solution.
During the concurrent interview with Dietary Supervisor (DS), she verified that DA 1 did not know the process of manual dishwashing with the three-compartment sink. The DS stated her expectation was for DA 1, to have a knowledge on manual dishwashing in case the dishwashing machine was not working. She stated she provided an in-service for the staff about manual dishwashing.
During an interview on June 22, 2021, at 3:28 p.m., [NAME] 1 verbalized the process of manual dishwashing with the three-compartment sink. [NAME] 1 stated the process began with scraping the food into the trash can, placing the dishes into the washing bin with detergent, then rinse the dishes in the rinse bin. He stated the wash and rinse water temperature should be at the range of 110-120 degrees Fahrenheit (F-unit of measurement for temperature). He then stated the next step was to sanitize the dishes into the sanitizing bin with the sanitizing solution and the dishes would be immersed in the solution for 15 seconds. He stated to check the effectiveness of sanitizing solution was to use the test stripe and the concentration should be 200 parts per million (ppm).
During the concurrent interview with the DS, she verified that [NAME] 1 had verbalized incorrectly the immersion time for the dishes into the sanitizing solution. The DS stated the immersion time should be at least 60 seconds. She stated her expectation was for [NAME] 1 to have the knowledge on the manual dishwashing process with the three-compartment sink.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) stated her expectation was for the Dietary staff and the Cooks to know the procedure for the three-compartment sink dishwashing, in case of dishwashing machine malfunction and also for food safety practices.
A concurrent review of competency audits of DA 1 and [NAME] 1 and interview with the DS were conducted on June 23, 2021, at 2:46 p.m. The facility documents titled, Verification Job Competency Demonstration - Diet Aides, and Verification Job Competency Demonstration - Cooks, indicated completion date on 2021 for DA 1 and [NAME] 1. Both competency audits showed that DA 1 and [NAME] 1 were competent to demonstrate and to verbalize the process of emergency dish washing policy and when to use it. The competency audits were evaluated by the DS. The DS stated that the emergency dish washing meant manual dishwashing with three-compartment sink.
A review of facility policy and procedure titled, 3 Compartment Procedure For Manual Dish Washing, dated 2018, it indicated wash and rinse water temperature should be at the range of 110-120 degrees F, and sanitize dishes by immersion in sanitizer solution for 60 seconds.
2. During an interview on June 22, 2021, at 9:48 a.m., the [NAME] (Cook 1) verbalized the cool down process for cooked meat. [NAME] 1 was not able to verbalize when he could start the process of cool down and the cool down log monitoring of cooked turkey. He was not able to verbalize the step to complete when the cooked turkey did not reach 70 degrees Fahrenheit (F) or less within two hours during the cool down process.
During a concurrent interview with the Dietary Supervisor (DS), she verified that [NAME] 1 was not able to verbalize and has a lack of understanding of the cool down process for cooked meat. She stated her expectation for all the Cooks, was to know and understand the process of cool down and the use of cool log in monitoring cooked meats. The DS stated her expectation was for the Cooks to know the step on cooling the meat that did not reach 70 degrees F or less within two hours after the starting the process, because all the staff had an in-service about cool down and reheat.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) stated her expectation was for the Cooks to know the cool down process and how to use the cool down log to monitor the temperature, because that was safe food handling and practices. She stated the Cooks were cooking food to serve the high risk population in the facility.
A review of the competency audit of [NAME] 1 and the facility document titled, Verification of Job competency Demonstration - Cooks, completed the year of 2021, indicated that [NAME] 1 was competent on proper use of the cool down log by demonstration and verbalization. The record indicated the competency was evaluated by the DS.
A review of facility document titled, Food and Nutrition Services In-Services, Topic: Cooling and Reheating Hazardous Foods, completed on April 28, 2021 and was given by the Registered Dietitian (RD), indicated that [NAME] 1 received the in-service on May 26, 2021. It also showed that the participant would understand the importance of and how to appropriately cool and reheat time and temperature controlled for safety foods.
A review of facility policy and procedure titled, Cooling and Reheating Potentially Hazardous Food (PHF) also Called Time/Temperature Control for Safety (TCS), dated 2018, indicated, Cooked potentially hazardous foods hall be cooled and reheated in a method to ensure food safety .potentially hazardous foods include .a food of animal origin that is raw .meat .poultry .The two-stage method .cool cooked food from 140 degree F to 70 F with two hours .then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours .when cooling down food, use the Cool Down Log to document proper procedure.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the menu for the therapeutic diet during lunch meal on June 21 and June 22, 2021, was followed, when:
1. One resident ...
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Based on observation, interview, and record review, the facility failed to ensure the menu for the therapeutic diet during lunch meal on June 21 and June 22, 2021, was followed, when:
1. One resident (Resident 53) on NAS (no added salt, diet with no salt packet), CCHO diet (consistent carbohydrate- used in the treatment for diabetes) received regular sugar packet instead of diet sugar packet as indicated on the menu; and
2. Two residents (Residents 45 and 172) on NAS, CCHO, Renal (used in treatment for chronic kidney disease or end stage kidney disease) received ice-cream as dessert instead of half a cup of diet pineapple as indicated on the menu.
These failures had the potential to result in compromising the medical and nutrition status of those three residents.
Findings:
1. During a dining observation of lunch meal on June 21, 2021, at 12:56 p.m., Resident 53, who was on NAS, CCHO diet received regular sugar packet on her meal tray.
A concurrent review of the undated facility document titled, Summer Menus, Week 3 Monday, showed that CCHO diet should receive diet sugar packet.
During an interview on June 21, 2021, at 3:55 p.m., the Dietary Supervisor (DS) stated CCHO diet was a therapeutic diet and should not get regular sugar packet. She stated that residents with CCHO diet, should have received the diet sugar packet or sweetener as stated on the menu.
During an interview on June 23, 2021, at 10:32 p.m., the Registered Dietitian (RD) stated that CCHO diet should have diet sugar packet but not regular sugar packet, to help control blood sugar for diabetes. She stated the dietary staff should pay attention during meal service and follow the menu.
A review of Resident 53's medical record on June 24, 2021, indicated Resident 53 had a diet order for NAS, CCHO diet. The record indicated Resident 53 had a pertinent medical history of Type 1 Diabetes Mellitus (condition in which the body does not make enough insulin to control blood sugar levels).
A review of facility document titled, Diet Manual: For Long Term Care and Residential Facilities, dated 2020, indicated CCHO diet was for diabetic residents with carbohydrates distributed evenly to maintain a stable blood sugar level throughout the day with meals and snacks. It also indicated the CCHO diet should avoid concentrated sweets and should provide diet sugar with meal.
2. During an observation of lunch meal service on June 22, 2021, beginning at 12:15 p.m., Residents 45 and 172, who were on NAS, CCHO, Renal diet did not receive half a cup of diet pineapple, but instead received ice-cream as dessert.
A concurrent review of the undated facility document titled, Summer Menus: Week 3 Tuesday, indicated that NAS, CCHO, Renal diet should have received half a cup of diet pineapple as dessert.
During an interview on June 22, 2021, at 1:23 p.m., the Dietary Supervisor (DS) acknowledged both residents with NAS, CCHO, Renal diet, and received ice-cream as dessert. She stated that they should have received half a cup of diet pineapple as dessert. The DS stated her expectation was for the dietary staff to read and follow the menu as indicated, especially for the therapeutic diet.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) stated that the menu indicated, to give diet pineapple as dessert was to decrease the levels of phosphorus and potassium for the renal disease and control blood sugar level for diabetes. She explained that ice-cream was not suitable for the NAS, CCHO, Renal diet because it is high in Phosphorous and Potassium levels; and high in sugar if the ice-cream was not sugar free. The RD also stated the staff needed to follow the menu and it was created to provide adequate nutrients for the residents' needs based on their medical conditions.
A review of medical records of Residents 45 and 172, on June 24, 2021, indicated that Residents 45 and 172 had diet orders for NAS, CCHO, Renal diet. Resident 45's medical record indicated Resident 45 had medical history of Type 2 Diabetes Mellitus (chronic medical condition that affects the way the body process blood sugar) and chronic kidney disease (chronic medical condition of the kidneys leading to kidney failure which cannot filter waste and excess fluid from the blood). Resident 172's medical record indicated the resident had medical history of Type 2 Diabetes Mellitus and end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life)
A review of a facility document titled, Diet Manual: For Long Term Care and Residential Facilities, dated 2020, indicated NAS, CCHO, Renal diet was designed for the diabetic resident with renal insufficiency with an appropriate and limited level of protein, salt and low in potassium and phosphorus.
A review of facility policy and procedure titled, Meal Planning, dated 2018, indicated, .the menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to extent medically possible .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failure to implement a policy and procedure on Foods Brought by Family/Visitors that included provisions on facility providing education and informat...
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Based on interview and record review, the facility failure to implement a policy and procedure on Foods Brought by Family/Visitors that included provisions on facility providing education and information about safe food handling practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who involved in preparing, handling, serving or assisting the resident with meals or snacks.
This failure had the potential to cause foodborne illnesses in a medically vulnerable population of 55 out of 58 residents who could consume food and receive food from family or visitors.
Findings:
During an interview on June 24, 2021, at 8:59 a.m., Certified Nurse Assistant (CNA) 8 stated food from family and visitors for residents were kept in the designated refrigerator. However, she was not sure how many days the food could be kept in the refrigerator. CNA 8 stated she had not been trained on safe food handling practices or reheating procedures. She also stated she was not aware that there was a policy and procedure for handling the residents' food brought by family and visitors.
During an interview on June 24, 2021, at 9:06 a.m., Restorative Nurse Assistant (RNA) 2 stated facility had a designated resident's refrigerator for residents' food that family or visitors brought in. She stated the food could be stored may be 48 hours, but she was not so sure if it was the correct answer. She stated she received some training regarding reheating and general hand hygiene but not on safe food handling practices. RNA 2 stated she was not aware if nurses or the facility provided any education for the family or visitors when they prepare food from home and brought in for residents.
During an interview on June 24, 2021, at 9:10 a.m., Licensed Vocational Nurse (LVN) 2 stated facility allowed family and visitors to bring food to the residents and had a designated refrigerator for the food. LVN 2 stated the food could be stored in the refrigerator up to 48 to 72 hours. She stated she received some training regarding reheat and general hand hygiene but not on safe food handling practices for residents' food from family or visitors. She also stated she was not sure if facility provided any education or information regarding safe food handling to the family or visitors who prepared food at home and brought in for the residents.
During an interview on June 24, 2021, at 9:17 a.m., the Director of Staff Development (DSD) stated the facility had no prior in-service regarding the policy and procedure on handling resident's food from family or visitors and no in-service or training done to the facility staff, who are involved in serving food to residents from outside sources, on safe food handling practices. The DSD confirmed that facility was not aware of providing information and education regarding safe food handling practices to family or visitors, who prepared food from home and brought in for the residents. She also acknowledged that facility staff had inconsistent information regarding the policy and procedure and duration of how long the food could be kept in the resident's refrigerator. The DSD stated the facility would develop the materials soon to train the staff and education and information for the family and visitors who brought in food for residents.
A review of facility policy and procedure titled, Foods Brought by Family/Visitors, revised October 2017, it showed .Implementation .Nursing staff will provide family/visitors who wish to bring foods .with a copy of this policy .Family/visitors .prepare and transport food using safe food handling practices .All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices .Safe food handling practices will be explained to family/visitors in a language and format they understand .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:
1. Several variou...
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Based on observations, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:
1. Several various size of metal sheet pans were stacked and stored wet;
2. The ice machine was not cleaned and sanitized properly;
3. Thawing meats were in the reach-in refrigerator without label of pull out and used by dates;
4. The microwave in the kitchenette had significant amount of food debris and sauce stings; and
5. The facial hair of Dietary Aide (DA) 2 was not covered.
These failures had the potential to cause foodborne illnesses in a medically vulnerable population of 55 out of total census of 58 residents who received food from the kitchen.
Findings:
1. During the initial tour in the kitchen, an observation and concurrent interview with the Dietary Supervisor (DS) on June 21, 2021, at 9:39 a.m. was conducted. Three of one-quarter (1/4) size metal pans and two of full sheet size metal pans were observed stacked wet and stored in the clean storage rack.
The DS confirmed the metal pans were wet and stacked on top of each other and stated all pans, pots, utensils, and dishes should be completely air dried before being stored away on the storage rack.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) stated all dishes, utensils, pots, and pans should be completely dry before being stored away. She stated if the dishes, utensils, pots, and pans were wet, the moisture would promote growth of mold or bacteria, which can cause food borne illnesses.
A review of facility policy and procedure titled, Pot and Pans Washing, dated 2018, indicated all items (dishes, pots, pans, and utensils) had to be air-dried and no water droplets were present.
According to FDA Federal Food Code 2017, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils .shall be air-dried .before contact with food.
2. During an observation on June 21, 2021, at 10:15 a.m., the ice machine in the kitchenette had visible orange residue at the side of interior of the ice storage bin. The residue with a slimy texture, was easily removed with a white paper towel. In addition, there was amount of black and dark green slimy residue on the bottom of the ice chute (area where the ice is dispensed) and was easily removed with a white paper towel.
During a concurrent interview with the Director of Environmental Service (DES), he acknowledged the residue was found from the ice machine. The DES stated he was responsible in conducting deep cleaning for the ice machine monthly and the last deep cleaning was on May 21, 2021. The DES explained the steps for deep cleaning of the ice machine. He stated he would empty the ice out from the ice storage bin and take the parts apart to clean the components with the cleaner solution with the brushes and then rinsed them. Then he would use the same cleaner solution to clean the interior of the ice storage bin and then rinse. The DES stated he never used any sanitizer solution to sanitize the component parts, and the ice storage bin. The DES stated he was not aware he had to use sanitizer solution to sanitize the ice machine.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) stated the ice machine needed to be clean and sanitize properly according to the manufacturer's guidance and had to be deep clean, at least once a month. The facility should contact the manufacturer's technician to mentor the maintenance personnel, who is responsible for the deep cleaning of the ice machine, if he was not sure of the proper procedure for deep cleaning. The RD stated ice was food, and if not in a clean and sanitize environment, may cause foodborne illness.
A review of undated ice machine manufacturer's manual, under Section 4: Maintenance, indicated to maintain the ice machine required cleaning and sanitizing procedure with appropriate ice machine cleaner and sanitizer solutions. It showed that ice machine cleaner is used to remove lime scale and mineral deposits and sanitizer is used to disinfect and remove algae (organism that has no roots, stems or leaves and is often grow and found in water or moist areas) and slime (a gelatinous substance).
3. During an observation of the reach-in refrigerator #1 and concurrent interview on June 21, 2021, at 9:20 a.m., it was noted there were two boxes of sliced lab bacon, two boxes of fish fillets, a box of 10 pounds of beef, and three bags of five pounds of chicken thighs in a plastic container thawing in a cart. All the thawing meats were without labeling of pull out and used by dates. The Dietary Supervisor (DS) confirmed there were no pull out and used by dates on the thawing meats. The DS stated the staff should put the pull out and used by dates on the thawing meats, not to cause confusion when the staff pulled out the meats from the freezer.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) stated the thawing meats should be labelled with pull out and used by dates. She stated the staff should write the pull out and used by dates to let the staff know when the meat started to thaw and when it would be use, so as not to create unnecessary confusion that may prolong the thawing days.
A review of facility policy and procedure titled, Food Preparation: Thawing of Meats, dated 2018, it showed .Thawing meat properly .in a refrigerator .Allow 2 to 3 days to defrost .Label defrosting meat with pull and use by date .
4. During an observation of the microwave in the kitchenette and concurrent interview on June 21, 2021, at 10:32 a.m., it was noted that the interior of the microwave had significant amount of food debris and sauce stings. The Dietary Supervisor (DS) confirmed and stated the microwave should be cleaned without any food debris or sauce stings. She stated housekeeping personnel was responsible in cleaning and sanitizing the microwave daily. The DS stated the microwave in the kitchenette was used by nurses to warm up food for the residents and was not sure of the system on how the nurses communicate with the housekeeping personnel when the microwave needed to be cleaned.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) stated the equipment needed to be clean when involving food and if the microwave has food debris, sauce stings, and not clean, would cause cross-contamination to the food and may cause foodborne illness. She stated dietary should coordinate in checking the cleanliness of the microwave.
During an interview on June 24, 2021, at 10:03 a.m., the housekeeper (HK) stated housekeeping was responsible in cleaning the kitchenette daily including the microwave. She stated housekeeping clean and sanitize the interior of the microwave after each meal daily. The HK stated sometimes nurses would communicate with housekeeping to do extra cleaning as needed. She acknowledged the microwave found with food debris and sauce stings on June 21, 2021, and she stated maybe there was a nurse who used it, with food spilled out during heating of food, but did not communicate with them to clean up.
A review of an undated facility policy and procedure titled, Microwave Oven, indicated the microwave should be cleaned inside and outside surfaces daily.
According to FDA Federal Food Code 2017, Section 4-602.12 Cooking and Baking Equipment, .The cavities and door seals of microwave ovens shall be cleaned .
5. On June 21, 2021, at 3:20 p.m., a concurrent observation and interview was conducted with the Dietary Supervisor (DS). Dietary Aide (DA) 2 was observed with beard not covered with any facial restraint, while cleaning the meal carts. The DS confirmed that DA 2 had facial hair and that the staff (DA 2) should wear the facial hair restraint for his facial hair.
A review of facility policy and procedure titled, Dress Code, dated 2018, indicated .Men .Beards and mustaches (any facial hair) must wear beard restraint .
According to Federal Food Code 2017, the food employees must wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that are designed and worn to effectively keep their hair from contacting exposed from food, clean equipment and utensils, and clean linens.
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 and interview, facility failed to provide a clean environment for the residents and visitors, when two of two garbage disposal bins located outside, by the kitchen, were overflowi...
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Based on observation and interview, facility failed to provide a clean environment for the residents and visitors, when two of two garbage disposal bins located outside, by the kitchen, were overflowing and were not securely covered with dumpster lids. In addition, trash was found on the floor next to the garbage disposal bins.
This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.
Findings:
On June 21, 21, at 9:06 a.m., two of two dumpsters located outside, near the facility kitchen, were observed with the lids not securely covering the dumpsters. There was significant amount of bags of trash, overflowing on top of the two dumpsters. There were trash found on the floor next to the dumpsters.
A concurrent interview was conducted with the Dietary Supervisor (DS). The DS stated the trash should not be overflowing and the dumpster lids should to be tightly closed. She stated waste management picked up trash daily except Sundays, and the two dumpsters are shared with the assisted living facility. The DS confirmed and acknowledged the trash found on floor. She stated the trash should not be on the floor and that was not acceptable.
During an interview on June 23, 2021, at 10:32 a.m., the Registered Dietitian (RD) acknowledged the trash was overflowing, dumpster lids could not close tightly for both dumpsters, and trash was found on the floor next to the dumpsters. She stated the trash should not be overflowing, the dumpster lids should cover tightly, and trash should not be on the floor. The RD stated it would be very easy to attract rodents and pest.
A review of facility policy and procedure titled, Miscellaneous Areas: Garbage and Trash, dated 2018, indicated that the storage of garbage and trash area must be clean and vermin-proof and the trash collection area was a potential feeding ground for vermin and rodents, which must be kept clean.
According to Federal Food Code 2017, the receptacles (containers) and waste handling units for refuse, recyclables, and returnable 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.
- • 33% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 59 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Riverside Village Healthcare Center's CMS Rating?
CMS assigns RIVERSIDE VILLAGE HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Riverside Village Healthcare Center Staffed?
CMS rates RIVERSIDE VILLAGE HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 33%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Riverside Village Healthcare Center?
State health inspectors documented 59 deficiencies at RIVERSIDE VILLAGE HEALTHCARE CENTER during 2021 to 2025. These included: 59 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Riverside Village Healthcare Center?
RIVERSIDE VILLAGE HEALTHCARE CENTER 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 BVHC, LLC, a chain that manages multiple nursing homes. With 59 certified beds and approximately 55 residents (about 93% occupancy), it is a smaller facility located in RIVERSIDE, California.
How Does Riverside Village Healthcare Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, RIVERSIDE VILLAGE HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (33%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Riverside Village Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Riverside Village Healthcare Center Safe?
Based on CMS inspection data, RIVERSIDE VILLAGE HEALTHCARE CENTER 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 2-star overall rating and ranks #100 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 Riverside Village Healthcare Center Stick Around?
RIVERSIDE VILLAGE HEALTHCARE CENTER has a staff turnover rate of 33%, 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 Riverside Village Healthcare Center Ever Fined?
RIVERSIDE VILLAGE HEALTHCARE CENTER 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 Riverside Village Healthcare Center on Any Federal Watch List?
RIVERSIDE VILLAGE HEALTHCARE CENTER 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.