What is CAPITAL POST ACUTE's CMS rating?

CAPITAL POST ACUTE has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does CAPITAL POST ACUTE have?

CAPITAL POST ACUTE has 63 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at CAPITAL POST ACUTE?

CAPITAL POST ACUTE has a three-star staffing rating from CMS with 0.69 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CAPITAL POST ACUTE located?

CAPITAL POST ACUTE is located in SACRAMENTO, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CAPITAL POST ACUTE have?

CAPITAL POST ACUTE has 121 certified beds.

Who owns CAPITAL POST ACUTE?

CAPITAL POST ACUTE is a for profit - limited liability company facility and is part of the SPYGLASS HEALTHCARE chain.

Is CAPITAL POST ACUTE safe?

CAPITAL POST ACUTE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at CAPITAL POST ACUTE stick around?

CAPITAL POST ACUTE has average staff turnover at 49%, which is typical for the nursing home industry.

Was CAPITAL POST ACUTE ever fined?

No, CAPITAL POST ACUTE has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is CAPITAL POST ACUTE on any federal watch list?

No, CAPITAL POST ACUTE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at CAPITAL POST ACUTE?

Medicare inspectors have found 63 deficiencies at CAPITAL POST ACUTE: 63 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting CAPITAL POST ACUTE?

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

How does CAPITAL POST ACUTE compare to other nursing homes?

CAPITAL POST ACUTE has a 2-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

CAPITAL POST ACUTE | 50/100 (Grade C)

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Based on interviews and record reviews the facility failed to ensure Resident 1 was treated with respect and dignity for a census of 116. This failure had the potential for Resident 1 to not experien...

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Based on interviews and record reviews the facility failed to ensure Resident 1 was treated with respect and dignity for a census of 116. This failure had the potential for Resident 1 to not experience her highest practicable physical, mental, and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record indicated Resident was admitted to the facility in February 2025 with diagnoses which included spinal cord disease (conditions that affect the spinal cord, causing damage or deterioration) and post-traumatic stress disorder (PTSD, an anxiety disorder caused by very stressful, frightening or distressing events). A review of Resident 1 ' s Brief Interview for Mental Status (BIMS, an assessment tool), dated 3/4/25, indicated Resident 1 was cognitively intact. A review of Resident 1 ' s Care Plan (CP, a document that outlines a person's specific care needs, medical history, and the interventions that will be used to address those needs), dated 3/5/25 indicated Resident 1 was dependent on facility staff for meeting her emotional, intellectual, physical and social needs. During an interview on 5/1/25 at 11:49 a.m. with Resident 1, in the resident ' s room, Resident 1 stated she had difficulty hearing, so the interview was conducted using a whiteboard. Resident 1 reported that she had been waiting to be cleaned and changed after having a bowel movement when Certified Nursing Assistant (CNA) 1 entered her room, walked past her bed to Resident 2 ' s side of the room, then turned around and started to walk out of the room. Resident 1 asked, Are you my CNA for tonight? CNA 1 ignored Resident 1 ' s question and continued to walk out of the room. CNA 1 then re-entered Resident 1 ' s room, stood at the foot of her bed and started to yell and wave her arms up and around her head. Resident 1 stated, I asked her [CNA 1] to write it down on the white board, I couldn ' t hear what she was saying .I was embarrassed and afraid, I can ' t hear well, and she [CNA 1] was moving her arms above her head rapidly .I was scared, I didn ' t know what she would do. Resident 1 stated another staff member came in and took CNA 1 out of the room. During an interview on 5/1/25 at 12:13 p.m. with Resident 2, in the resident ' s room, Resident 2 stated CNA 1 stood at the foot of Resident 1 ' s bed and was yelling and waving her arms over her head at Resident 1. Resident 2 stated, She [CNA 1] pushed herself inside our room and another staff member had to come into the room and physically remove her. During an interview on 5/1/25 at 3:49 p.m. with Family Member (FM), the FM stated that FM witnessed CNA 1 yelled at Resident 1, I told you I ' d come back . I have other patients to attend to . on 4/29/25 during the evening shift. FM stated, There ' s a white board with a pen on her bedside table, I don ' t know why staff don ' t use it .[Resident 1] can be hard of hearing, this is a new condition, she doesn ' t read lips effectively and it doesn ' t help when the staff continue to yell through their masks .when there ' s a white board right there .what happens when we aren ' t here to advocate for [Resident 1]. During an interview on 5/1/25 at 4:36 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 would verbally tell you when she needed to be cleaned or changed and would ask questions about her care. LN 1 stated, [Resident 1] requested assistance from [CNA 1] but I couldn ' t find [CNA 1] at first .a few minutes passed, and I saw [CNA 1] go into another resident ' s room .I told her [Resident 1] was asking for her and [CNA 1] became defensive, complaining about having to assist [Resident 1] .At that point, I told the supervisor on the floor .Yes, CNA 1 was yelling at [Resident 1]. During an interview on 5/1/25 at 5:16 p.m. with the Director of Nursing (DON), the DON acknowledged she was aware of the incident with CNA 1 on 4/29/25. The DON stated the facility did not follow up on Resident 1's psychosocial or emotional needs.The facility ' s policy and procedure (P&P) related to resident Communication and Respect and Dignity was requested but was not provided.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to report an allegation of abuse (the willful infliction ...

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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 report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Survey Agency for one of nine sampled residents (Resident 4). This failure placed the residents at risk for continued exposure to potential abuse. Findings: Resident 4 was admitted to the facility on [DATE] with medical diagnoses which included acute and chronic respiratory failure with hypercapnia (the body's inability to efficiently remove carbon dioxide from the blood), anemia (a condition where the body does not have enough healthy red blood cells), and difficulty in walking. Resident 4 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 4 was cognitively intact. Resident 5 was admitted to the facility in March 2024 with medical diagnoses which included adult failure to thrive, anxiety disorder, and unspecified dementia. Resident 5 had a BIMS score of 15 out of 15 which indicated Resident 5 was cognitively intact. During a review of Resident 4's medical record, the record indicated Resident 4 was discharged from the facility on 5/9/24 and was not living in the facility at the time of the investigation. During a review of Resident 5's medical record, the record indicated Resident 5 was discharged from the facility on 5/14/24 and was not living in the facility at the time of the investigation. During a review of Resident 4's progress note, dated 5/8/24, signed by Licensed Nurse 1 (LN 1), the progress note indicated, [Resident 4] said [Resident 5] is threatening her, the family [sister] called the facility and said, I am going to call 911 if you didn't move her. Notified to manage team & DON (Director of Nursing), same time [Resident 4] moved to room .for her comfort and safety. During a concurrent interview and record review on 4/23/25 at 1:01 p.m. with the Administrator (Admin), Resident 4's progress note dated 5/8/24 was reviewed. The progress note indicated, [Resident 4] said [Resident 5] is threatening her, the family [sister] called the facility and said, I am going to call 911 if you didn't move her. Notified to manage team & DON, same time [Resident 4] moved to room .for her comfort and safety. When Admin was asked if the incident was reported to the State Survey Agency, the Admin stated, It should have been if the patient is expressing anything like that. The Admin later stated the facility did not escalate past that (report the incident). During an interview on 4/23/25 at 1:45 p.m. with the DON, the DON stated she had received a report over text from LN 1 that Resident 5 was yelling at Resident 4. The DON stated, I don't remember all the details; it was a year ago. The DON confirmed she conferred with LN 1 at the time of the incident and Resident 4 was moved to another room. The DON further stated the incident was not reported to the State Survey Agency. During a subsequent interview on 4/23/25 at 3:31 p.m. with Admin and DON, a request was made to interview LN 1. The Admin stated LN 1 only works per diem and did not provide a phone number for LN 1. The DON attempted to reach LN 1, but later stated LN 1 was unavailable and did not provide a phone number for LN 1. During a review of LN 1's Employee Attestation of Commitment to Standards and Ethics, dated and signed by LN 1 on 4/8/21, the Employee Attestation of Commitment to Standards and Ethics indicated LN 1, Acknowledge my responsibility to report any reasonable suspicion of a crime committed against a resident of this facility to local law enforcement AND to the state survey agency within required time frames. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated July 2017, the P&P indicated, All reports of resident abuse .shall be promptly reported to local, state, and federal agencies. Based on observation, interview and record review, the facility failed to report an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) to the State Survey Agency for one of nine sampled residents (Resident 4). This failure placed the residents at risk for continued exposure to potential abuse. Findings: Resident 4 was admitted to the facility on [DATE] with medical diagnoses which included acute and chronic respiratory failure with hypercapnia (the body's inability to efficiently remove carbon dioxide from the blood), anemia (a condition where the body does not have enough healthy red blood cells), and difficulty in walking. Resident 4 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 4 was cognitively intact. Resident 5 was admitted to the facility in March 2024 with medical diagnoses which included adult failure to thrive, anxiety disorder, and unspecified dementia. Resident 5 had a BIMS score of 15 out of 15 which indicated Resident 5 was cognitively intact. During a review of Resident 4's medical record, the record indicated Resident 4 was discharged from the facility on 5/9/24 and was not living in the facility at the time of the investigation. During a review of Resident 5's medical record, the record indicated Resident 5 was discharged from the facility on 5/14/24 and was not living in the facility at the time of the investigation. During a review of Resident 4's progress note, dated 5/8/24, signed by Licensed Nurse 1 (LN 1), the progress note indicated, [Resident 4] said [Resident 5] is threatening her, the family [sister] called the facility and said, I am going to call 911 if you didn't move her. Notified to manage team & DON (Director of Nursing), same time [Resident 4] moved to room .for her comfort and safety. During a concurrent interview and record review on 4/23/25 at 1:01 p.m. with the Administrator (Admin), Resident 4's progress note dated 5/8/24 was reviewed. The progress note indicated, [Resident 4] said [Resident 5] is threatening her, the family [sister] called the facility and said, I am going to call 911 if you didn't move her. Notified to manage team & DON, same time [Resident 4] moved to room .for her comfort and safety. When Admin was asked if the incident was reported to the State Survey Agency, the Admin stated, It should have been if the patient is expressing anything like that. The Admin later stated the facility did not escalate past that (report the incident). During an interview on 4/23/25 at 1:45 p.m. with the DON, the DON stated she had received a report over text from LN 1 that Resident 5 was yelling at Resident 4. The DON stated, I don't remember all the details; it was a year ago. The DON confirmed she conferred with LN 1 at the time of the incident and Resident 4 was moved to another room. The DON further stated the incident was not reported to the State Survey Agency. During a subsequent interview on 4/23/25 at 3:31 p.m. with Admin and DON, a request was made to interview LN 1. The Admin stated LN 1 only works per diem and did not provide a phone number for LN 1. The DON attempted to reach LN 1, but later stated LN 1 was unavailable and did not provide a phone number for LN 1. During a review of LN 1's Employee Attestation of Commitment to Standards and Ethics, dated and signed by LN 1 on 4/8/21, the Employee Attestation of Commitment to Standards and Ethics indicated LN 1, Acknowledge my responsibility to report any reasonable suspicion of a crime committed against a resident of this facility to local law enforcement AND to the state survey agency within required time frames. During a review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated July 2017, the P&P indicated, All reports of resident abuse .shall be promptly reported to local, state, and federal agencies.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases...

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Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when staff did not wear a gown when providing high contact care to three residents (Residents 1, 2, and 3) on Enhanced Barrier Precautions [EBP-set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)] for a census of 116 These failures could lead to increased risk of infection spreading among residents. Findings 1. Resident 1 was re-admitted to the facility in March 2025 with multiple medical diagnoses which included anemia (a condition where the body does not have enough healthy red blood cells). Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 1 was cognitively intact. During an observation on 4/22/25 at 1:21 p.m. outside of Resident 1's room, an orange Enhanced Barrier Precautions (EBP) sign was posted along with four magnets across the doorway in the following order: orange, orange, white, orange. During an observation on 4/22/25 at 1:28 p.m. inside of Resident 1's room, Certified Occupational Therapy Assistant 1(COTA 1) was seen entering the curtained area around Resident 1's bed wearing gloves, but no gown. During an interview on 4/22/25 at 2:05 p.m. with COTA 1, COTA 1stated he was not wearing a gown while assisting Resident 1 with transferring. COTA 1 stated he had been working with Resident 1 for the past few weeks once daily, five days a week. COTA 1 stated he wore gloves, but never a gown while assisting Resident 1 with therapy activities. During an interview on 4/23/25 at 9:30 a.m. with Resident 1, Resident 1 stated she worked with therapy staff on weekdays. Resident 1 stated therapy staff wore gloves, but they never wore a gown while exercising her right leg and assisting her with sitting and standing. During a review of Resident 1's MD (Medical Doctor) orders, dated 4/5/25, the MD orders indicated, OT (Occupational Therapy) Frequency: Daily for 5x/wk (five times per week) for 4 weeks. During a review of Resident 1's MD orders, dated 4/5/25, the MD orders indicated, Enhanced Barrier Precautions (EBP) required d/t (due to) MDRO Hx MRSA colonized .providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens. 2. Resident 2 was re-admitted to the facility in February 2025 with medical diagnoses which included acquired absence of left leg above knee, dementia, and acute pyelonephritis (a bacterial infection that causes inflammation of the kidneys). Resident 2 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15 which indicated Resident 2 was severely cognitively impaired. During an observation on 4/22/25 at 4:42 p.m. outside of Resident 2's room, an orange Enhanced Barrier Precautions (EBP) sign was posted along with three magnets across the doorway in the following order: orange, orange, white. Certified Nursing Assistant 1 (CNA 1) was observed entering the curtained area around Resident 2's bed wearing gloves, but no gown. Subsequently, CNA 1 was observed exiting Resident 2's curtained area with a used brief in his hand wearing gloves, but no gown. During an interview on 4/22/25 at 4:51 p.m. with CNA 1, CNA 1 stated he was wearing gloves, but no gown while assisting Resident 2 with transferring him to bed and a subsequent brief change. When CNA 1 was asked if he should have been wearing a gown, CNA 1 stated, Yes, I should have. During a review of Resident 2's MD orders, dated 3/19/25, the MD orders indicated, Enhanced Barrier Precautions (EBP) required d/t (due to) MDRO ( .urine .) Providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. 3. Resident 3 was admitted to the facility in February 2025 with medical diagnoses which included cellulitis (a skin infection that causes swelling and redness) of left lower limb, cutaneous abscess (a pocket of pus that develops under the skin, typically due to a bacterial infection) of right lower limb, and methicillin resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics) infection. Resident 3 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 3 was cognitively intact. During an observation on 4/22/25 at 3:28 p.m. outside of Resident 3's room, an orange Enhanced Barrier Precautions (EBP) sign was posted along with three magnets across the doorway in the following order: orange, white, orange. Restorative Nursing Assistant 1 (RNA 1) transferred Resident 3's legs bilaterally into bed and placed a pillow under each leg. RNA 1 was wearing gloves, but no gown. During an interview on 4/22/25 at 3:34 p.m. with RNA 1, RNA 1 stated she was wearing gloves, but no gown when she transferred Resident 3's legs into bed and placed pillows under them. RNA 1 stated she worked with Resident 3 three days a week, but did not wear a gown while exercising Resident 3. During a review of Resident 3's MD orders, dated 3/27/25, the MD orders indicated, RNA Program: ROM (range of motion) for BUE/BLE (bilateral upper and lower extremities) 3x/week (three times per week) Functional sit to stand from EOB (edge of bed). During a review of Resident 3's MD orders, dated 2/17/25, the MD orders indicated, Enhanced Barrier Precautions (EBP) required d/t (due to) MDRO MRSA LLE (left lower extremity) wound .Providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens. During an interview on 4/23/25 at 9:00 a.m. with Infection Preventionist (IP), the IP stated staff should wear gloves and a gown when assisting residents on EBP with high-contact activities. When the IP was asked what PPE (personal protective equipment) staff should be wearing when assisting residents with transferring, lifting legs, adjusting pillows or brief changes, the IP stated, A gown and gloves. The IP further stated the facility posted an orange EBP sign authored by the CDC (Centers for Disease Control and Prevention) with color coded magnets outside of the room of residents on EBP, so that staff could easily identify residents on EBP in case of emergencies. During an interview on 4/23/25 at 9:49 a.m. with Director of Nursing (DON), the DON acknowledged the use of the CDC EBP sign with color coded magnets to identify residents on EBP. The DON stated staff should be wearing gloves and a gown when assisting with high-contact activities such as changing a brief. When the DON was asked if staff should wear gloves and a gown when lifting legs and transferring a resident back to bed, the DON stated, Yes, the CDC sign clearly says transferring. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated April 2025, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .changing briefs or assisting with toileting .transferring .providing bed mobility .prolonged, high-contact with items in the resident's room, with resident's equipment or with resident's clothing or skin. Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when staff did not wear a gown when providing high contact care to three residents (Residents 1, 2, and 3) on Enhanced Barrier Precautions [EBP-set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)] for a census of 116 These failures could lead to increased risk of infection spreading among residents. Findings 1. Resident 1 was re-admitted to the facility in March 2025 with multiple medical diagnoses which included anemia (a condition where the body does not have enough healthy red blood cells). Resident 1 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 1 was cognitively intact. During an observation on 4/22/25 at 1:21 p.m. outside of Resident 1's room, an orange Enhanced Barrier Precautions (EBP) sign was posted along with four magnets across the doorway in the following order: orange, orange, white, orange. During an observation on 4/22/25 at 1:28 p.m. inside of Resident 1's room, Certified Occupational Therapy Assistant 1(COTA 1) was seen entering the curtained area around Resident 1's bed wearing gloves, but no gown. During an interview on 4/22/25 at 2:05 p.m. with COTA 1, COTA 1stated he was not wearing a gown while assisting Resident 1 with transferring. COTA 1 stated he had been working with Resident 1 for the past few weeks once daily, five days a week. COTA 1 stated he wore gloves, but never a gown while assisting Resident 1 with therapy activities. During an interview on 4/23/25 at 9:30 a.m. with Resident 1, Resident 1 stated she worked with therapy staff on weekdays. Resident 1 stated therapy staff wore gloves, but they never wore a gown while exercising her right leg and assisting her with sitting and standing. During a review of Resident 1's MD (Medical Doctor) orders, dated 4/5/25, the MD orders indicated, OT (Occupational Therapy) Frequency: Daily for 5x/wk (five times per week) for 4 weeks. During a review of Resident 1's MD orders, dated 4/5/25, the MD orders indicated, Enhanced Barrier Precautions (EBP) required d/t (due to) MDRO Hx MRSA colonized .providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens. 2. Resident 2 was re-admitted to the facility in February 2025 with medical diagnoses which included acquired absence of left leg above knee, dementia, and acute pyelonephritis (a bacterial infection that causes inflammation of the kidneys). Resident 2 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15 which indicated Resident 2 was severely cognitively impaired. During an observation on 4/22/25 at 4:42 p.m. outside of Resident 2's room, an orange Enhanced Barrier Precautions (EBP) sign was posted along with three magnets across the doorway in the following order: orange, orange, white. Certified Nursing Assistant 1 (CNA 1) was observed entering the curtained area around Resident 2's bed wearing gloves, but no gown. Subsequently, CNA 1 was observed exiting Resident 2's curtained area with a used brief in his hand wearing gloves, but no gown. During an interview on 4/22/25 at 4:51 p.m. with CNA 1, CNA 1 stated he was wearing gloves, but no gown while assisting Resident 2 with transferring him to bed and a subsequent brief change. When CNA 1 was asked if he should have been wearing a gown, CNA 1 stated, Yes, I should have. During a review of Resident 2's MD orders, dated 3/19/25, the MD orders indicated, Enhanced Barrier Precautions (EBP) required d/t (due to) MDRO ( .urine .) Providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting. 3. Resident 3 was admitted to the facility in February 2025 with medical diagnoses which included cellulitis (a skin infection that causes swelling and redness) of left lower limb, cutaneous abscess (a pocket of pus that develops under the skin, typically due to a bacterial infection) of right lower limb, and methicillin resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics) infection. Resident 3 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 which indicated Resident 3 was cognitively intact. During an observation on 4/22/25 at 3:28 p.m. outside of Resident 3's room, an orange Enhanced Barrier Precautions (EBP) sign was posted along with three magnets across the doorway in the following order: orange, white, orange. Restorative Nursing Assistant 1 (RNA 1) transferred Resident 3's legs bilaterally into bed and placed a pillow under each leg. RNA 1 was wearing gloves, but no gown. During an interview on 4/22/25 at 3:34 p.m. with RNA 1, RNA 1 stated she was wearing gloves, but no gown when she transferred Resident 3's legs into bed and placed pillows under them. RNA 1 stated she worked with Resident 3 three days a week, but did not wear a gown while exercising Resident 3. During a review of Resident 3's MD orders, dated 3/27/25, the MD orders indicated, RNA Program: ROM (range of motion) for BUE/BLE (bilateral upper and lower extremities) 3x/week (three times per week) Functional sit to stand from EOB (edge of bed). During a review of Resident 3's MD orders, dated 2/17/25, the MD orders indicated, Enhanced Barrier Precautions (EBP) required d/t (due to) MDRO MRSA LLE (left lower extremity) wound .Providers and staff must wear gloves and gown for the following High-Contact Resident Care Activities: Dressing, bathing/showering, transferring, changing linens. During an interview on 4/23/25 at 9:00 a.m. with Infection Preventionist (IP), the IP stated staff should wear gloves and a gown when assisting residents on EBP with high-contact activities. When the IP was asked what PPE (personal protective equipment) staff should be wearing when assisting residents with transferring, lifting legs, adjusting pillows or brief changes, the IP stated, A gown and gloves. The IP further stated the facility posted an orange EBP sign authored by the CDC (Centers for Disease Control and Prevention) with color coded magnets outside of the room of residents on EBP, so that staff could easily identify residents on EBP in case of emergencies. During an interview on 4/23/25 at 9:49 a.m. with Director of Nursing (DON), the DON acknowledged the use of the CDC EBP sign with color coded magnets to identify residents on EBP. The DON stated staff should be wearing gloves and a gown when assisting with high-contact activities such as changing a brief. When the DON was asked if staff should wear gloves and a gown when lifting legs and transferring a resident back to bed, the DON stated, Yes, the CDC sign clearly says transferring. During a review of the facility's policy and procedure titled, Enhanced Barrier Precautions, dated April 2025, indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities .examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .changing briefs or assisting with toileting .transferring .providing bed mobility .prolonged, high-contact with items in the resident's room, with resident's equipment or with resident's clothing or skin.

Feb 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to ensure medications were secure for a census of 118 when a medication/treatment cart was unlocked and unattended with prescription medications...

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Based on observation and interview, the facility failed to ensure medications were secure for a census of 118 when a medication/treatment cart was unlocked and unattended with prescription medications in it. This failure had the potential to expose residents, staff, and visitors to unauthorized access to medications resulting in possible injury or drug diversion. Findings: During an observation on 2/4/25 at 10:19 a.m. in the facility front lobby, the treatment cart was observed to be up against the wall, unattended and unlocked. During a concurrent observation and interview on 2/4/25 at 10:26 a.m. with the license Nurse (LN) 1, the LN 1 confirmed the treatment cart with prescription medications was unlocked. The LN stated, The cart should always be locked when not in use. During an interview on 2/4/25 at 12:15 p.m. with Director of Nursing (DON), the DON stated, I would expect all medication and treatment carts with prescribed medications to be locked when unattended for safety. During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage dated 3/1/2023, the P&P indicated, It is the policy of this facility to ensure .All drugs and biologicals will be stored in locked compartment (medication carts, cabinet, drawer, refrigerators, medication room).

Nov 2024 16 deficiencies

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 record review, the facility failed to maintain resident's right to privacy and confidentiality of personal and medical records for one resident out of a census of ...

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Based on observation, interview, and record review, the facility failed to maintain resident's right to privacy and confidentiality of personal and medical records for one resident out of a census of 112 residents when a computer screen that showed a resident's photo and confidential personal and medical information was left unsecured and unattended. These failures had the potential to result in unauthorized access of residents' personal and medical information. Findings: During an observation on 11/4/24 at 1:50 p.m. near nurse's station 1, 2, & 3, next to the facility lobby, a computer on top of a treatment cart had a screen showing a resident's photo, complete name, medical record number, current room and bed number, gender, date of birth , age, attending physician, and other pertinent personal and medical information. It was left unattended facing the facility lobby. Four residents and three facility staff were observed passing by the treatment cart. Multiple staff were in the facility lobby. During a concurrent observation and interview on 11/4/24 at 1:50 p.m. near nurse's station 1, 2, & 3, next to the facility lobby, Physical Therapy Assistant (PTA) 1 confirmed the observation of a computer on top of a treatment cart with screen showing a resident's photo and pertinent personal and medical information left unattended and was facing the facility lobby. PTA 1 stated the computer should have been closed or covered because it has resident's confidential personal and medical records. During an interview on 11/6/24 at 3:46 p.m. with the Director of Nursing (DON), the DON stated the staff should protect residents' records. The DON further started, .It's [leaving resident's personal and medical records unattended] HIPAA (Health Insurance Portability and Accountability Act- a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed) violation . A review of the facility's policy and procedure (P&P) titled, Confidentiality of Personal and Medical Records, dated 7/1/23, indicated, This facility honors the resident's right to secure confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. A review of the facility's P&P titled, Resident Rights, dated 6/1/24, indicated, 7. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and homelike environment for one of 25 sampled residents (Resident 70) when a hole was observed...

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Based on observation, interview, and record review, the facility failed to maintain a safe, comfortable, and homelike environment for one of 25 sampled residents (Resident 70) when a hole was observed in the wall of Resident 70's room. This failure created a non-homelike environment for Resident 70. Findings: Resident 70 was admitted to the facility in 2024 with diagnoses that included a stroke (damage to the brain from an interruption of its blood supply), hemiplegia (the inability to move one side of the body), and aphasia (a condition affecting the ability to express language). A review of Resident 70's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 9/27/24, indicated Resident 70 had a Brief Interview for Mental Status (a tool to assess a persons' full understanding) score of 14 out of 15 which indicated Resident 70 was cognitively intact. During an observation on 11/4/24 at 10:17 a.m., Resident 70's room had a six inch by 12 inch hole in the drywall with exposed plumbing approximately two feet above the floor below the television. During an interview with Resident 70 on 11/4/24 at 10:17 a.m., Resident 70 pointed to the hole in the drywall and when asked if the hole bothered him, Resident 70 nodded his head indicating yes. During a concurrent observation and interview with the Administrator (ADM) on 11/6/24 at 10:12 a.m., the ADM verified the six inch by 12 inch hole in the wall. The ADM stated the sink was removed and the wall had not been patched. The ADM further stated, There should not be a hole in the wall, and it should have been fixed. A review of the facility policy titled, Safe and Homelike Environment dated 6/1/23 indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and policy review, the facility failed to ensure an assessment accurately reflected the ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and policy review, the facility failed to ensure an assessment accurately reflected the resident's status for one of 25 sampled residents (Resident 112). This deficient practice had the potential for inaccurate care. Findings: Resident 112 was admitted to the facility on [DATE] with diagnoses that included encounter for surgical aftercare following surgery on the digestive system and chronic obstructive pulmonary disease (COPD-lung disease). Review of Resident 112's MDS (Minimum Data Set-an assessment tool), dated 9/7/24 under section A0310 Type of Assessment-Continued indicated unplanned discharge. Under section A2105 Discharge Status indicated Resident 112 went to 04. Short-Term General Hospital (acute hospital .). During a review of Resident 112's Progress Note dated 9/7/24 at 10:54 a.m., indicated Res (resident) decided that he wanted to go home against medical advice (AMA) today. Risk and benefits explained to the res but still doesn't want to stay and verbalized i (sic) rather be home. MD (Medical Doctor), DON (Director of Nursing) and administrator was tonified (sic). Res signed the AMA release form; he was picked up by his roommate at 0955am (9:55 a.m.) During a review of Resident 1's medical record contained a form tilted AMA Release Form, dated 9/7/24 at 9:40 a.m. indicated Resident 1 was discharging against medical advice. During an interview on 11/06/24 at 9:17 a.m. with the MDS Coordinator Assistant (MDSCA), she confirmed Resident 112 went home AMA on 9/7/24. The MDSCA confirmed Resident 112's MDS dated [DATE] under section A2105 Discharge Status was the wrong code. The MDSCA further confirmed the MDS should have been coded 01 (Home/Community). Review of the facility policy and procedure (P&P) titled Conducting an Accurate Resident Assessment dated 9/1/24 indicated, The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. The P&P indicated, ''Accuracy of assessment'' means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, significant change in status).

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one out of 25 sampled residents (Resident 105) when Resident 105's resp...

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Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one out of 25 sampled residents (Resident 105) when Resident 105's respiratory care and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) treatment care plan was not developed. This failure placed Resident 105 at risk to not meet his medical needs and to not achieve the highest practicable well-being. Findings: A review of Resident 105's clinical record indicated Resident 105 was admitted October of 2024 and had diagnoses that included parkinsonism (a clinical syndrome characterized by tremor, slowed movement, rigidity, and postural instability), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe), dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 105's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/18/24, indicated Resident 105 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 105 had a moderately impaired cognition. A review of Resident 105's MDS Health Conditions, dated 10/18/24, indicated Resident 105 had experienced shortness of breath or trouble breathing when lying flat. A review of Resident 105's physician's order, dated 10/16/24, indicated, Ipratropium-Albuterol Solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] . 1 vial (a glass container used for holding liquid medicines) inhale orally via nebulizer four times a day for Asthma WAIT 5 MINUTES BEFORE GIVING ANOTHER INHALER/NEBULIZER SOLUTION. During a concurrent interview and record review on 11/6/24 at 9:57 a.m. with Licensed Nurse (LN) 4, Resident 105's active care plan was reviewed. LN 4 confirmed that Resident 105 had no respiratory care and nebulizer treatment care plan developed. LN 4 stated she knew Resident 105 used a nebulizer and she expected that it should be in Resident 105's care plan. LN 4 further stated, It [respiratory care and nebulizer treatment] should be in the care plan .It's [respiratory care and nebulizer treatment care plan] not there [list of active care plan] .It's [care plan] the plan for the resident .So we [facility staff] will know what care we need to provide to him [Resident 105]. During an interview on 11/6/24 at 3:46 p.m. with the Director of Nursing (DON), the DON stated she would expect that respiratory care and nebulizer treatment will be part of the care plan for Resident 105. The DON further stated that care plan is for nurses' guidance on providing care to the resident. A review of the facility's policy and procedures titled, Care Plan Revisions Upon Status Change, dated 6/1/24, indicated, 1. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .f. Resident-specific interventions that reflect the resident's needs and preferences .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure safe Quality Control (or QC, proactive testing and calibration for accuracy of devices) and resident care practices wit...

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Based on observation, interview, and record review the facility failed to ensure safe Quality Control (or QC, proactive testing and calibration for accuracy of devices) and resident care practices with resident census of 112 based on standards of practice and facility's policy when: 1. The facility did not perform Quality Control (testing and calibration for accuracy) for glucometer (a machine that measures the blood sugar level) devices consistently based on facility's policy and the manufacturer recommendations. 2. Nursing care did not follow orders for checking feeding tube (surgically inserted tube into the stomach for feeding or medication administration when oral route not available) residuals (practice of checking volume of residue in the tube connected to stomach; this helped with reduced risk of aspiration [when stomach contents get into lung]) and keeping head elevated when medication was given to Resident 82 via feeding tube. These failed practices could contribute to unsafe care of diabetes resident with blood sugar monitoring and risk of complications from tube feeding. Findings: 1. During a concurrent interview and record review of facility's document, titled Quality Control Record, with date range of June 2024 to November of 2024, accompanied by Licensed Nurse 9 (LN 9), on 11/5/24, at 9:51 AM, at back nursing station, the QC records for facility's glucometer devices were not consistently performed. LN 9 stated the QC checks were done by night shift staff for all glucometers in the medication carts. LN 9 acknowledged the following inconsistent testing and/or documentation: The review of glucometer QC record for medication cart #4 did not have complete documentation from 6/21/24 to 6/30/24. LN 9 could not locate QC record for the month of July and August of 2024. The QC record for 9/2024 was missing input from 9/21/24 to 9/30/24. The QC record for 10/2024 was missing input from 10/11/24 to 10/16/24. The QC record for first week of 11/2024 was missing input from 11/1/24 to 11/4/24. In an interview with the Director of Nursing (DON), in her office, on 11/5/24, at 3:35 p.m., the DON stated the night shift staff were responsible to do QC check of glucometers and the Director of Staff Development (or DSD, a role responsible for initial and ongoing staff education and onboarding) and DON were responsible to check if QC were documented. DON stated the glucometer QC check assured the accuracy of blood sugar measurements. Review of the facility's policy, titled Blood Glucose Monitoring, dated 1/1/23, the policy indicated Calibration checks on glucometer must be performed as per the manufacturer's instruction. Review of the facility's glucometer manufacturer, brand name EVENCARE G3, dated 2016, the document indicated The purpose of the control solution testing is to validate that the EVENCARE G3 Meter is working properly with the test strips . 2. During a medication administration observation of Resident 82, with Licensed Nurse 6 (LN 6), on 11/4/24, at 4:27 p.m., LN 6 prepared a new feeding bag (nutritional fluid) for use at a later time, then crushed a medication called glycopyrrolate (Drug used to reduce secretions in the mouth) to administer to Resident 82 through the feeding tube (a surgically inserted tube into the stomach.) LN 6 entered the room with Resident 82 lying down on her left side, accessed the feeding tube, flushed the feeding tube with water in a syringe, then administered the medication diluted in water. LN 6 did not raise the resident's head during medication administration and did not check for residual volume in the feeding tube prior to medication administration. In an interview with LN 6 on 11/4/24, at 4:50 p.m., LN 6 stated Resident 82's head should have been raised by at least 20-30 degrees to prevent aspiration during medication administration. LN 6 stated she did not check the feeding tube residuals because it was ordered to be checked three times a day during each shift. Review of Resident 82's electronic medical record, titled Medication Administration Record (Or MAR, a record that listed doctor's orders for nurses to follow and document), the MAR record indicated the following orders: a. Enteral Feed (same as tube feeding) Order: every shift Enteral - Check Residuals before beginning a feeding and before medication administration. If Greater than 100 cc (CC is an abbreviation for cubic centimeter, a unit of volume in the metric system), HOLD Feedings and Recheck in 1 HR. If not resolved, CALL MD -Start Date 4/13/23. b. Enteral Feed Order: every shift Enteral - Elevate Head of bed at least 30 Degrees during feeding, any medication administration and for 30 minutes after feeding. -Start Date 4/13/23. In an interview with the DON, on 11/5/24, at 3:43 p.m., the DON stated the staff should follow facility's policy and physician's orders. Review of the facility's policy, titled Care and Treatment of Feeding Tube Policy, dated 6/1/24, the policy indicated It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complication to the extent possible . The Resident's plan of care will address the use of feeding tube, including strategies to prevent complications.

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 an observation, interview and record review, the facility failed to ensure one out of 25 sampled residents (Resident 29) r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based an observation, interview and record review, the facility failed to ensure one out of 25 sampled residents (Resident 29) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 29's physician's order for G-Tube Insertion Site (Gastronomy tube-a tube used to provide nutrition and medications) treatment was not followed. This failure had the potential for Resident 29's G-tube insertion site to become infected and for Resident 29 to not achieve their highest practicable well-being. Findings: Resident 29 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and as having a G-Tube. During a review a Resident 29's physician orders contained an order dated 5/10/24 for Enteral - Cleanse G Tube Insertion Site QD (every day) with NSS (normal sterile saline), pat dry, cover with gauze or abdominal pad. Monitor and report to MD if s.s. (signs & symptoms) of worsening. every day shift. During a concurrent observation and interview on 11/6/24 at 9:51 a.m., with Licensed Nurse (LN) 1, Resident 29's G-Tube was observed with no gauze or abdominal pad on the insertion site. LN 1 confirmed the G-Tube insertion site should have gauze on it. During a review of the facility's policy and procedure (P&P) titled, Provision of Physician Ordered Services, dated 3/1/23 indicated, The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. ''Professional Standards of Quality'' means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. During a review of the facility's P&P titled, Care and Treatment of Feeding Tube Policy, dated 6/1/24 indicated, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) care and treatm...

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Based on observation, interview, and record review, the facility failed to provide pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) care and treatment consistent with professional standards of practice and facility's policy and procedures (P&P) for one of 25 sampled residents (Resident 89) when Resident 89's newly applied pressure ulcer dressing was not initialed and dated. This failure has the potential for Resident 89's stage 4 PU (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) to not get ordered care and treatment, to get worse, and/or develop complications, and for Resident 89 to not achieve the highest practicable well-being. Findings: A review of Resident 89's clinical record indicated Resident 89 was admitted March of 2023 and had diagnoses that included stage 4 PU of sacral region (lower back near the crease of the buttocks), severe malnutrition, muscle weakness, and need for assistance with personal care. A review of Resident 89's admission Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/24/24, indicated Resident 89 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 14 out of 15 which indicated Resident 89 had intact cognition. A review of Resident 89's MDS Skin Conditions, dated 10/24/24, indicated Resident 89 was at risk of developing pressure ulcers/injuries, had one unhealed Stage 4 PU, and had treatments which included pressure reducing device for bed, PU/PI care, and application of ointments/medications, and nonsurgical dressings. During an interview on 11/4/24 at 9:37 a.m. with Resident 89, Resident 89 stated he has a wound on his bottom area and was receiving treatment daily. A review of Resident 89's active physician's order, dated 10/23/24, indicated, Sacrum [sacral region] stage 4 PI: Cleanse with NS [normal saline- a mixture of water and salt] +Vashe [wound cleanser], apply collagen followed by opticell AG [an antibacterial wound dressing] and cover with foam sacral dressing. every day shift for SACRAL PRESSUR ULCER During a concurrent wound treatment observation and interview on 11/6/24 at 9:37 a.m., with Treatment Nurse (TN)1, TN 1 cleansed Resident 89's stage 4 sacral PU, applied ordered treatment, and covered it with a waterproof foam dressing. TN 1 did not label the dressing with her initials and the date of treatment. TN 1 confirmed the observation and stated she should have initialed and dated the wound dressing. During an interview on 11/6/24 at 12:26 p.m., with TN 2, TN 2 stated she would expect wound dressings to be dated and initialed so staff would know what date the dressing was changed and who did the dressing change. TN 2 further stated if a wound dressing is not labelled with initials and date, it would be a risk for infection because staff would not know when exactly the wound dressing was changed. During an interview on 11/6/24 at 2:03 p.m. with the Infection Preventionist (IP), the IP stated wound dressings should be dated and initialed to let the staff know if the wound dressing was really changed. During an interview on 11/6/24 at 3:46 p.m. with the Director of Nursing (DON), the DON stated she would expect that newly applied wound dressings would be initialed and dated to verify for the next nurse that the treatment was completed. The DON further stated that labeling a wound dressing with initials and date is an extra layer of making sure that the ordered treatment was done and was followed. A review of the facility's P&P titled, Clean Dressing Change, dated 7/1/23, indicated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination .16. Secure dressing. [NAME] with initials and date.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to follow a physician's order for care of a feeding tube (a tube placed in the gastrointestinal (GI) tract to deliver nutrition a...

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Based on observation, interview and record review, the facility failed to follow a physician's order for care of a feeding tube (a tube placed in the gastrointestinal (GI) tract to deliver nutrition and calories (enteral nutrition) to your body if you can't safely chew or swallow), when a water flush (water given to hydrate patients via enteral feeding tube) volume and frequency received by Resident 107 was not consistent with the physician's order for one (Resident 107) of 25 sampled residents. This deficient practice placed Resident 107 in danger of receiving incorrect amounts of water flushes and may have resulted in depleted nutrition. Findings: A review of Resident 107's admission Record, indicated, Resident 107 was admitted in the facility in October 2024 and had diagnoses that included Type 2 Diabetes (high blood sugar), Dysphagia (difficulty swallowing), and the need for assistance with personal care. A review of Resident 107's Brief Interview for Mental Status, Section C, (BIMS, cognitive screening test), indicated, Resident 107 was unable to complete the interview. During an observation in Resident 107's room, on 11/4/24 at 11 a.m., the water flush in the kangaroo epump (medical device that delivers enteral [enteral means intestines or digestive system] feeding and hydration to patients) was programmed at 150ml (ml, unit of measurements) every 6 hours, but on the water flush bag dated 11-3-24, it was labeled at 200ml every 4 hours. During a review of Resident 107's Order Summary, dated 11/1/24, indicated ., Water flush 200mls Q [every] 4 hrs . During an interview with License Nurse 10 (LN 10) at Resident 107's room, on 11/6/24 at 9:50 a.m., LN 10 confirmed water flush was at 150ml every 6 hours as indicated/programmed in the kangaroo epump but in the water flush bag, it was labelled at 200ml every 4 hours. LN 10 stated the volume and frequency of water flush did not match. During a record review of Resident 107's eMar (electronic medication administration record) with LN 10 on 11/6/24 at 10:35 a.m., LN 10 acknowledged, the physician's order on 11/1/24 was 200cc flush water every 4 hours but currently the kangaroo pump was programmed to 150cc flush water every 6 hours. LN 10 stated, the current order should have been followed, it should show in the pump 200cc flush water every 4 hours, resident is getting less fluids, not the correct volume and frequency of flush, yes, we're not following the doctor's order. During an interview with the Director of Nursing (DON), on 11/7/24 at 12:05 p.m., the DON stated, My expectation from the nurses is to follow physician's order, and it should reflect on Resident 107's pump and water flush bag. During a review of the facility's policy and procedure titled, Care and Treatment of Feeding Tube Policy, dated 6/1/24, indicated, .Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush .

CONCERN (D)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident 94's medically related social services...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Resident 94's medically related social services needs were met when, Social Services Assistants (SSA) did not clarify his surgery with his primary physician for one of 25 sampled residents, Resident 94. This failure had the potential to cause delay in Resident 94's healing and recovery. Findings: During a review of Resident 94's admission Record (AR), the AR indicated Resident 94 was admitted to the facility in March 2024 with diagnoses that included cerebral infarction (disrupted blood flow to the brain), and dysphagia (difficulty of swallowing) following cerebral infarction and depression. During a review of Resident 94's summary score for Brief Interview for Mental Status (BIMS, cognitive screening test) was 12 out of 15 which indicated Resident 94 had moderately impaired cognitive function. During an interview with Resident 94 on 11/4/24 at 10:30 a.m., Resident 94 stated, together with her husband, she had an appointment with [physician's name] in [DATE] and discussed the plan for cranioplasty surgery (repair of an injury to the skull). When they came back to the facility, they brought back paperwork and a surgical kit prep and gave it to the nurse who kept it in the med room (medication room). Resident 94 further stated, she mentioned it to the nurses and Social Services staff and reminded them to call the clinic to find out the date for the surgery, but they never followed up on it. My husband reminded them too, but nothing happened up to this day. During an interview with License Nurse 4 (LN 4), on 11/6/24 at 10:55 a.m., LN 4 acknowledged, Resident 94 had an appointment with [physician's name] in August 2024 with her husband, and when they came back from the clinic, they brought back paperwork and surgical kit prep. LN 4 stated, the surgical kit prep was kept in the medication room and stated we should have followed up and clarified with the clinic about the surgery. She further stated she heard Resident 94 and her husband mention possible surgery for Resident 94, and they said, we [staff] should call the clinic to find out the date. During an interview with the Responsible Party (RP) on 11/6/24 at 3:46 p.m., RP stated, In [DATE] he accompanied Resident 94 for her doctor's appointment and told the staff she should have a follow up to do the surgery. I've been reminding the nurses and the SSA that Resident 94 needs to see [physician's name] again, but nobody followed up, it is now November, and we're still waiting, we have no idea what's going on. We want her home, after the surgery. During an interview with the SSA 1 and SSA 2 on 11/6/24 at 4:06 p.m., SSA 1 and SSA 2 confirmed Resident 94 was accompanied by her husband and was seen by [physician's name] in [DATE], and came back from the physician's clinic with paperwork and a surgical kit prep. SSA 1 and SSA 2 acknowledged that Resident 94 and her husband mentioned to them that they need to call the clinic to clarify the date for Resident 94's surgery. SSA 1 stated, the RP spoke to me last week and told me Resident 94 should have a follow up with [physician's name] about Resident 94's surgery. SSA 1 acknowledged she did not call the clinic. SSA 2 also stated, she spoke with RP in the last week of October and told me Resident 94 should see [physician's name] to do the surgery. Both SSA 1 and SSA 2 agreed Resident 94 should not have to wait this long [from Aug to Nov] to wait for an answer about the surgery. During an interview with the Director of Nursing (DON), on 11/7/24 at 12:05 p.m., the DON stated her expectations from the Social Services staff is to follow up with the clinic to clarify the surgery date and ask why Resident 94 was given a surgical kit prep. During a review of Resident 94's Progress Notes, dated 8/26/24, indicated, Resident had Neurosurgery appt today at Kaiser South accompanied by Husband transported by Modivecare via gurney. Came back to the facility, pt, in stable condition. No new order given in the packet that was sent to the appointment, but per pt, and husband RP, will have surgery but no schedule given at this time. Was given a surgical kit prep, placed at Med Room for safety. During a review of the facility's, Job Description: of Social Service, undated, indicated, ., The primary purpose of your job position is to assist in planning, developing, organizing, implementing evaluating, and directing social service programs in accordance with current federal, state, and local standards, guidelines ., to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio ...

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Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with Resident census of 112. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 37 opportunities which resulted in a facility wide medication error rate of 8.11 % in two out of 10 residents (Resident 69 and Resident 105) observed for medication administration. These failures may result in unsafe medication use, medication error, and use of spoiled or ineffective drugs. Findings: During a medication administration observation, in facility's Units 1-2, accompanied by Licensed Nurse 3 (LN 3), on 11/4/24, at 9:38 a.m., LN 3 administered a total of seven medications to Resident 105. LN 3 pulled a unit of liquid inhalation medication called DuoNeb (a combination product with albuterol-ipratropium used to treat shortness of breath or asthma), which was out of the foil pouch, and instilled the liquid in the inhalation device for Resident 105 to inhale (breath in). The DuoNeb box was pen-marked with open date 10/16/24. In a concurrent interview and record review, with LN 3, on 11/5/24, at 10:30 a.m., LN 3 stated she did not realize the DuoNeb product labeling indicated Once removed from the from the foil pouch, the individual vials should be used within two weeks. During a medication administration observation, in the facility's Units 1-2, accompanied by LN 3, on 11/4/24, at 10:10 a.m., LN 3 administered a total of eight medications to Resident 69. LN 3 with bare (ungloved) hand crushed seven pills including two products as follow: Aspirin EC 81 mg (EC stands for Enteric Coated, mg is milligram, a unit of measure) and Finasteride 5 mg (a hormone like drug used to treat prostate issues). In a concurrent interview and record review, with LN 3, on 11/5/24, at 10:30 a.m., LN 3 stated she forgot not to crush the enteric coated aspirin and did not know finasteride should not be crushed, in addition to be a hazardous drug for crushing and handling. LN 3 confirmed the order to crush was for medications that were qualified to be crushed based on manufacturer or safe medications use and handling. LN 3 stated the Medication Administration Record (or MAR- a record that guide the nurses for medication administration) did not have the warning to tell the nursing staff not to crush and handle hazardous drugs with gloves. In an interview with Director of Nursing (DON), in her office, on 11/5/24, at 3 p.m., the DON stated the nursing staff were trained upon hire on medication administration workflow and they should follow the computer prompts like enteric coated to tell them if a product is non-crushable. The DON stated the nursing staff if not familiar with a drug they can google (a free online search website for information) it or look at the drug book. Review of online drug information by Pharmacist Letter, titled Meds That Should Not Be Crushed, updated in February 2023, last accessed via https://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2014/Aug/Meds-That-Should-Not-Be-Crushed-7309, on 11/12/24, the document indicated aspirin Enteric Coated (or Ecotrin) and finasteride (or Proscar) among the drugs that should not be crushed. The document further indicated Crushing delayed-release meds can alter the mechanism designed to protect the drug from gastric acids or prevent gastric mucosal irritation . Crushing irritating or hazardous meds (medication that pose health risk when handled without protective measures) can be harmful to the individual crushing the meds . Hazardous meds . explicitly state not to crush in the product information. Review of the facility's policy, titled Medication Administration, dated 3/1/23, the policy on section 14 indicated Administer medications as ordered in accordance with manufacturer's specification. Crush medications as ordered. Do not crush medication with do not Crush instruction.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices were maintained in the medication room and medication carts with the census of 112 w...

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Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices were maintained in the medication room and medication carts with the census of 112 when: 1. The Back Station medication room stored expired, unlabeled, and undated medications. 2. Medication Cart #2 found a pill in the pill cutter, and Pro-Stat AWC had yellow/orange streaks running down the bottle. 3. Hazardous medications (drugs that can cause harm to the body when handled unsafely) were stored in medication Carts # 1 and Cart #4 with no warning label on how to be handled by nursing staff. 4. Inhalation products called Ipratropium Bromide and Albuterol Sulfate (or DuoNeb, a breathing treatment) stored in medication Cart #1 and Cart #4 were not dated, and/or the beyond use date was not followed. These failures had the potential to negatively impact the residents' well-being and the use of spoiled or expired medications. Findings: 1. During a concurrent observation and inspection on, 11/4/24 at 10:27 a.m., at the Back Station medication room, accompanied by Licensed Nurse 8 (LN 8), the medication room stored expired, unlabeled, undated medications, and unsafe storage practices in the active storage areas as follows: i. Osmolite bottle (a nutritional feeding product in liquid form) with an expiration date of 11/1/24 stored in active storage areas. ii. Omeprazole liquid bottle 2 mg/ml (mg/ml is milligram/milliliter - a metric unit of measurement used for medication dosage and/or amount, a drug used for stomach ulcer) was stored in the refrigerator in active storage areas with an open date of 10/1/24 and discard after 30 days on the product label. iii. House supply of Aplisol Tuberculin Purified Protein (product used to test for TB (or tuberculosis)- a serious lung infection) was undated when first opened; the Label says, Once entered (opened for the first time), the vial should be discarded after 30 days. iv. The influenza vaccine (Afluria brand name, 2024-2025 formula) was outdated, with an open date of 9/20/24. The product label on the box indicated, Once entered, the vial should be discarded after 30 days. v. A staff drink bottle was found in the freezer section of the medication refrigerator. vi. Two Intravenous (IV-fluids given directly into the bloodstream) bags of Lactated Ringer's solution (LR-helps replace fluids and minerals), 1000 ml [milliliters] (ml-unit of volume), were sitting on the medication room counter. They had no resident-specific label or name. LN 8 stated she could not tell who the IV bags were used for. LN 8 concurred with the findings in the Back Station medication room and removed the products from active storage areas. 2. During a concurrent observation and inspection on 11/4/24, at 12:14 p.m., on medication Cart #2, accompanied by LN 7, the following was found: i. The pill cutter stored in the top drawer of the cart contained white powder and a pink pill (half a tablet). LN 7 was unsure when it was last used and stated that it should not have been there. ii. The pro-Stat AWC (dietary management to increase protein) bottle had yellow/orange streaks of sticky liquid running down the outer bottle. LN 7 stated, That [Pro-Stat AWC] should be wiped down after it has spilled over . 3. During a concurrent observation and inspection of medication Cart #6, on 11/5/24, at 10:08 a.m., in the Sub Acute Unit, accompanied by LN 11, the cart stored one bottle of medication in liquid form called Depakene (used to treat seizure disorders), in the bottom drawer and the liquid Depakene had spilled all over the bottle which was sticky to touch. The label on the Depakene liquid bottle did not have any auxiliary information for hazardous drugs or how they should have been handled by nursing staff. The Depakene bottles were not stored in a Ziplock bag to prevent hand contamination during storage. LN 11 was unaware of safe handling and did not know this medication should have been labeled for safe handling. 4. During a concurrent observation and inspection of medication Cart #4, on 11/5/24, at 2:30 p.m., at the Back Station, accompanied by LN 12, the medication cart stored a bubble pack (medication packaged in a flat unit dose) of medication called Arimidex (same as anastrozole, used to treats breast cancer). The label on the bubble pack for Arimidex did not have any auxiliary information for hazardous drugs or how they should have been handled by nursing staff. Further inspection indicated storage of two boxes of opened inhalation products called Ipratropium Bromide and Albuterol Sulfate (or DuoNeb, used for breathing treatment and the symptoms of lung diseases). One box of DuoNeb was undated and was out of overwrap foil. The second DuoNeb box was open and out of overwrap foil dated 10/1/24. The storage information on the package indicated, Once removed from the foil pouch, the individual vials should be used within two weeks . LN 12 stated she didn't realize the breathing treatment was good for two weeks once it was out of the overwrap foil. During an interview on 11/7/24 at 2:28 p.m. with the Director of Nursing (DON), the DON stated that she expected the nursing staff to remove outdated medications from active storage areas and, when indicated, date the products when they are opened. The DON also stated that the date beyond use should be checked and followed by the staff. The DON also stated that there should be instruction on safely handling hazardous medications. During a review of the facility's Policy & Procedure (P&P) titled, Medication Storage, dated 3/1/23, the P&P indicated, .Ensure all medications housed on our premise will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient .Unused medications: .are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance .with state regulations and federal guidelines .

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 ensure accurate documentation of Resident 100's diagnosis in the medical records in one out of five residents. This failure of inaccurate do...

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Based on interview and record review the facility failed to ensure accurate documentation of Resident 100's diagnosis in the medical records in one out of five residents. This failure of inaccurate documentation of resident's diagnosis may contribute to unsafe care and treatment by the facility and subsequent care providers. Findings: During a concurrent interview with Assistant Director of Nursing (ADON), on 11/7/24, at 11:31 AM, and record review of Resident 100's medical record, titled Discharge Summary, dated 9/30/24, the record indicated Resident 100 had history of dementia (loss of memory) along with other medical diagnoses for heart disease and bedsore infection. The record indicated Resident 100 was ordered olanzapine (or Zyprexa, a mind-altering drug) 2.5 mg (mg is milligram, a unit of measure) at bedtime on discharge from hospital which was a reduced from 7.5 mg previous dosage. ADON acknowledged the indication for use of olanzapine was dementia related behavior. During a concurrent interview with Assistant Director of Nursing (ADON), on 11/7/24, at 11:31 AM, and record review of Resident 100's medical record, titled Physician Progress Note, dated 10/6/24, the record under Assessment/Plan indicated dementia (as a diagnosis), medications reviewed, continue current regimen, monitor and record behaviors. During a concurrent interview with Assistant Director of Nursing (ADON), on 11/7/24, at 11:31 AM, and record review of Resident 100's medical record, titled Nursing Weekly Summary Review, dated 11/3/24, the record under Behavior/Mood section indicated Resident 100 was receiving a mind-altering drug olanzapine at bedtime for dementia behavioral psychological problem m/b (manifested by) shaking fist to people and for bipolar disorder (a mental disease with extreme mood swings). ADON stated she was not sure where the bipolar diagnosis came from. During a concurrent interview with Assistant Director of Nursing (ADON), on 11/7/24, at 11:31 AM, and record review of Resident 100's medical record, titled Psychotropic Medication Consent V.2024, dated 9/30/24, the record for use of olanzapine indicated diagnosis for medication: Anxiety; Target/manifested by behavior: Bipolar. ADON stated the documented indication was not correct and it was signed by the medical doctor. In a telephone interview with Medical Doctor 2 (MD 2), on 11/7/24, at 1 PM, MD 2 stated the nursing staff should follow the documented diagnosis written by medical provider. MD 2 could not comment on the consent document for use of olanzapine he signed with notation of bipolar as an indication. MD 2 stated the diagnosis should come from a medical source otherwise invalid. In an interview with Director of Nursing (DON), on 11/7/24, at 2:30 PM, the DON stated the use of bipolar indications in Resident 100's medical record was inaccurate and an error. The DON stated wrong documentation of a diagnosis could contribute to unsafe care in this and any other health facility the resident may go in the future. Review of facility's policy, titled Psychotropic Medication Use, dated 6/2021, the policy indicated When a physician/prescriber orders a psychotropic medication (mind altering drug) for a resident, facility should ensure that physician/prescriber has conducted a comprehensive assessment of resident and has documented in clinical record that psychopharmacological medication is necessary .It is the responsibility of attending healthcare practitioner to inform the resident and or resident representative of the initiation, reason for use and the risk associated with use of psychotropic medication per facility policy or applicable state regulation.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure proper storage, handling, labeling, and delivery of respiratory care and equipment consistent with the facility's poli...

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Based on observation, interview, and record review, the facility failed to ensure proper storage, handling, labeling, and delivery of respiratory care and equipment consistent with the facility's policy and procedures (P&P) for three out of 25 sampled residents (Resident 105, Resident 23, and Resident 88) when: 1. Resident 105's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mask and tubing set was left on top of the bedside drawer, uncovered after use and was not changed after 72 hours; 2. Resident 23's nebulizer mask and tubing set was left on top of the bedside drawer, uncovered after use; and, 3. Resident 88's physician's order for oxygen therapy was not followed, and Resident 88's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) and humidifier bottle (a device prefilled with water that adds moisture to oxygen to make it more comfortable and effective to breathe) were not labeled with the date it was first used. These failures had the potential to result in unsafe and unsanitary delivery of nebulizer medication to Resident 105 and Resident 23, and oxygen to Resident 88. Findings: 1. A review of Resident 105's clinical record indicated Resident 105 was admitted October of 2024 and had diagnoses that included parkinsonism (a clinical syndrome characterized by tremor, slowed movement, rigidity, and postural instability), asthma (a condition in which a person's airways become inflamed, narrow, and swell, and produce extra mucus, which makes it difficult to breathe), dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 105's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/18/24, indicated Resident 105 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 11 out of 15 which indicated Resident 105 had moderately impaired cognition. A review of Resident 105's MDS Health Conditions, dated 10/18/24, indicated Resident 105 had experienced shortness of breath or trouble breathing when lying flat. A review of Resident 105's physician's order, dated 10/16/24, indicated, Ipratropium-Albuterol Solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] . 1 vial (a glass container used for holding liquid medicines) inhale orally via nebulizer four times a day for Asthma WAIT 5 MINUTES BEFORE GIVING ANOTHER INHALER/NEBULIZER SOLUTION. During an observation on 11/4/24 at 10:50 a.m. in Resident 105's room, Resident 105 was currently not in his room. A nebulizer mask and tubing set hooked to a nebulizer machine was observed left on top of the bedside drawer, uncovered. Nebulizer mask and tubing set indicated it was last changed on 10/27. During a concurrent observation and interview on 11/4/24 at 10:53 a.m. with Licensed Nurse (LN) 3 in Resident 105's room, LN 3 confirmed that Resident 105's nebulizer mask and tubing set was left on top of the bedside drawer, uncovered, and was last changed on 10/27. LN 3 stated the nebulizer mask and tubing set should be placed in a bag when not being used and should be changed every 72 hours to prevent it from contamination and for infection control. 2. A review of Resident 23's clinical record indicated Resident 23 was admitted November of 2019 and had diagnoses that included hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following nontraumatic intracerebral hemorrhage (a condition where a pool of blood is formed within the brain causing structural, biochemical or electrical abnormalities in the brain, spinal cord, or other nerves) affecting left non-dominant side, diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing), and shortness of breath. A review of Resident 23's MDS Cognitive Patterns, dated 9/17/24, indicated Resident 23 had a BIMS score of 9 out of 15 which indicated Resident 23 had moderately impaired cognition. A review of Resident 23's physician's order, dated 1/8/24, indicated, Ipratropium-Albuterol Solution .3 ml [milliliters- unit of measurement] inhale orally every 4 hours as needed for SOB [shortness of breath] .via nebulizer. During a concurrent observation and interview on 11/4/24 at 10:57 a.m. with Resident 23 in Resident 23's room, Resident 23's nebulizer mask and tubing set hooked to a nebulizer machine was observed left on top of the bedside drawer, uncovered. Resident 23 confirmed the observation and stated he last used the nebulizer mask and tubing set yesterday. During a concurrent observation and interview on 11/4/24 at 10:5 a.m. with Certified Nurse Assistant (CNA) 1 in Resident 23's room, CNA 1 confirmed that Resident 23's nebulizer mask and tubing set was left on top of the bedside drawer, uncovered. CNA 1 stated, .They [facility] have not told us [CNAs] anything about putting it [nebulizer mask and tubing set] in a bag when not in use . A review of Resident 23's Medication Administration Record (MAR-a document that listed administered drugs) for the month of November 2024 indicated Resident 23 last received Ipratropium-Albuterol Solution via nebulizer on 11/3/24 at 4:49 p.m. During an interview on 11/6/24 at 2:03 p.m. with the Infection Preventionist (IP), the IP stated, .when it's [nebulizer mask and tubing set] not being used, it should be in an antimicrobial bag to prevent contamination . the set-up [nebulizer mask and tubing set] is changed once a week .It's a risk of infection if not being changed regularly. During an interview on 11/6/24 at 3:46 p.m. with the Director of Nursing (DON), the DON stated the nebulizer mask and tubing set should be placed in an antimicrobial bag when not being used for infection control. The DON further stated, I believe it's [changing of nebulizer mask and tubing set] 7 days . for infection control. A review of the facility's P&P titled, Oxygen Administration, dated 5/1/23, indicated, .5 .Other infection control measures include: .d . change nebulizer tubing and delivery devices every 72 hours .e. Keep delivery devices covered in a plastic bag when not in use. A review of the facility's P&P titled, Oxygen Administration Infection Prevention, dated 5/1/23, indicated, Infection Control Considerations Related to Medication Nebulizers .7. Store the circuit in bag, marked with date and resident's name, between uses. 3. A review of Resident 88's clinical record indicated Resident 88 was admitted March of 2024 and had diagnoses that included respiratory failure (is a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), asthma, and shortness of breath. A review of Resident 88's MDS Cognitive Patterns, dated 9/9/24, indicated Resident 88 had a BIMS score of 15 out of 15 which indicated Resident 88 had intact cognition. A review of Resident 88's MDS Health Conditions, dated 9/9/24, indicated Resident 88 had experienced shortness of breath or trouble breathing when lying flat. A review of Resident 88's MDS Special Treatments, Procedures, and Programs, dated 9/9/24, indicated Resident 88 had oxygen therapy while he is a resident in the facility. A review of Resident 23's physician's order, dated 6/7/24, indicated, Oxygen at 2 LPM [liters per minute- unit of measurement for oxygen administration flow rate] via Nasal Canula continuous every shift for monitoring. During an observation on 11/4/24 at 11:13 a.m. in Resident 88's room, Resident 88's was observed using an oxygen concentrator set at 4 lpm delivered via nasal cannula. Resident 88's nasal cannula and humidifier bottle were not labeled with the date of when it was first used. During a concurrent observation and interview on 11/4/24 at 4:22 p.m. with LN 6 in Resident 88's room, LN 6 confirmed that Resident 88's nasal cannula, and humidifier bottle were not labeled with the date it was first used. LN 6 also confirmed that Resident 88's oxygen flow rate was set at 4 lpm. LN 6 stated that the humidifier bottle and nasal cannula should be labelled with the date it was first used. LN 6 further stated the nasal cannula should be changed every Sunday for infection control. During a concurrent observation and interview on 11/5/24 at 10:25 a.m. with LN 3 in Resident 88's room, LN 3 confirmed that Resident 88's oxygen flow rate was set at 4 lpm. LN 3 stated, It's [Resident 88's oxygen flow rate] should be 2 lmp .It can cause hyperoxygenation (a condition in which the body is exposed to an unusual amount of oxygen causing respiratory and/or neurological problems) .and can affect her [Resident 88] health. During an interview on 11/6/24 at 2:03 p.m. with the IP, the IP stated, .Nasal cannula and humidifier bottle .all tubing, should be labelled [with the date it was first used] .It [first used date label] gives [facility] staff a reference on changing them [nasal cannula, humidifier bottle, and other respiratory tubing], which is once a week or as needed. During an interview on 11/6/24 at 3:46 p.m. with the DON, the DON stated she would expect the physician's order for oxygen therapy to be followed. The DON further stated she also expects that nasal cannula and humidifier bottle would be labeled with when it was first used because nasal cannula and humidifier bottle needs to be changed out within a specific time frame. A review of Resident 88's active care plan and interventions, undated, indicated, The resident [Resident 88] has oxygen therapy as ordered .Give medications [oxygen] as ordered by physician .OXYGEN SETTINGS: O2 [oxygen] via (SPECIFY: nasal prongs) @ 2L [lpm] continuous . A review of the facility's P&P titled, Oxygen Administration, dated 5/1/23, indicated, Oxygen is administered to residents .consistent with professional standards of practice, the comprehensive person-centered care plans .1. Oxygen is administered under orders of a physician .5 .Other infection control measures include: .b. Change oxygen tubing and . cannula weekly .c. If indicated change the humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer .

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

6. A review of Resident 63's clinical record indicated Resident 63 was admitted June of 2022 and had diagnoses that included hepatic failure (occurs when the liver is unable to perform its normal func...

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6. A review of Resident 63's clinical record indicated Resident 63 was admitted June of 2022 and had diagnoses that included hepatic failure (occurs when the liver is unable to perform its normal functions), chronic pain, diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect nerves), and neuropathy (a nerve condition that can cause pain, numbness, tingling, or weakness in the body). A review of Resident 63's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 10/23/24, indicated Resident 63 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 63 had an intact cognition. A review of Resident 63's MDS Health Conditions, dated 10/23/24, indicated Resident 83 had experienced pain occasionally and had received scheduled and as needed pain medication regimen, and non-medication intervention for pain. A review of Resident 63's physician's order, dated 10/27/24, indicated, oxyCODONE HCl [a controlled pain medication] Oral Tablet 10 MG [milligrams- unit of measurement] .Give 10 mg by mouth every 4 hours as needed for chronic pain. A random audit of Resident 63's MAR and the CDR for oxycodone, for the month of October 2024, indicated nursing staff did not document oxycodone administration on the MAR when signed out from CDR as follows: 1 tablet on 10/2/24 at 9:35 p.m., 1 tablet on 10/7/24 at 11:46 a.m., 1 tablet on 10/14/24 at 5:17 a.m., 1 tablet on 10/14/24 at 9:15 p.m., 1 tablet on 10/16/24 at 2:39 a.m., 1 tablet on 10/16/24 at 9:59 p.m., 1 tablet on 10/20/24 at 10:30 p.m., 1 tablet on 10/22/24 at 10:35 p.m., 1 tablet on 10/27/24 at 10:15 p.m., and 1 tablet on 10/28/24 at 10:30 p.m. During a concurrent interview and record review on 11/7/24 at 9:16 a.m. with Licensed Nurse (LN) 5, Resident 63's CDR and MAR for October 2024 were reviewed. LN 5 confirmed the finding of oxycodone being signed out of the CDR but was not accurately documented on the MAR on 10 occasions. LN 5 stated, .We [facility staff] would sign out the medication [oxycodone] on both [CDR and MAR] .I sign it out here [CDR] and then the MAR. LN 5 further stated signing out oxycodone on the CDR and MAR is part of being accountable of the controlled medication. During an interview on 11/7/24 at 9:30 a.m. with the Director of Nursing (DON), Resident 63's CDR and MAR for October 2024 were reviewed. The DON confirmed the finding of oxycodone being signed out of the CDR but was not accurately documented on the MAR on multiple occasions. The DON stated the process should be staff would sign out controlled medication both in CDR and MAR. The DON further stated, It's [CDR and MAR does not reconcile] a problem with the accuracy of documentation .It [CDR and MAR] should reconcile, both signed off in the MAR and here [CDR]. During an interview on 11/7/24 at 11:40 a.m. with the Consultant Pharmacist (CP), the CP stated, No, I'm not aware of that [Resident 63's CDR and MAR does not reconcile] . The implication .record [CDR and MAR] is not accurate and possible theft [of controlled medication]. The CP further stated it would be a risk of controlled medication diversion if the CDR and MAR would not reconcile and signing out the medication on the CDR and MAR is part of accountability of the controlled medication. A review of the facility's P&P titled, Medication Administration, dated 3/1/23, indicated, .17. Sign MAR after administered .18. If medication is a controlled substance, sign narcotic book [CDR]. Based on observation, interview, and record review the facility failed to ensure safe pharmaceutical services with a census of 112 when: 1. Hazardous medications (drugs that can cause harm to the body when handled unsafely) were stored in the medication carts with no warning label on how to be handled by nursing staff. 2. Emergency Kit (Ekit, a supply of medication used for urgent needs of residents) for oral and injectable medications in both medication rooms were opened and were not replaced in timely manner. 3. Prescription and narcotic medication delivery manifest or receipts from provider pharmacy were not signed by licensed staff for accountability. 4. Medication destruction for non-controlled prescription drugs were not consistently co-signed by two licensed staff and controlled drug destruction log did not include chain of custody with date and final destruction information. 5. Resident 108's controlled drug (drug with potential for abuse) use and removal from Controlled Drug Record or CDR (a paper log of controlled drug removal for administration to resident) was not accurately documented in the resident electronic medical record and Medication Administration Record or MAR (a document that listed administered drugs). 6. Resident 63's controlled medications use and removal from CDR were not accurately documented in the MAR. These failed practices may contribute to unsafe medication use and risk of drug diversion. Findings: 1a. During a medication administration observation, in facility's unit 1-2, accompanied by Licensed Nurse (LN) 3, on 11/4/24, at 10:10 AM, LN 3 crushed a medication called finasteride (a hormone like drug used to treat prostate issues) along with other medications with bare hands. The medication label and the MAR did not instruct how the medication should have been handled by the nurse. In an interview with LN 3, on 11/5/24, at 10:30 AM, LN 3 stated she did not know finasteride was hazardous and should not have been crushed. LN 3 stated the MAR record did not have the warning or comments not to crush or handle with gloves. 1b. During a concurrent inspection of facility's medication Cart #6, in the Sub-Acute Unit, accompanied by LN 11, on 11/5/24, at 10:10 AM, the cart on the bottom drawer stored a bottle of liquid medication called Valproic Acid (or Divalproex, a medication used to treat mood disorder or seizure [uncontrolled brain activity]) in a dark colored bottle with traces of spills on the outer bottle and the label. The Valproic bottle did not have a hazardous warning label for handling and was not contained in a Ziplock bag. LN 11 stated the Hazardous label would have prompted her to use gloves when using the product, similar to other products in the cart. 1c. During a concurrent inspection of facility's medication Cart #4, in the middle Unit, accompanied by LN 12 on 11/5/24, at 2:30 PM, the cart stored a medication in the bubble pack form called anastrozole (a hormone like cancer drug) without any hazardous labeling on how it should have been handled. The small label on the bubble pack indicated, Do not use if you are pregnant . LN 12 acknowledged no warning label on if the nurse should be wearing gloves when handling this cancer drug. In an interview with Director of Nursing (DON), on 11/7/24, at 9:03 AM, the DON stated the facility did not have a policy on hazardous medication use and handling. The DON stated the facility needed to work on it and educate staff on safe handling of hazardous medications. Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/2023, the document indicated Many . drugs intended for individual use can be hazardous to healthcare workers with potential occupational exposure to those who handle, prepare, dispense, administer, or dispose of these drugs. Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. PPE (or Personal Protective Equipment, items like glove or mask) provides worker protection to reduce exposure to hazardous drugs. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. NIOSH suggests careful precautions and safeguards to protect workers, fetuses, and breastfed infants. Further review of the document indicated to use single glove for handling intact tablet form and double glove for handling oral liquid form of the hazardous medications as directed. Review of the drug information for finasteride, valproic acid and anastrozole, last accessed via Lexicomp (an online drug information resource) on 11/2024, the drug information indicated the following: Hazardous Drugs Handling Considerations: Hazardous agent (NIOSH .). Use appropriate precautions for receiving handling, storage, preparation, dispensing, transporting, administration, and disposal . 2. During a concurrent inspection of facility's Back station medication room, accompanied by LN 8 on 11/4/24, at 10:20 AM, the EKit for oral medications had a yellow seal indicating that it has been opened and used. When the Ekit was opened, a paper log inside indicated it was last used on 10/31/24, at 8 PM. LN 8 stated the Ekit should been replaced within 72 hours. LN 8 stated she was not sure if the pharmacy had been notified as the sticker on outer label was still on the box and the duplicate copy of the removal sheet was not faxed to pharmacy. During a concurrent interview and inspection of facility's Front station medication room, accompanied by LN 7 on 11/4/24, at 10:54 AM, the EKit for injectable medications (drugs given as a shot into skin or veins) had a yellow seal indicating that it has been opened and used. When the Ekit was opened, a paper log inside indicated it was last used on 10/31/24, at 8 PM for removal an antibiotic. LN 7 stated the Ekit stated she was not sure why not replaced. In an interview with Director of Nursing (DON), in her office, on11/5/24, at 3:43 PM, the DON stated the staff should have called provider pharmacy directly to replace the Ekit right after a drug removal. The DON stated the facility's policy required the Ekit replaced within 72 hours. Review of the facility's policy, titled Emergency Medication Policy, dated 5/1/23, the policy indicated Any medication that is removed from the emergency kit must be documented on emergency medication administration log. Medication and supplies used from emergency medication kit must be replaced upon next routine drug order. 3. During a concurrent interview and inspection of facility's Back station, accompanied by LN 9 on 11/4/24, at 10:20 AM, the medication delivery manifests from the provider pharmacy, titled Consolidated Delivery Sheets, were reviewed. The records from month of November 2024 included prescription and narcotic medications delivery documents. LN 9 stated the nurses signed the delivery driver's record. LN 9 was not sure how the delivery medications were compared with the manifest. LN 9 acknowledged the facility's delivery sheet were not signed and dated by licensed nurses. In an interview with Director of Nursing (DON), in her office, on 11/5/24, at 3:56 PM, the DON stated the medication delivery sheets should have been signed by nursing staff for accuracy and accountability. Review of the facility's policy, titled Medication Ordering and Receiving From Pharmacy, dates 4/2008, the policy indicated The dispensing pharmacy will transport medication through the facility in a manner that prevents contamination, degradation, and diversion of medication . Upon arrival at the facility, the courier delivers the medication directly to licensed nurse. The pharmacy provides a method for both parties to confirm delivery. The pharmacy should be notified within 24 hours regarding any discrepancy or respect to medication delivery. 4a. During a concurrent interview and review of facility's document, titled Medication Disposition Record/Pass Log, at the back station, accompanied by LN 9 on 11/4/24, at 10:20 AM, the medication destruction record for non-controlled drugs were reviewed and three pages of medication destruction dated 10/13/24 did not have a witness signature by a licensed nurse. LN 9 acknowledged the finding. In an interview with Director of Nursing (DON), in her office, on 11/5/24, at 3:35 PM, the DON stated there should have been a witness signature for destruction and disposition of medications. Review of the facility's policy, titled Discarding and Destroying Medications, dated 5/1/23, the policy indicated medications that cannot be returned to dispensing pharmacy . are disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceutical, hazardous waste and controlled substances. The Policy on section 10 indicated The medication disposition record contains as minimum the following information . and signature of witnesses. 4b. During a concurrent interview and record review with DON, in her office, on 11/5/24, at 3 PM, the DON stated the controlled drugs were stored in her office in a locked cabinet and were destroyed with the pharmacist. The DON stated she was following previous leadership at the facility and kept a recorded book that logged the drug name, quantity, and signature of nurse that handed her the controlled drug. The record did not show chain of custody from nurse to DON and destruction witness with the pharmacist. The record further did not have the dates of destruction consistently. The DON stated the pharmacist's signatures were recorded in the Controlled Drug Record sheet which were stored in the individual residents' charts. The DON did not provide examples of recent destruction records. In a telephone interview with Consultant Pharmacist (CP), on 11/7/24, at 12:53 PM, the CP stated she followed the facility's system of controlled drug destruction on making sure the CDR and actual controlled drug quantity were matched for disposition. The CP was not sure how the CDR sheets were filed and how the DON kept track of the recordings in the logbook. Review of the facility's policy, titled Discarding and Destroying Medications, dated 5/1/23, the policy indicated All unused controlled substances are retained in securely locked area with restricted access until disposed of . control substances are disposed of in accordance with state regulation and federal guidelines regarding disposition of nonhazardous controlled medications. The policy on section 10 indicated The medication disposition record contains, as a minimum, the following information: a. The residents name, b. the name and strength of the medication, c. The prescription number, (if any), d. The name of the dispensing pharmacy, e. The date medication destroyed, f. The quantity destroyed, g. Method of destruction, h. Reason for destruction, i. Signature of witnesses. Completed medication disposition records are kept on file in the facility for at least two years or as mandated by state law governing the retention and storage of such records. 5. A comparative review of the Resident 108's Controlled Drug Record use and documentation in the MAR, with date range of 10/20/24 to 11/4/24, showed the record for oxycodone use (an opioid pain medication) did not accurately reflected medication use and accountability of use. The record indicated oxycodone removal on 10/26/24 from CDR when it was not documented in Resident 108's MAR and was crossed off when the oxycodone count was not corrected. The CDR record additionally indicated one removal between 10/31/24 and 11/1/24 which was crossed off when the actual oxycodone count was not corrected. In an interview with DON, on 11/7/24 at 9 AM, the DON stated Resident 108's oxycodone documentation on 10/26/24 was erroneously documented. The DON could not explain the accuracy of oxycodone count as it was crossed out without count correction. Review of the facility's policy, titled Medication Administration, dated 3/1/23, the policy indicated Review MAR to identify medication to be administered. Compare medication source . with MAR to verify resident name, medication name, form, dose, route, and time . Sign MAR after administered . If a medication is a controlled substance, sign narcotic book . Correct any discrepancy and report to nurse manager . and/or DON.

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 policy review, the facility failed to ensure dishes and utensils were cleaned in a sanitary condition for a census 112. This had the potential for foodborne illne...

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Based on observation, interview, and policy review, the facility failed to ensure dishes and utensils were cleaned in a sanitary condition for a census 112. This had the potential for foodborne illnesses. Findings: During an interview on 11/6/24 at 11:18 a.m. with the Dietary Manager (DM) she confirmed the facility had a low temperature dishwasher. During a concurrent kitchen observation and interview on 11/6/24 at 2:09 p.m. the facility's dishwasher had a yellow sign on it indicating it was Low Temperature Dishwasher. The Dietary Aide (DA) 1 was asked to check the dishwasher's sanitizing solution. DA 1 proceeded to take one of the chlorine test strips and dipped in the water of the final rinse cycle. The strip came back less than 10 parts per million (ppm). The DM re-checked chemical strip again less than 10 ppm. The DM confirmed the chemical strip was to be dark color in purple indicating 50 ppm. During a concurrent interview and record review on 11/6/24 at 2:14 p.m. with DA 1, the facility's document titled, Dish Machine Temperature Log (Low Temp Machine) for October and November 20204 was reviewed. There was no documentation the dishwasher's chemical solution was being tested, at least once per shift and recorded. DA 1 confirmed there was no documentation the dishwasher's chemical solution was being tested and documented once a shift. During a review of the facility's policy and procedure (P&P) titled, Dishwasher Policy dated 3/1/23 indicated, It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwater temperatures .All items cleaned in the dishwater will be washed in water that is sufficient to sanitize any and all items .For low temperature dishwaters (chemical sanitization): a. The wash temperature shall be 120 F. b. The sanitizing solution shall be 50 ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse. 5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 112 when; 1. A shared glucometer (a...

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Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 112 when; 1. A shared glucometer (a device which measures blood sugar using blood from the fingertip) was not cleaned and sanitized properly after use and before storage; 2. A clean residents' personal items delivery cart was found with a thick layer of dust on its tray; 3. Shared glucometers (a device used to measure blood sugar) were not cleaned and sanitized based on manufacturer instruction when used for Resident 109 and Resident 315. 4. The facility did not follow safe infection prevention practices when care provided to Resident 82 with tube feeding and medication administration, in a room marked as Enhanced Barrier Precaution (or EBP, staff to use gown and gloves as protection to prevent spread of bugs or infections) These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of Resident 92, Resident 109, and Resident 315 to germs, and may cause infection among residents, staff, and visitors. Findings: 1. During an observation on 11/4/24 at 11:44 a.m., Licensed Nurse (LN) 6 was observed checking a resident's blood sugar using a glucometer [EvenCare G3 blood glucose monitoring system] which was shared between residents. LN 6 used a lancet (a sharp piercing device) to pierce the resident's finger to get blood and then applied the blood to the test strip that was attached to the glucometer. After reading the result, LN 6 discarded the used lancet and test strip, wiped the shared glucometer with alcohol prep pad (pads used to clean the skin prior to bandaging, wiping off surfaces like desks, sinks and counters, and cleaning hands), and stored the glucometer in the medication cart. During a concurrent observation and interview on 11/4/24 at 11:48 a.m. with LN 6, LN 6 confirmed that she used an alcohol wipe to clean and sanitize the used glucometer before storing it in the medication cart. LN 6 stated staff should use the purple top wipes (Medline Micro-Kill Germicidal Wipes) when cleaning a glucometer after it was used for a resident. LN 6 also stated she did not have the germicidal wipes in the medication cart as the reason why she used the alcohol prep pad. LN 6 further stated it is not okay to use an alcohol prep pad. During an interview on 11/6/24 at 2:03 p.m. with the Infection Preventionist (IP), the IP stated, We [facility staff]don't have dedicated glucometers for each resident, we use shared glucometers .That's [cleaning a shared glucometer with alcohol wipes] a concern of transmission of blood borne pathogens [microorganisms that can cause disease and are present in human blood] .It [glucometer] should be disinfected properly before and after use . We [facility] utilize Medline's Micro-kill antimicrobial wipes- the purple tops which are indicated for the glucometers we use .No, most definitely not [okay to use alcohol wipes in cleaning and sanitizing used glucometers]. During an interview on 11/6/24 at 3:46 p.m. with the Director of Nursing (DON), the DON stated that per the facility's policy and manufacturer's instructions, the purple top (Medline Micro-Kill Germicidal Wipes) is one of the approved wipes for the glucometers the facility utilizes. The DON further stated she would expect the staff to follow the facility's policy in cleaning the glucometers. A review of the facility's policy and procedures (P&P) titled, Glucometer Disinfection, dated 6/1/24, indicated, 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. A review of the manufacturer's instructions for EvenCare G3 blood glucose monitoring system titled, CLEANING AND DISINFECTING, undated, indicated, .The EVENCARE G3 Meter should be cleaned and disinfected between each patient .The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: .Medline Micro-Kill .Germicidal .Wipes . Alcohol prep pad was not listed as an approved product for cleaning and disinfecting the glucometer. 2. During a concurrent observation and interview on 11/4/24 at 9:47 a.m., at Hallway 1, with Laundry Staff [LS], LS was observed delivering clean personal items to residents in hallway 1. Upon checking the clean residents' personal item delivery cart, the delivery cart's tray was found with a thick layer of dust. LS confirmed the observation. During a concurrent observation and interview on 11/4/24 at 9:52 a.m., at Hallway 1, with Central Supply [CS], CS confirmed that the clean residents' personal item delivery cart has thick layer of dust on its tray and stated, It's [clean residents' personal items delivery cart] supposed to be always clean. During an interview on 11/6/24 at 10:52 a.m. with the Laundry Supervisor (LSPV), the LSPV stated they only have one clean resident's personal item delivery cart in the facility and staff should clean it every day. The LSPV also stated he would expect staff to make sure residents' personal item delivery cart to be always clean to make sure that residents' personal items are also clean. The LSPV agreed that if the delivery cart has dust, it could get into the clean clothes and would have a potential for residents to be exposed to dust and germs. During an interview on 11/6/24 at 3:46 p.m. with the DON, the DON stated she would expect the clean residents' personal items delivery cart should not be dusty. The DON further stated if the delivery cart is dusty, the dust could transfer to the clean residents' clothes. A review of the facility's P&P titled, Infection Prevention and Control Program, dated 7/1/23, indicated, 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . A review of the facility's P&P titled, Handling Clean Linen, dated 3/1/23, indicated, It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection .4. Clean linens must be transported by methods that ensure cleanliness and protect from dust and soil .such as: .b. Placing clean linen in a properly cleaned cart . 3. During a medication administration observation, with Licensed Nurse 7 (LN 7), on 11/4/24, at 11:57 a.m., LN 7 with a gloved hand took the glucometer and supplies in Resident 315's room to measure the blood sugar. LN 7 poked Resident 315's right middle finger to get the blood and soaked the test strip (a plastic strip contains chemicals to help with blood sugar measurement) with blood to measure the blood sugar. LN 7 used one Sani-Cloth wipe (brand name for a wipe with chemicals to disinfect surfaces) quickly (less than 10 seconds) to clean the glucometer outer surface once out of the Resident 315's room. During the subsequent medication administration observation, with LN 7, on 11/4/24, at 12:03 p.m., LN 7 with a gloved hand used the same glucometer and took supplies into Resident 109's room to measure blood sugar. LN 7 placed the glucometer on Resident 109's bed-side table when he poked Resident 109's left finger to get blood. LN 7 then soaked the test strip with blood for the blood sugar measurement. LN 7 used one Sani-Cloth wipe to quickly (less than 10 seconds) clean the outer surface of glucometer. In an interview with LN 7 on 11/5/24, at 10:48 a.m., LN 7 stated she assumed using one wipe to clean the glucometer was adequate enough to sanitize. LN 7 stated the Sani-Wipe bottle indicated 2 minutes wet time (the time for surface of glucometer remained wet to kill possible bugs on the surface) and when the surface was dry, she placed the glucometer in the drawer. In an interview with the Infection Prevention nurse (IP), on 11/5/24, at 2:07 p.m., the IP stated the nursing staff were educated to clean and disinfect the shared glucometer in-between resident use. The IP stated it was a two-step process to use one wipe to clean and then a second wipe used to sanitize and keep the outer surface wet so you can see the wetness with eye for minimum of 2 minutes per Sani-Wipe instruction. In an interview with DON on 11/5/24, at 2:16 p.m., the DON stated the new staff received orientation and skill checks on how to use shared glucometers and how to clean and sanitize after each resident use to prevent the spread of infection. The DON stated the nursing staff should have followed the facility's policy to avoid cross contamination in-between use. Review of the facility's policy, titled Blood Glucose Monitoring, dated 1/1/23, the policy indicated The nurse will perform the blood sugar test utilizing the facilities glucometer as per manufacturer's instruction. The nurse will abide by infection control practices of cleaning and disinfection of glucometer as per manufacturer instruction and in accordance with facility's glucometer disinfection policy. The nurse is responsible for cleaning and disinfection of machine following the manufacturer's instructions. Review of EVENCARE G3 glucometer (brand name glucometer used in the facility) manufacturer instructions, dated 2016, the document indicated The EVENCARE G3 Meter should be cleaned and disinfected between each patient. The document further indicated there were two steps for cleaning and disinfecting the meter. Cleaning and disinfecting the meter was very important in the prevention of infectious disease. Cleaning also allowed for subsequent disinfection to ensure germs and disease-causing agents were destroyed on the meter as follow: a. To clean the meter, use a moist lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter until visibly clean. B. To disinfect the meter, wipe with one of the validated disinfecting wipes and allow to remain wet for the contact time (time needed for the disinfectant stay in touch with the outer surface of the glucometer to kill all the germs) listed on the wipe's directions for use. 4. During a medication administration observation, with LN 6, on 11/4/24, at 4:27 p.m., LN 6 crushed a medication called glycopyrrolate (drug used to reduce secretions in the mouth) to administer to Resident 82 through the feeding tube (a surgically inserted tube into the stomach.) LN 6 entered the room with gloved hand and no gown was put on. Resident 82's room was marked as Enhanced Barrier Precaution (or EBP) room, which required to put on gloves and protective gown to enter the room for tasks like medication administration through a feeding tube. LN 6 administered the medication using a syringe to push the medication inside the stomach via the feeding tube hub. In a concurrent observation and interview with LN 6 on 11/4/24, at 4:50 p.m., LN 6 acknowledged the room was marked as EBP which required use of a gown and gloves to care for a resident with tube feeding care. The gown supply was located behind the resident's room and not visible to the nurse. In an interview with Director of Nursing (DON), on 11/5/24, at 3:43 p.m., the DON stated the staff should follow the guidelines for the use of protective gowns and gloves when accessing the feeding tube for medication administration. Review of the facility's policy, titled Enhanced Barrier Precaution, dated 5/1/24, the policy indicated Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi drug resistant organisms that employs targeted gown and glove use during high contact resident care activities . Make gown and gloves available immediately near or outside residence room . PPE (Personal Protective Equipment, items such as gloves, mask, or gown) for enhanced barrier precaution is only necessary when performing high contact care activities . High contact resident care activities include: . device care or use: . feeding tube.

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two residents (Resident 1 and Resident 2) of two sampled re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two residents (Resident 1 and Resident 2) of two sampled residents' right to be free from verbal and physical abuse when Resident 1 yelled racial slurs and Resident 2 slapped Resident 1 in the face. This deficient practice resulted in both residents feeling either discontent, pain, and concerns about safety. Findings: The following documents were reviewed in Resident 1's medical record: - An admission record, printed on 10/10/24, indicated Resident 1 was re-admitted to the facility in summer of 2024 with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission record also indicated Resident 1 was under conservatorship (had an appointed conservator to make personal decisions). - A Minimum Data Set (MDS, an assessment tool) dated 9/20/24, indicated a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 13 which suggested Resident 1's cognition (the thinking process) was intact. - A care plan initiated on 8/8/24, indicated, The resident is/has potential to be verbally aggressive by using obscenities to staff . [Interventions] Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. - An Interdisciplinary Team (IDT) progress note dated 10/9/24, indicated, Patient was hit in the face by another resident. [Resident 1] was sitting in his wheelchair in the hallway outside of room [Resident 1's room number]. He was yelling racially charged profanities, which is a common occurrence. [Resident 2] was coming from the subacute area, heard [Resident 1] yelling and he said, Say that again. [Resident 1] continued to yell, then [Resident 2] used his right hand to slap him on the left side of his face . The following documents were reviewed in Resident 2's medical record: - An admission record, printed on 10/10/24, indicated that Resident 2 was re-admitted to the facility in 2023 with diagnoses which included major depressive disorder. The admission record also indicated Resident 2 was his own responsible party (RP, a decision maker). - An MDS dated [DATE], indicated BIMS score of 14 which indicated Resident 2's cognition was intact. - A care plan initiated 5/30/19, indicated, The resident is/has potential to be physically aggressive . Depression, Poor impulse control. 10/4/2022- Argument incident with another resident. 10/8/24- slapped other resident's face. A review of Resident 3's admission record, printed on 10/10/24, indicated Resident 3 was his own RP. A review of Resident 3's MDS, dated [DATE], indicated BIMS score of 15 which indicated Resident 3's cognition was intact. In an interview on 10/10/24 at 9:38 a.m., Resident 3 stated a resident in this neighboring room (Resident 1) comes out of his room on the daily basis and shouts profanities including the N-word [a racial slur]. Resident 3 stated it was offensive but he 'let it roll off my back. During a concurrent observation and interview on 10/10/24 at 10:35 a.m., Resident 2 was observed in his room on a wheelchair. Resident 2 stated Resident 1 regularly came out of his room and shouted profanities including the word, Nigga. Resident 2 also stated a few days ago, Resident 1 asked him for a cigarette lighter and called Resident 2 a Nigga when the lighter was not provided. Resident 2 expressed frustration when Resident 1 shouted Nigga on a daily basis and the facility staff did nothing about it. Resident 2 denied slapping Resident 1 and appeared resentful when he turned his back to this Surveyor. In an interview on 10/10/24 at 10:54 a.m., Resident 1 stated one day he was out in the hallway and said, Nigger and another resident approached him and slugged him in the face and he felt pain in his right cheek. Resident 1 stated he apologized for saying, Nigger. Resident 1 expressed concerns about his safety and stated he could be slapped in the face again. In an interview on 10/10/24 at 11:26 a.m., the Licensed Nurse (LN 1) confirmed she worked with Resident 1 and Resident 2 and verified Resident 1 had daily, loud outbursts shouting very discriminatory comments including the N-word. In a phone interview on 10/10/24 at 12:24 p.m., the Certified Nursing Assistant (CNA 1) stated on 10/8/24 she observed Resident 1 shout the N-word outside of his room when Resident 2 was coming down the hallway. Resident 2 approached Resident 1 and asked him to say it again. When Resident 1 said the N-word again, Resident 2 used the back of his right hand to tap Resident 1's right cheek. In a phone interview on 10/10/24 at 9:34 a.m., the CNA 2 stated she did not directly witness Resident 1 and Resident 2's physical interaction on 10/8/24 as she was on a break when it occurred; however, the CNA 2 stated when she looked at Resident 1 after the incident, she saw his right cheek was more red than his left cheek. A review of facility's policy and procedure (P&P) titled, Reporting Allegations of Abuse/Neglect/Exploitation, dated 1/1/24, indicated, The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences .

Aug 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 119 when two bags of medications were left unlocked and unattended on t...

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Based on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 119 when two bags of medications were left unlocked and unattended on top of a cabinet. These failures had the potential for medication misuse and drug diversion. Findings: During an observation on 8/6/24 at 9:58 a.m. in the Director of Nursing's (DON) office, there were two bags with approximately 30-40 bottles and boxes of medications on top of the black cabinet that was left unlocked. The door was open and unlocked. The DON was not in the room, and there was a female staff entering the DON's office. There were other staff members walking outside of the hallway. There was a resident's room that consisted of three residents positioned in front of the DON's office. During an interview on 8/6/24 at 10:14 a.m. with the DON, the DON confirmed expecting the medications to be locked in a locked compartment or a locked room without resident access. The DON stated residents or staff could have taken and ingested the expired medications. A review of the facility's policy titled, Medication Storage, dated 3/1/23, stipulated, All drugs and biologicals will be stored in locked compartments .

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to meet the professional standards of practice for Resident 1 when the nasal cannula (a device used to deliver oxygen to the nose...

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Based on observation, interview and record review, the facility failed to meet the professional standards of practice for Resident 1 when the nasal cannula (a device used to deliver oxygen to the nose) was not labeled with an open date (start of use) and the nasal cannula replacement order was scheduled for a longer interval than indicated on the facility's policy. These failures decreased the facility's potential to prevent the spread of infection. Findings: Resident 1 was most recently admitted to the facility in 2022 with diagnoses which included cirrhosis of the liver (a chronic liver damage from a variety of causes leading to scarring and liver failure), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and chronic respiratory failure (a condition when blood has too much carbon dioxide or not enough oxygen). A review of Resident 1's Medication Administration Record (MAR), dated April 2024, indicated the following orders: Order initiated on 6/6/23 indicated, Change Oxygen tubing monthly every night shift every 28 day(s) for preventative measures. Marked as last administered on 4/8/24. Order initiated on 7/30/23 indicated, Oxygen at 2 LPM [liters per minute] via NASAL CANNULA continuous every shift. Marked as administered every shift. A review of Resident 1's undated Care Plan Detail [CP] indicated, The resident has oxygen therapy .The resident will have no s/sx [signs and symptoms] of poor oxygen absorption through the review date. During a concurrent observation and interview on 4/12/24 at 10:01 a.m. with Resident 1 in the resident's room, Resident 1 was observed with a nasal cannula in place and the tubing had no label to indicate the date when the nasal cannula was changed. Resident 1 stated the nasal cannula was changed once every one or two months. During a concurrent observation and interview on 4/12/24 at 11:18 a.m. with the Infection Preventionist (IP) in the Resident 1's room, Resident 1's bed was observed empty with the nasal cannula laying on the bed and the tubing looped down to the floor. The IP confirmed the nasal cannula did not have a label which indicated the date it was changed and it should, and tubing should not touch the floor. In an interview on 4/12/24 at 12:13 p.m. the IP confirmed the facility policy required oxygen tubing to be changed every 7 days and Resident 1's order called for changes every 28 days. The IP stated current orders need to be updated to bring practices in line with facility policy. Not changing tubing timely increases risk of bacteria buildup and infections. A review of facility's policy titled Oxygen Administration Infection Prevention, dated 5/1/23, indicated, Change the oxygen cannula and tubing every seven (7) days, or as needed .Keep the oxygen cannula and tubing used PRN in a clean bag when not in use .

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to report an incident of allegation of abuse for one of four sampled residents (Resident 1) as required by the regulations. This...

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Based on observation, interview, and record review, the facility failed to report an incident of allegation of abuse for one of four sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from physical and psychosocial harm. Findings: A review of Resident 1's admission Record, dated 4/4/24 indicated, Resident 1 was admitted to the facility over two years ago with multiple diagnoses which included hemiplegia ( paralysis of half of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). The admission record also indicated Resident 1 was non-English speaking. The Minimum Data Set (MDS, an assessment tool) dated 3/14/24, indicated the resident had severe cognitive impairment. During a review of Resident 1's change in condition (CIC) notes, dated 3/16/24, the notes indicated, On 3/16/2024 at around 8:00 AM, resident reported to RNA [Restorative Nursing Assistant] that he was hit on the chest twice by his CNA [Certified Nursing Assistant] the day before. Nurse reported the incident to Administrator and DON [Director of Nursing] . A review of Resident 1's nursing progress notes, dated 3/16/24, indicated, @[at]0700 RNA reported to charge nurse that [Resident 1] called her over to his bed and stated that the evening CNA the day before on 3/15/24 struck him twice in the chest .[Resident 1] was very adamant about being struck and kept repeating it over and over again. Administrator and DON notified. During a review of a facility provided document titled Report of Suspected Dependent Adult/Elder Abuse, dated 3/16/24, the document indicated, On 3/16 between 0645-0700 am resident reported to CNA that the PM [afternoon] shift CNA hit him 2x [twice] in his chest. Report made to supervisor. Supervisor informed abuse coordinator and DON. The document also had a line struck across it and had a written note that stated, DID NOT SEND *Based on information. During a review of the Interdisciplinary Team (IDT) notes, dated 3/18/24, the notes indicated, LATE ENTRY .Root Cause: Resident stated he was hit by a CNA twice to the chest area with his hand .Interventions: Incident reported to Administrator, DON and MD (Medical Doctor). Closely monitor for behavior changes, thought process, skin issue/discoloration or pain/discomfort to the chest area, internal/facility investigation initiated as per facility protocol. A review of Resident 1's CIC notes dated 3/29/24 indicated, .On 3/29/2024 at around 4:00 PM, resident reported that he was hit on the chest twice by his CNA 2 weeks ago . During a review of the IDT notes dated, 3/29/24, notes indicated, Root cause: Resident stated he was hit by a CNA twice to the chest area with his fist 2 weeks ago .Interventions: Incident reported to Administrator, DON, MD and RP Responsible Party] .internal/facility investigation initiated as per facility protocol. Incident reported to the following agencies within time frame: Ombudsman, CDPH and local Law Enforcement. A review of a document titled Intake Information, dated 4/2/24 indicated the report was received by the Department on 4/2/24. The report indicated Resident 1 had reported on 3/29/24 on an incident that happened two weeks ago when a CNA allegedly hit him twice on his chest. During an interview on 4/4/24 at 10:40 a.m. with CNA 1, she stated an RNA came out that day in the morning, and asked if she can come and translate to make sure what Resident 1 was saying was understood. CNA 1 stated, I went with him and asked what happened, he said - he hit me - and I said who hit you and he said that guy and he said that the CNA from yesterday and I said why did he hit you. CNA 1 stated Resident 1 didn't answer but responded by an action that indicated he did not know. CNA 1 stated, He said I don't want him anymore, I'm scared. CNA 1 stated she informed the nurse and the nurse made a report on 3/16/24. During a concurrent observation and interview on 4/4/24 at 11:10 a.m. with Resident 1 in his room, Resident 1 was observed sitting on wheelchair, alert, calm, and responded to questions using short English words. When asked about the incident, Resident 1 stated, two time punch, hurt a little, and demonstrated with a ball of fist and punched on the chest. Resident 1 stated he felt scared, and he reported to the nurse. During an interview on 4/4/24 at 11:18 a.m. with the DON, the DON confirmed the incident was reported to her and the administrator on 3/16/24. The DON stated, As per that situation, the event that happened 2 weeks ago, we made this an isolated incident, that's why the [report] was not sent out. Then after two weeks, the Ombudsman was notified .and then when that still it came up, that's when we were like let's do another investigation and then that's when we decided let's just proceed with the whole thing. The DON confirmed the report was filled out on 3/16/24, and stated, The administrator as the abuse coordinator decided that it's not reportable. DON stated they considered it as non-reportable at that point on that event on the 3/16/24 but after two weeks decided it's reportable. The DON confirmed the incident was reported to the department on 3/29/24. In an interview on 4/4/24 at 11:34 p.m. with the Administrator (ADM), the ADM stated, The stories were changing, and I told them let us start writing everything out because it happened on weekend .we held on to it because the story was changing, left and right, and nothing really made sense. So I had them fill it all out, I held on to it and then when I talked to everybody when I got back, I wrote it on there that we're not sending this because nothing makes sense on this. When asked about the process on reporting allegations of abuse, the ADM stated, It depends on capacity of the resident .I decided to just hold off because nothing added up to what he was saying. A review of the facility ' s policy and procedure (P&P) titled, Reporting Allegations of Abuse/Neglect/Exploitation, dated 1/1/24, the P&P indicated, 8. Reporting/Response: The facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required .Procedure for Response and Reporting Allegations of Abuse/Neglect/Exploitation: When suspicion of abuse/neglect/exploitation of reports of abuse/neglect/exploitation occur, the following procedure will be initiated. 1. The facility will: .h. Notify the appropriate agencies immediately: as soon as practically possible, no later than two hours after observing, obtaining knowledge of, or suspecting the alleged abuse or neglect. i. Submit a written report to the long-term care ombudsman; Local law enforcement; and the California Department of Public Health (CDPH) within 24 hours.

Mar 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, record review and policy review, the facility failed to provide supervision and monitoring for one of three ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to provide supervision and monitoring for one of three sampled residents (Resident 1) when Resident 1, after several attempts, eloped from the facility. This failure had the potential to result in serious injury or death for Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke) affecting right dominant side, intracranial injury (brain injury) without loss of consciousness, mild cognitive impairment, right knee pain, and cognitive communication deficit. Resident 1's admission MDS (Minimum Data Set-an assessment tool), dated 6/4/13 documented Resident 1 as having unclear speech, usually able to understand others, usually able to make self-understood and his Brief Interview for Mental Status (BIMS) summary score as an 8 (moderate impairment). The MDS described Resident 1 as having no delirium or behavioral symptoms. The MDS also described Resident 1 as needing limited assistance with bed mobility, transfers, locomotion on and off unit, dressing, and toilet use. During a review of Resident 1's Elopement Risk-V2, dated 5/3/23 indicated Resident 1's Elopement Risk Category: At Risk for Elopement. During a review of Resident 1's Order Summary Report, for July 2023, a physician's order, dated 5/31/23, indicated, MD (Medical Doctor) determines that resident does NOT have the mental capacity to make healthcare decisions as per history & physical or transfer orders or preferred intensity of care. During a review of Resident 1's Nurses Progress Note (PN), dated 7/25/23 at 5:54 a.m., the PN indicated, Resident awake most of the shift, being intrusive in peers rooms, asking staff 'Where can I buy meth,' writer explained that asking that is inappropriate, resident continued, resident also left out of facility @0545 (5:45 a.m.), he propelled himself out to the back parking lot of the facility and had to be redirected by staff. During a review of Resident 1's PN, dated 7/25/23 at 5:55 a.m., the PN indicated, At approximately 0550 (5:50 a.m.) the custodian alerted the nurse for station 4 that he (Resident 1) was escaping the building. When supervisor found out the news, she witnessed the custodian and the nurse coming back from the neighborhood just beyond the field to the side of the building. Resident safely escorted back into the facility. During a review of Resident 1's PN, dated 7/25/23 at 8:05 a.m., the PN indicated, At the beginning of AM shift writer was notified by one of the staff that she saw the res (resident) outside the facility heading to the streets. Found res outside right by the church, asked res why he was wandering outside res verbalized, 'I'm looking for Meth.' Res was refusing to go back to the facility, risk and benefits explained then res verbalized I dont (sic) give a shit. After couple of minutes of talking to the res, he finally turned around and returned back to the facility. Res is calm at the moment. Will cont (continue) to monitor. During a review of Resident 1's PN, dated 7/25/23 at 10:07 p.m., the PN indicated, Res left facility around 5pm, Staff was unsuccessful with locating Res. Res had attempted to leave facility several times earlier in the day. Res did not return to facility after 4 hrs. Due to Res physical condition a police report was made to the Sacramento Police Dept. with incident #23-2097816 and Res was noted to have left AMA (Against Medical Advice) @2145 (9:45 p.m.). During an interview, on 3/26/24 at 9:06 a.m. with the Director of Nursing (DON), the DON confirmed Resident 1 did not have capacity per physician's order, dated 5/31/23, and Resident 1's responsible party (RP) was his brother. The DON also confirmed there was no documentation Resident 1 had a scheduled appointment or went out on a leave of absence (LOA) on 7/25/23. The DON confirmed according to Resident 1's elopement risk assessment that Resident 1 was as risk for elopement. The DON stated there was no documentation Resident 1's RP, physician, or the Department were notified of his elopement. The DON did not know where Resident 1 went or what happened to him after eloping from the facility on 7/25/23. During a review of the facility's policy and procedure (P&P) titled, Elopement and Missing Resident Policy, revised October 2009, indicated, It is standard policy to monitor and evaluate residents at risk for wandering and elopement. The Interdisciplinary Team (IDT) is responsible for identifying residents at risk for elopement, implementing preventative measures to reduce risk, and provide a process for action if an incident of elopement occurs. Elopement Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization or staff notification and/or any necessary supervision to do so If wandering or exit seeking behavior is identified for any resident who previously has not exhibited this behavior, a change of condition IDT Walking Rounds should be completed .If the resident is not located on the grounds of the facility, the Executive Director/designee takes over primary responsibility for managing the response plan. The Executive Director/designee should follow all internal communication guidelines outlined in the Incident Management Standard .Notify the Responsible party and query possible destinations that the resident may have attempted to travel. Notify the Primary care physician .The Executive Director/or designee is responsible for notification to State Agencies if applicable.

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0573 (Tag F0573)

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 sampled residents (Resident 1's) representative...

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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 sampled residents (Resident 1's) representative obtained a copy of Resident 1's record or any portions thereof upon request and of two working days advance notice to the facility. This failure resulted in the impingement of Resident 1's representative rights. Findings: Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (neurological disorders) and acute respiratory failure with hypoxia (low levels of oxygen in the body). During an interview on 3/22/24 at 9:11 a.m., with the Administrator, he confirmed he received the request for Resident 1's medical records, from the complainant, on 3/14/24 and sent the request to legal on 3/14/24. The Administrator confirmed Medical Records had all requested documents copied and ready to go on 3/14/24. The Administrator stated he received an email from legal, on 3/15/24, not to send anything until further notice. The Administrator further stated he had not received any additional directions from legal at this time. During an interview on 3/22/24 at 9:36 a.m., with the Health Information Assistant (HIA), she verified the facility received the request for Resident 1's medical record, from the complainant, on 3/14/24 by mail. During a review of the facility's policy titled, Release of Medical Records, dated 6/1/23, indicated Medical records will be release with a valid request and in accordance with state and federal laws. The resident or his/her legal representative may receive a copy of his/her record within 2 working days after the request has been made.

Mar 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to observe professional standards of practice to meet the needs of one of three sampled residents (Resident 1), when the facility failed to ca...

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Based on interview and record review, the facility failed to observe professional standards of practice to meet the needs of one of three sampled residents (Resident 1), when the facility failed to carry out physician's order for management of shortness of breath as ordered upon discharge from a General Acute Care Hospital (GACH). This failure resulted in worsening of Resident 1's shortness of breath and subsequent need to be transferred to a hospital. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident in 2021 with multiple diagnoses including diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Resident 1's medical history indicated that he had multiple hospitalizations while living in the facility. A review of Resident 1's Physician's Order dated 6/29/2021 indicated the resident had the capacity to understand and make decisions. A review of Resident 1's most recent Minimum Data Set (MDS, an assessment tool) dated 3/1/24 indicated the resident was cognitively intact and had no memory issues. A review of Resident 1's Hospital discharge orders dated 2/27/24 included oxygen treatment order. The order indicated to start oxygen at 2 liters per minute (unit of measurement) if Resident 1 experienced shortness of breath, chest pain, and if his oxygen saturation (amount of oxygen present in the blood) became less than 90% [level below 90% may indicate a severe medical emergency problem]. A review of Resident 1's clinical records indicated the resident was readmitted to facility on 2/27/24 after hospitalization. Resident 1's 'Order Summary Report' contained a list of physician's orders for treatment and medications and indicated, Active Orders As of 02/27/2024. A review of Resident 1's 'Order Summary Report' with active orders did not contain the order for oxygen treatment. A review of Resident 1's Situation, Background, Assessment, Recommendations (SBAR, a document to communicate with physicians and other practitioners) dated 3/3/24 and timed at 12:47 p.m., indicated the resident was experiencing a change of condition. The nurse recorded Resident 1's oxygen saturation level was 87% (normal oxygen saturation level is 98-100%) and documented, Method: Room air .Shortness of breath, Labored or rapid breathing. There was no documented evidence that the nurse initiated oxygen administration per physician order to alleviate Resident 1's shortness of breath before the resident was sent to the hospital. A review of nursing progress note dated 3/3/24 at 1:11 p.m., indicated when staff attempted to move Resident 1 to sit in the chair, the resident became short of breath and stated he could not breathe. Res [resident] had a sudden onset of rapid breathing .Res [resident] O2 [oxygen level] wouldnot [sic] exceed 87% .Asked [Resident 1's name] how long his SOB [shortness of breath] had been going on and Res [resident] stated a few days. The nurse documented she had made several attempts to contact resident's physician and his office and was not able to reach him. The nursing progress note did not indicate the nurse administered oxygen treatment or performed other interventions to help Resident 1 with his difficulties in breathing. During an observation and concurrent interview with Resident 1 on 3/19/24 at 2:05 p.m., Resident 1 was lying in his bed with oxygen tubing connected to oxygen concentrator (electrical device that extracts oxygen from surroundings and filters it for the person to breathe). Resident 1 responded to questions appropriately and stated, Earlier this month, on March 3rd I started having difficulties with breathing. [Felt] like the air was trapped inside of my chest and I couldn't exhale it . I kept repeating I can't breathe, I can't breathe. Resident 1 stated that one of the staff checked his oxygen level and told him it was 85% and explained that it was low. Resident 1 stated his nurse told him she was trying to call doctor while he was struggling with breathing, and he had to wait for an hour. Resident 1 added, I was scared, [I] thought I was going to die. Resident 1 pointed to his oxygen tubing and stated, I did not have this back then. The ambulance people .came .checked my oxygen level and told [the nurse] it was very low. They put this tubing on me and connected to the oxygen tank. I felt relief right away. During a concurrent interview and record review with Director of Nursing (DON) on 3/19/24, at 3:30 p.m., the DON validated that Resident 1 was transferred to the hospital on 3/3/24 due to rapid breathing and low oxygen saturation level. The DON stated the nurse was not able to get hold of the resident's physician after several attempts. When the DON was asked what interventions were implemented while waiting for the physician to respond and Resident 1 was having difficulties with breathing, the DON replied, I don't see any interventions. The DON stated if resident experienced breathing difficulties, she would expect the nurse to immediately elevate Resident 1's head of bed and apply oxygen. The DON searched Resident 1's records and was not able to find any documented evidence that the nurse administered oxygen to help Resident 1 with the shortness of breath. The DON reviewed the resident's hospital discharge orders dated 2/27/24 and confirmed the GACH transfer order for oxygen was not transcribed on Resident 1's orders and was not carried out when the resident experienced breathing difficulties. The DON added, If the doctor ordered it, should be reflected on resident's orders, but I don't see it. The DON stated that shortness of breath was considered an emergency and she would expect the nurse to apply oxygen even when there was no order. This represented 6 days that a physician order for oxygen for Resident 1 was not carried forward from the hospital orders to his nursing home orders. A review of the facility policy titled, Physician Orders, implemented 6/15/23, indicated, Each medication order should be entered into the electronic medical record .Written Transfer Orders (sent with a resident by a hospital or other health care facility) - Implement a transfer order without further validation, if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete .Notify the physician or health care provider for any order unable to by [sic] carried out or refused by the resident.

Feb 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on notification of changes ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) on notification of changes for one of six sampled residents (Resident 1) when Resident 1's family member was not notified of Resident 1's change of condition and transfer to the hospital. This failure resulted in Resident 1's family member to be unaware and not involved with Resident 1's current medical status and transfer to the hospital. Findings: A review of Resident 1's clinical record indicated Resident 1 was admitted [DATE], and had diagnoses that included cerebral palsy (a group of conditions that affect movement and posture), convulsions (an involuntary action of jerking and contractions), hemiplegia (complete loss of the ability to move one side of the body) and hemiparesis (partial weakness of one side of the body) following cerebral infarction (damage to a part in the brain due to a disrupted blood flow) affecting right dominant side. A review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 12/13/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 8 out of 15 which indicated Resident 1 had a moderately impaired cognition. A review of Resident 1's LATE ENTRY progress notes, dated 2/9/24, indicated, .On 2/7/24 resident [Resident 1] has changed of condition observed patient [Resident 1] lethargic [a state of diminished energy, mental capacity, and motivation] and MD [Medical Doctor] ordered CBC and BMP [Complete Blood Count and Basic Metabolic Panel- blood tests that provides information about overall health and the body's chemical balance and metabolism]. On 2/8/24 charge nurse received a call from the lab [laboratory] regarding critical lab results. MD made aware and ordered to transfer to acute hospital for further tx [treatment] and eval [evaluation] . A review of Resident 1's physician's orders, dated 2/8/24, indicated, Transfer to [name of acute hospital] . During an interview on 2/22/24 at 12:07 p.m. with Licensed Nurse (LN) 3, LN 3 stated when a resident is being transferred to the hospital, the staff would call and inform the resident's responsible party (RP) about the transfer. LN 3 further stated, .If the resident is his own RP .when the patient is being transferred to the hospital; the patient is ill and out of himself .so we need to notify the listed family members so they would be aware about it [change of condition and transfer to the hospital] .It's for courtesy . During a concurrent interview and record review on 2/22/24 at 12:15 p.m. with the Social Services Director (SSD), Resident 1's clinical record was reviewed. The SSD confirmed that resident 1 was transferred to an acute hospital on 2/8/24. The SSD stated, .MD was notified .I don't see any notes that the family was notified The SSD further stated, .they're [Resident 1's brother (RP 1) and case worker (CW 1)] supposed to be notified .Brother [RP 1] also wants to be notified .that's definitely an issue .That's a patient's right . During a telephone interview on 2/22/24 at 12:22 p.m. with RP 1, RP 1 stated that Resident 1 was transferred at around 5:30 a.m. on 2/8/24 to the hospital, and RP 1 was called by the hospital doctor later in the afternoon on 2/8/24, and asked for a treatment consent. RP 1 further stated he was never notified by the facility about the transfer and his brother's change of health condition, and he doesn't know why his brother was transferred. During a concurrent interview and record review on 2/22/24 at 12:43 p.m. with the Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON stated that on 2/8/24, Resident 1 was listed as his own responsible party and they have a physician's order declaring Resident 1 was mentally competent, so they informed Resident 1 about the change of his condition and his transfer to the hospital. The DON also stated that on 2/8/24, RP 1 was listed as a family member and CW 1 as a case worker for Resident 1. The DON further stated that on 2/13/24, Resident 1's clinical record was updated and listed CW 1 and RP 1 as Resident 1's responsible parties. During a telephone interview on 2/22/24 at 12:46 p.m. with CW 1, CW 1 stated the facility did not notify him about Resident 1's transfer to the acute hospital on 2/8/24. CW 1 further stated, .I reached out to the facility, and they [facility] said [name of Resident 1] was his own responsible party .I get it but, if he's [Resident 1] being transferred [to the hospital], at least someone should have been notified . During a concurrent interview and record review on 2/22/24 at 12:43 p.m. with the DON, Resident 1's clinical record was reviewed. The DON confirmed that no family member of Resident 1 was notified of Resident 1's change of condition and transfer to the hospital. The DON further stated, .At least [name of RP 1] should have been informed .What if something happens to the patient [Resident 1], then none of them [Resident 1's family members] will be aware .That might be the repercussions for not notifying a family member . A review of the facility's P&P titled, Notification of Changes, dated 3/1/2023, indicated, .1. Competent individuals: .c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a written notice of bed-hold was provided for 2 of 3 sampled residents (Resident 1 and Resident 3) or their representatives. These f...

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Based on interview and record review, the facility failed to ensure a written notice of bed-hold was provided for 2 of 3 sampled residents (Resident 1 and Resident 3) or their representatives. These failures caused residents or their representatives to not be fully informed of bed-hold options and rights. Findings: A review of the clinical record indicated Resident 1 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia (a serious condition that makes it difficult to breath), tracheostomy status (an opening created into the windpipe from outside the neck to help air and oxygen reach the lungs), and unspecified dementia (decline in cognitive ability). Resident 1's Brief Interview for Mental Status (BIMS, a cognitive screening) dated 11/27/23 indicated Resident 1 had moderate cognitive impairment with a score of 9. Further review of Resident 1's clinical record indicated a 'Transfer Form' dated 1/8/2024. Resident 1's reason for transfer was due to respiratory arrest (respiratory failure). A review of the clinical record indicated Resident 3 was admitted with diagnoses including aftercare following explantation (to remove a device that has been implanted) of knee joint prosthesis (a surgical procedure to replace parts of worn out knee joints). Resident 3's BIMS dated 1/9/2024 indicated the resident was cognitively intact with a score of 15. Further review of Resident 3's clinical record indicated a 'Transfer Form' dated 2/13/2024. Resident 3's reason for transfer was due to family request. There was no documented evidence in the clinical records of a written bed-hold notice provided to residents [Resident 1 and Resident 3] or their representatives. In an interview on 2/16/2024 at 2:11 p.m., the Director of Nursing 1 (DON 1) stated her expectation was for the bed-hold notice to be signed on admission and every time a resident was transferred to the hospital. The DON 1 further stated the licensed nurse at the time of transfer should call or have the family sign the bed-hold notice form. In a telephone interview on 2/21/2024 at 2:09 p.m., the DON 2 confirmed the bed-hold notice for Resident 1 or his representative was missed. In an electronic mail received on 2/21/2024 at 5:38 a.m., the DON 2 confirmed there was no bed-hold notice initiated for Resident 3 or her representative during the transfer to the hospital. A review of the facility's policy titled, Bed-Holds and Returns revised October 2022 indicated, .All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: . notice 1: well in advance of any transfer (e.g., in the admission packet); and . notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).

Feb 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

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of p...

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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when there was no care plan, no wound assessment, and no monitoring for Resident 1's left middle toe wound. These failures contributed to Resident 1 being admitted to the hospital with osteomyelitis (serious infection of the bone from injuries that cause damage to deep tissues) and gangrene (tissue death often caused by lack of blood flow or infection) on his left second and third toes and, as a result; both toes were amputated. Findings: A review of the admission Record indicated Resident 1 was originally admitted in 2023 with multiple diagnoses that included Type 2 Diabetes (body's inability to regulate blood sugar) and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/17/23 indicated, Resident 1 was cognitively intact. His skin conditions assessment indicated he was at risk for developing pressure wounds. A review of Resident 1's Nursing Weekly Summary Review dated, 12/21/23 and 1/4/24 indicated, 4. Skin (includes heel checks): 2. Current skin concerns (See Skin & Wound Evaluation and Treatment Administration Record) . Further review of Resident 1's clinical record indicated, Resident 1 had no Skin and Wound Evaluation and Treatment Administration Record for the identified skin concerns on 12/21/23 and 1/4/24. A review of Resident 1's Shower Sheet-Skin Inspection dated, 12/22/23 indicated, Left foot (open area notified nurse) .open area 2.0cm x 1.5cm [cm, unit of measurement .]. The diagram in the shower sheet indicated the left foot middle toe was encircled where the open area was found. A review of Resident 1's Nurses Progress Note dated, 12/22/2023, indicated, The writer was notified by the CNA that the res [resident] left middle toe was bleeding upon taking him to the shower. The writer immediately went to the room to check the res middle toe .Will continue on the POC [Plan of Care] A review of Resident 1's clinical record indicated, there was no care plan, no wound assessment, and no monitoring for his left middle toe wound. A review of Resident 1's Acute Hospital Clinical record indicated he was admitted to the acute hospital on 1/11/24. Resident 1's Consultation record dated, 1/13/24 indicated, .Reason for Consultation .Left 2nd and 3rd toe gangrene . History of Present Illness . Reports left 2nd and 3rd pain/wounds x [times] unknown months . Physical Exam .Left 2nd and 3rd toe with wet gangrene/foul smelling . A Review of Resident 1's Surgical Pathology Report dated, 1/18/2024, indicated, .Diagnosis 2nd and 3rd toe, left foot, amputation .Acute osteomyelitis .Overlying skin with ulcer [painful wound], gangrenous necrosis, and soft tissue abscess [collection of pus] .Abscess extends to soft tissue margin .gross description .Distally both toes are involved by gangrenous black ulceration up to 2.5 cm extending to within 0.1 cm of the skin margin . During a concurrent observation and interview on 1/24/24 at 12:49 p.m., in Resident 1's room, the resident was lying in bed, with his left foot covered with a bandage. Resident 1 stated, his two toes were removed when he was recently admitted to the hospital. He stated, he had the wound on his toes for a while. Resident 1 stated that about three weeks ago his toes started bleeding in the shower and the staff helped to stop the bleeding. He further stated the staff did not do anything after that day. During an interview on 1/24/24 at 12:55 p.m., the Certified Nursing Assistant (CNA 1) stated, Resident 1 had a wound on the ball of his left foot (pointing on the toes) for a while. She stated she was not exactly sure when it started but probably around end of December. CNA further stated, she had seen the toes covered with a small dressing but not fully covered like it was currently. During a concurrent interview and record review on 1/24/24 at 2:13 p.m., the Director of Nursing (DON) verified, Resident 1's weekly nursing assessment, dated 12/21/23 and 1/4/24, was marked that the resident had skin concerns. On further review, there was no wound care notes and no treatment administration record (TAR) for the documented skin concerns. The DON verified Resident 1's left middle toe was bleeding on 12/22/23, according to the progress notes. The DON stated, the staff were expected to initial on the TAR they had completed the wound care and weekly wound assessment until the wound was healed. The DON verified Resident 1's records had no documented evidence the treatment and weekly wound assessment were done until the wound was healed. The DON verified Resident 1 had no TAR for his wound. The DON stated, there should have been treatment every day until the wound was healed and wound assessment should have been done weekly until it was healed. The DON also verified Resident 1 had no care plan for the new wound on the toe. The DON stated, she was not sure what happened. She verified, there was no documentation regarding Resident 1's wound after 12/22/23. During a concurrent telephone interview and record review on 1/31/24 at 2:41 p.m., the Acute Hospital Pathologist (AHP) stated, the osteomyelitis came from the wound. The AHP verified both toes had gangrenous black ulceration up to 2.5 cm extending to within 0.1 cm of the skin margin. He stated, it was a huge ulcer. It was a significant ulcer and gangrene. The AHP also stated, deep tissue abscess was present, and it could have started long time ago which means the wound was not healed. A review of Facility policy titled, Skin Tears - Abrasions and Minor Breaks, Care of, revised September 2013, indicated, Record the following information in the resident's medical record:1. Complete in-house investigation of causation .2. Generate Non-Pressure form . 3. Report other information in accordance with facility policy/guideline and professional standards of practice . A review of Facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . e. reflects currently recognized standards of practice for problem areas and conditions A review of Facility policy titled, Activities of Daily Living (ADLs), Supporting, dated, March 2018, indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .

Feb 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were 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 necessary treatment and services were provided to promote healing and prevent further progression of wounds for 2 residents (Resident 1 and Resident 2), for a census of 116, when: 1. Resident 1's open area on the coccyx (tailbone) and surgical wound on the posterior spine (backbone) were not assessed weekly; and 2. Resident 2 was not provided with a low air loss mattress (LAL, designed to distribute the body weight and help prevent skin breakdown) and heel suspension boots (removes pressure from the heel). These failures increased the risk for Resident 1 and Resident 2 to develop new pressure ulcers and the deterioration of existing wounds. Findings: 1. A review of the clinical record indicated Resident 1 was admitted with diagnoses including fusion (connects two or more bones) of the spine, thoracolumbar region (parts of the spine supporting the chest and lower back, and the nerves which receives and sends messages between the body and the brain). Further review of Resident 1's clinical record indicated the following: 'Wound - Weekly Observation Tool,' dated 7/28/23, indicated Resident 1 was admitted with an open area in the coccyx. The measurement was 5 mm (millimeter, unit of measurement) for the length, 5 mm for the width, and 1.0 mm for the depth. 'Wound - Weekly Observation Tool,' dated 7/28/23, indicated Resident 1 was admitted with a surgical site (a surgical wound]) on the posterior spine. The measurement was 430 mm for the length and 10 mm for the width. The current treatment plan was to keep steri strips (used to help seal wounds by pulling the two sides of skin together after removal of stitches) in place. There was no weekly wound observation conducted for Resident 1's coccyx wound in the first week of August. There was no weekly wound observation conducted for Resident 1's surgical site in the first week of August. 'Wound - Weekly Observation Tool,' dated 8/7/23, indicated Resident 1 had acquired an open area on the mid-back. The measurement was 30 mm for the length, 10 mm for the width, and 1.0 mm for the depth. The visible tissue was described as 80 % slough (dead tissue, often yellow/white in color) and 20% granulation (red, moist, may bleed easily). There was no weekly wound observation conducted for Resident 1's coccyx wound on the second week of August. 'Wound - Weekly Observation Tool,' dated 8/16/23, indicated Resident 1's coccyx wound measured 20 mm for the length and 20 mm for the width. There was no weekly wound observation conducted for Resident 1's surgical site or the open area on the mid back on the third week of August. A Change in Condition Evaluation, dated 8/18/23 indicated, During a.m. shift, treatment nurse change dressing and noted more drainage from wound than usual. tx was done as order [sic] and [Resident 1] went to therapy. (Left note for NP [Nurse Practitioner] to visit [Resident 1] today NP arrive and assess [Resident 1] and noted dressing to be soaking wet with drainage and active bleeding from wound. Pressure apply [sic] . but bleeding wouldn't stop. NP aware and order to send resident out. A review of the clinical records from the acute care hospital indicated Resident 1 was admitted on [DATE], and discharged on 9/16/23, with diagnoses including Operative Wound Dehiscence (a surgical complication where the incision or cut reopens) and gram negative (high resistance to antibiotics) bacteremia (presence of bacteria in the bloodstream). In an interview on 2/7/2024 at 9:57 a.m., the Licensed Nurse (LN) stated she was the treatment nurse for Resident 1. The LN further stated she was responsible for the wound observation every Wednesday or Thursday. The LN confirmed Resident 1 was sent out to the hospital due to the worsening of the surgical wound on her back. The LN stated the purpose of the weekly wound observation was to monitor if wounds had improved or worsened. In a telephone interview on 2/8/2024 at 3:16 p.m., the Director of Nursing (DON) stated her expectation was for the wound observation to be conducted weekly. The DON confirmed Resident 1's wound observation on the coccyx area was not done on the first and second week of August and the wound observation on the surgical site was not done on the first and third week of August 2023. 2. A review of the clinical record indicated Resident 2 was admitted with diagnoses including pressure ulcer (damage to the skin and underlying tissue caused by reduced blood flow due to constant pressure on the area) of the sacral (the large bone at the base of the spine) region, stage 4 (full thickness tissue loss with exposed bone, tendon or muscle). Resident 1's Brief Interview for Mental Status (BIMS, an assessment used to monitor cognition), dated 1/27/2024, indicated he was cognitively intact with a score of 15. Further review of Resident 2's clinical record indicated the following: 'Wound - Weekly Observation Tool,' dated 1/25/2024 indicated Resident 2 was admitted with a stage 4 pressure ulcer on the sacrum. The wound measurement was 61 mm for the length, 49 mm for the width, and 28 mm for the depth. There was tunneling (a narrow tract extending from the wound's surface into deeper tissue) at 3 o'clock. The special equipment/preventative measures indicated LAL. 'Wound - Weekly Observation Tool' dated 1/25/2024 indicated Resident 2 was admitted with a Suspected Deep Tissue Injury (SDTI, a purple or maroon discolored intact skin due to pressure) on the left heel. The wound measurement was 49 mm for the length, and 31 mm for the width. The special equipment/preventative measures indicated LAL. A physician order, dated 1/23/2024, indicated Use heel suspension boots to B/L [bilateral] heels at all times while in bed every shift for skin integrity and maintenance. In an observation on 1/30/2024 at 10:23 a.m., Resident 2 was lying in bed and he had a regular mattress. In a follow up observation on 1/30/2024 at 2:05 p.m., Resident 2 was lying in bed and he had a regular mattress. In an interview on 1/30/2024 at 3:41 p.m., the Treatment Nurse (TN) confirmed Resident 2 had a stage 4 pressure wound based on the wound observation dated 1/25/2024. In an interview on 1/30/2024 at 3:41 p.m., the Director of Nursing (DON) stated the facility should provide air mattress for residents with a stage 3 (full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle are not exposed) and above pressure wounds. In a concurrent observation and interview on 1/30/2024 at 3:46 p.m., the DON and the TN confirmed Resident 2 had a regular mattress. A concurrent observation and interview was conducted on 1/30/2024 at 3:59 p.m. with the Assistant Director of Nursing (ADON). The ADON checked Resident 2's bilateral feet and she confirmed the resident had no heel suspension boots. The ADON found Resident 2's heel suspension boots inside the closet. Resident 2 stated he had not worn the boots for a couple of days, since Sunday [1/20/2024] until today. A review of the facility's policy dated 3/3/2023 and titled, Pressure Injury Prevention and Management indicated, This facility is committed to the prevention . and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . Licensed nurses will conduct a full body skin assessment on all residents on admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the clinical record . Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: . Redistribute pressure . protecting and/or offloading heels . Provide appropriate, pressure-redistributing, support surfaces .

Jan 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to implement acceptable standards of practice in the use of controlled medications when Resident 1's unused narcotic was taped b...

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Based on observation, interview, and record review, the facility failed to implement acceptable standards of practice in the use of controlled medications when Resident 1's unused narcotic was taped back into the peeled blister pack and Resident 2's discontinued narcotics were stored in the medication cart for available for use and, had a reconciliation discrepancy. These failures increased the potential for controlled medication diversion, loss, and medication errors for a census of 119. Findings: Resident 1 was a long term resident in the facility with diagnoses that included unspecified pain. During a controlled medication reconciliation conducted on 1/11/24 at 11:29 a.m. with Licensed Nurse (LN 1) , LN 1 verified Resident 1's Norco 5/325 mg (a narcotic pain medication, Hydrocodone 5 milligram per 325 mg of Acetaminophen) blister pack was torn open in the back and resealed with clear plastic tape with a pill in it. LN 1 indicated when the narcotic was taken from the blister pack and unused, LNs were to discard the unused narcotic in the presence of another LN instead of taping the pill back into the blister. LN 1 stated, She [LN] is supposed to discard .Infection control issue. Resident 2 was admitted to the facility in the Fall of 2023 with diagnoses that included bone infection and bone fracture. During the controlled medications reconciliation conducted on 1/11/24 at 12:05 p.m. with LN 2, LN 2 pulled out Resident 2's Norco 5/235 mg medication blister pack that contained 28 pills from the locked box in the medication cart. LN 2 indicated Resident 2 had two pills of Norco 5/235 mg on 12/31/23 at midnight as evidenced by the narcotic administration log, Antibiotic or Controlled Drug Record, logged on 12/31/23 at 0000 [midnight]. The blister pack contained 28 pills of Norco 5/325 mg and the narcotic log indicated 28 pills remained after LN pulled out two pills on 12/31/23 at midnight. During a concurrent record review on 1/11/24 at 12:05 p.m., LN 2 verified the Medication Administration Record (MAR) for December 31, 2023 or January 1, 2024 had no documented evidence Resident 2 received the two pills of Norco 5/325 mg. In addition, the MAR indicated Norco 5/325 mg was discontinued on 12/31/23. LN 2 stated she was unable to answer whether Resident 2 took the medications and the LN failed to document in the MAR on 12/31/23, or the two pills were destroyed and undocumented. LN 2 explained when the physician discontinued the narcotic order, it was the facility practice that two LNs counted the unused narcotics, both signed the log sheets, documented on the Controlled Inventory Item Reconciliation Log, and turned in the remaining narcotics with the inventory sheet to the Director of Nursing (DON). LN 2 stated Resident 2's Norco blister pack should have been turned in to the DON and removed from the medication cart. LN 2 acknowledged the narcotic order was discontinued on 12/31/23 and there were three narcotic reconciliations per day; therefore, LNs had more than 30 opportunities to return the discontinued narcotics to the DON since the discontinuation of the order. Review of the facility's policy and procedure, revised November 2022, Discarding and Destroying Medications, stipulated, Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. In an interview on 1/11/24 at 1:01 p.m., in the presence of the Administrator, the DON acknowledged resealing an unused narcotic back to the peeled blister pack was not an acceptable practice. The DON stated any unused medications, including narcotics, should be discarded. The DON verified Resident 2's narcotic log for 12/31/23 and the December 2023 MAR for the two tablets of Norco 5/325 mg and acknowledged the discrepancy. The DON stated it was the facility's expectations the LNs documented administration of narcotics in the narcotic log and the MAR. The DON validated the physician discontinued the order for Norco for Resident 2 on 12/31/23. The DON stated Resident 2's Norco should have been brought to the DON when the order was discontinued. The DON acknowledged the failure to follow standards of practice increased the risks for drug diversion drug loss, misuse, and medication errors.

Jan 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to implement its policy and protocols on abuse for one of six sampled residents (Resident 1), when: 1. The facility failed to provide a nursing...

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Based on interview and record review the facility failed to implement its policy and protocols on abuse for one of six sampled residents (Resident 1), when: 1. The facility failed to provide a nursing assessment immediately after Resident 1 alleged he had been physically abused by a staff member, and 2. The facility failed to immediately place a staff member, who was accused of physically abusing a resident, on leave. These failures resulted in Resident 1 not receiving an immediate assessment and interventions to ensure safety. Findings: 1. In an interview on 1/9/24 at 11:27 a.m., the Administrator in Training (AIT) acknowledged during the nocturnal shift (NOC shift, the overnight shift) on 1/1/24, Resident 1 was allegedly physically abused by a staff member and had alleged skin redness to one shoulder as a result of the physical abuse. In an interview on 1/9/24 at 12:47 p.m., Resident 3 stated he was Resident 1's roommate on 1/1/24, when Resident 1 alleged a nurse had pushed him. Resident 3 stated he observed a red mark on Resident 1's right arm. In an interview on 1/9/24 at 2:19 p.m., Licensed Nurse 3 (LN 3) stated she has been trained to immediately assess a resident for injuries when there was an allegation of a resident being physically abused. In an interview on 1/10/24 at 7:26 a.m., LN 4 stated on 1/1/24 around 2:40 a.m., she was notified by police that Resident 1 was alleged to have been physically abused earlier during the NOC shift. LN 4 acknowledged when a resident was allegedly abused, nurses were supposed to assess the resident for injuries. LN 4 stated she nor any other nurses working the NOC shift on 1/1/24, assessed Resident 1 for injuries after being made aware of the allegation of physical abuse. In an interview on 1/10/24 at 10:33 a.m., LN 5 stated police arrived at the facility on 1/1/24 around 2:50 a.m., and informed her Resident 1 alleged he had been physically assaulted by a staff member earlier during the NOC shift. LN 5 acknowledged nurses were supposed to assess a resident who alleged physical abuse, but denied she had assessed Resident 1 for injuries during the NOC shift. In an interview on 1/11/24 at 7:46 a.m., LN 6 stated during the NOC shift on 1/1/24, police informed staff that Resident 1 was allegedly physically assaulted by a staff member earlier in the NOC shift. LN 6 added the police informed nursing staff Resident 1 had a bruise on one shoulder. LN 6 stated he was trained to conduct a skin assessment and assess for injuries when a resident alleges being physically abused. LN 6 denied he or any other nurse assessed Resident 1 for injuries during the NOC shift on 1/1/24. In an interview on 1/17/24 at 8:06 a.m., LN 7 stated during the NOC shift on 1/1/24 at approximately 4 a.m., Resident 1 told LN 7 a staff member had hit him in the arm earlier in the shift. LN 7 denied assessing Resident 1 for injuries after being informed of the allegation of physical abuse. In an interview on 1/12/24 at 12:02 p.m., the Director of Nursing (DON) stated she expected a skin assessment to be performed on a resident who alleged they had been physically abused. The DON acknowledged a skin assessment had not been performed during the NOC shift on 1/1/24. A review of the facility's daily assignment sign-in sheet, dated 12/31/23, indicated LN 4, LN 5, LN 6 and LN 7 worked the NOC shift from 10:30 p.m. on 12/31/23 to 7 a.m. on 1/1/24. A review of the facility's protocols titled, Abuse and Neglect - Clinical Protocol, revised July 2017, .Assessment and Recognition .The nurse will assess the individual and document related findings. Assessment data will include .Injury assessment (bleeding, bruising deformity, swelling, etc.) .pain assessment . 2. In an interview on 1/9/24 at 11:27 a.m., the AIT stated he was the facility's abuse coordinator. The AIT further stated he expected staff to notify him immediately when a resident alleged abuse. In an interview on 1/10/24 at 7:26 a.m., LN 4 stated at approximately 2:40 a.m. on 1/1/24, the police arrived at the facility and informed her Resident 1 had made an allegation she had hit him earlier in the shift. LN 4 stated the AIT came to facility prior to her completing her shift, as scheduled at 7 a.m., and was informed later that day she was suspended pending an investigation into the allegation of abuse. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, undated, indicated, .All reports of resident abuse .must be reported immediately to the administrator .'immediately' is defined as .within two hours of an allegation involving abuse .the administrator is responsible for determining what actions (if any) are needed for the protection of residents .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete .

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to report an allegation of abuse involving one of six sampled residents (Resident 1) to the California Department of Public Health (CDPH) with...

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Based on interview and record review, the facility failed to report an allegation of abuse involving one of six sampled residents (Resident 1) to the California Department of Public Health (CDPH) within two hours after facility staff were made aware of the allegation of abuse. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment. Findings: In an interview on 1/9/24 at 11:27 a.m., the Administrator in Training (AIT) stated on 1/1/24 at approximately 6:30 a.m., he received a phone call from Licensed Nurse 4 (LN 4) informing him Resident 1 had called the police earlier in the morning. The AIT stated he arrived at the facility, spoke to LN 4 before she left her shift around 7 a.m., and then spoke to Resident 1. AIT stated Resident 1 alleged LN 4 had pushed him during a verbal altercation which occurred earlier that morning. The AIT acknowleged he reported the allegation of physical abuse to CDPH via phone after the interview with Resident 1. In an interview on 1/10/24 at 7:26 a.m., LN 4 stated at approximately 2:40 a.m. on 1/1/24 the police arrived at the facility. LN 4 stated police informed her Resident 1 alleged he had been hit by LN 4 earlier in the morning. LN 4 denied she reported the allegation of abuse to CDPH. In an interview on 1/10/24 at 10:33 a.m., LN 5 stated on 1/1/24 at approximately 3 a.m., the police informed her Resident 1 alleged LN 4 had hit him earlier in the morning. LN 5 stated she knew when there was an allegation of abuse it needed to be reported to the facility administrator (ADM)/AIT and CDPH but denied reporting Resident 1's allegation of abuse to CDPH. In an interview on 1/11/24 at 7:46 a.m., LN 6 stated after the police left the faciity on 1/1/24, he heard LN 4 and LN 5 discuss Resident 1's allegation of physical abuse to the police. LN 6 stated allegations of abuse needed to be reported to the AIT/ADM and to CDPH but denied reporting Resident 1's allegation of abuse to CDPH. In an interview on 1/11/24 at 3:46 p.m., Certified Nursing Assistant 4 (CNA 4) stated on 1/1/24, police arrived at the facility and spoke with Resident 1, LN 4, and LN 5. CNA 4 stated she heard the police officer notify LN 4 she had been accused of hitting Resident 1. CNA 4 denied she reported Resident 1's allegation of abuse to CDPH. In an interview on 1/17/24 at 8:06 a.m., LN 7 stated on 1/1/24 around 3 a.m., the police arrived at the facility and spoke to Resident 1, LN 4 and LN5 approximately 30 minutes after arriving. LN 7 stated after the police left, LN 4 and LN 5 discussed Resident 1's allegation of abuse to the police. LN 7 denied he reported Resident 1's allegation of abuse to CDPH. In an interview on 1/11/24 at 12:02 p.m., the Director of Nursing (DON) stated the moment facility staff found out about an allegation of abuse the staff needed to report it to the AIT/ADM and the facility must report it to CDPH within the first two hours. The DON added, All the staff know to report [allegations of abuse] in two hours. A review of the facility's daily assignment sign-in sheet, dated 12/31/23, indicated LN 4, LN 5, LN 6, LN 7, and CNA 4 all worked the nocturnal (NOC) shift from 10:30 p.m. on 12/31/23 to 7 a.m. on 1/1/24. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, undated, indicated, .All reports of resident abuse .are reported to local, state, and federal agencies (as required by current regulations) .If resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator of the individual making the allegation immediately reports .to . the state licensing/certification agency responsible for surveying/licensing the facility [CDPH] .'immediately' is defined as .within two hours of an allegation involving abuse .

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection control practices for a census of 121...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection control practices for a census of 121 residents when a Certified Nursing Assistant (CNA) did not perform hand hygiene when entering and exiting multiple resident rooms before providing care to a resident during lunch. This failure decreased the facility's potential to prevent the spread of infection among the residents. Findings: In an observation on 1/9/24 at 12:30 p.m. during lunch time, CNA 1 entered room [ROOM NUMBER] and exited the room with a lunch tray with used dishes, used utensils, and partially eaten food. CNA 1 put the used lunch tray on a tray cart and did not perform hand hygiene after holding the used lunch tray. CNA 1 immediately proceeded to enter and exit rooms [ROOM NUMBERS] without performing hand hygiene. CNA 1 then entered room [ROOM NUMBER], did not perform hand hygiene, and then began wiping food from Resident 6's face. In an interview on 1/9/24 at 12:36 p.m., CNA 1 stated in order to reduce risk of spreading infection staff were expected to perform hand hygiene when leaving one resident's room and before entering another resident's room. CNA 1 acknowledged leaving room [ROOM NUMBER] with a used lunch tray and had gone into room [ROOM NUMBER], 108, and 109 where she assisted Resident 6. CNA 1 alleged she could not remember if she performed hand hygiene in between going into or exiting each room or prior to helping Resident 6. In an interview on 1/9/24 at 12:42 p.m., License Nurse 1 (LN 1) stated staff are expected to their clean hands when going in and going out of rooms and added, It's a standard precaution to prevent the spread of infections. In an interview on 1/9/24 at 2:19 p.m., LN 3 stated hand hygiene is the most important thing staff can do to prevent the spread of infections. In an interview on 1/9/24 at 2:38 p.m., the Infection Preventionist (IP) stated a staff member who went room to room without performing hand hygiene would not be following infection prevention polices and added hand sanitizer has been conveniently placed outside of all the residents' rooms. In an interview on 1/11/24 at 12:02 p.m. the Director of Nursing stated she expected staff to perform hand hygiene when leaving one resident room and before going into another resident's room. A review of the facility's policy and procedure titled, Handwashing/hand hygiene policy, revised 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 .Use an alcohol-based hand rub .or alternatively, soap . and water for the following situations .before and after direct contact with residents .After contact with objects .in the immediate vicinity of the resident before and after entering isolation precautions settings .before and after assisting a resident with meals .

Jan 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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received respiratory care in accordance with professional standards of practice when: 1. Resident 1's Bilevel Positive Airway Pressure (BiPAP, a machine that pushes pressurized air into the lungs to help with breathing) treatment was not signed as given for 63 days, and 2. Resident 1's nasal cannula (used to deliver oxygen to patients who need supplemental oxygen) and humidifier (adds moisture to the oxygen) were not dated, her BiPAP mask and tubing were found uncovered on top of the oxygen concentrator (a machine that delivers oxygen) ; and a used nasal cannula was found on the bedside table. These failures had the potential to result in Resident 1 developing hypoxia (low oxygen) and infections. Findings: A review of Resident 1's admission records indicated, Resident 1 was admitted to the facility in mid-2023 with multiple diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Exacerbation (lung condition that causes breathing difficulties) and Obstructive Sleep Apnea (sleep related breathing disorder). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/15/23, indicated she was cognitively intact. A review of Resident 1's . SBAR [type of nursing assessment tool] Summary dated 12/8/2023, indicated, .writer was called in by family member. [sic] and writer realized with Increased confusion lethargy [deep unresponsiveness and inactivity] and zoning out throughout conversation .MD [Medical Doctor] was called and okayed for resident to be sent out to [Name of Acute Hospital] . A review of Resident 1's Acute Hospital Discharge summary, dated , 12/12/23, indicated, admit date : [DATE] .Patient was found with an altered mental status after going through the night without her BiPAP .She had similar symptoms last time she did not have her BiPAP at night making acute hypoxic hypercapnic respiratory failure (occurs when there is not enough oxygen in the blood) likely cause of her AMS [Altered Mental Status]. A review of Resident 1's ORDER SHEET dated 8/11/23, indicated, BIPAP per protocol .when sleeping DAY and NOC [night] OSA [Obstructive Sleep Apnea, intermittent airflow blockage during sleep] . A review of Resident 1's Administration Record: VENTILATOR .BiPAP . at bedtime . indicated, the BiPAP treatment was started August 11, 2023. The Administration record, dated 10/11/23 through 12/12/23, indicated the BiPAP treatment was not signed as given. There was no documented evidence Resident 1 refused the BiPAP treatment for this period. During a concurrent observation and interview on 12/19/23 at 11:17 a.m., Resident 1 was lying in bed with a nasal cannula attached to the oxygen concentrator. Resident 1's nasal cannula and the oxygen humidifier attached to the oxygen concentrator were not dated to indicate when they were last changed. Resident 1's BiPAP mask and tubing was observed uncovered on top of the oxygen concentrator and, a used and unlabeled nasal cannula was observed on the bedside table. Resident 1 stated she needed her BiPAP from 10:15 p.m. at night until morning. Resident 1 stated, if I do not use the BiPAP I lose oxygen. Resident 1 further stated, she did not know why the staff did not give her the BiPAP. During an interview on 12/19/23 at 11:55 a.m., with Licensed Nurse (LN 1), LN 1 stated, Resident 1 would tell her in the morning that the night nurse did not put on the BiPAP. LN 1 indicated the night nurse would report Resident 1 refused the BiPAP therapy. LN 1 further stated if the Resident refused the treatment, it should be documented in the administration record. During a concurrent interview and record review on 12/19/23 starting from 2:50 p.m., with the Director of Nursing (DON), the DON verified Resident 1's BiPAP treatment administration record was not signed as given from 10/11/23 through 12/12/23. The DON also verified that there was no documentation of the reason why the BIPAP therapy was not given and no documentation the resident had refused it. The DON stated that the order was there, but the staff did not sign it. She further stated that if the administration record was not signed, there was no evidence that it was done. A review of the facility's Policies and Procedure titled, . BiPAP Support, revised, 3/2015, indicated, .Document the following in the resident's medical record: .Time [BiPAP] was started and duration of the therapy .Notify the physician if the resident refuses the procedure . 2. A review of Resident 1's Physician's order indicated, Oxygen at .2 LPM [liters per minute] via .NC [ nasal cannula] .continuous every shift. During a concurrent observation and interview on 12/19/23 at 11:55 a.m., LN 1 verified Resident 1's BiPAP mask and tubing was on top of the oxygen concentrator. LN 1 stated, it should not be there, it should be kept in the bag. LN 1 also verified, there was a used nasal cannula on the bedside table. LN 1 stated, it is probably an extra tubing. LN 1 was observed removing the nasal cannula from the bedside table and proceeded to throw it in the garbage bin. LN 1 also verified Resident 1's nasal cannula and humidifier were not dated and stated the nasal cannula and humidifier should have contained the date when last changed. She further stated the nasal cannula should be changed at least weekly and the humidifier bottle changed when empty. During an interview and record review on 12/19/23 starting from 2:50 p.m. with the DON, the DON stated the BiPAP mask and tubing should be kept in a bag if it is not in use. The DON further stated the bag was to protect it from being contaminated. The DON also stated the used nasal cannula on Resident 1's bedside table was probably an old one and should have been discarded. The DON further stated the nasal cannulas should be changed once a week and the staff should label the tubing with the date it was changed. A copy of policy for Oxygen Equipment/ Changing of Oxygen equipment was requested from the DON on 12/22/23 at 11:50 a.m. and 1/4/24 at 11:39 a.m., but was not provided. A review of the NIH National Library of Medicine website document, titled, Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care dated 2014 indicated, .Equipment used for respiratory therapy (e.g. items that come into contact with mucous membranes) is considered semicritical; such items should be cleaned . Store equipment dry in closed packages . https://www.ncbi.nlm.nih.gov/books/NBK214361/ Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received respiratory care in accordance with professional standards of practice when: 1. Resident 1's Bilevel Positive Airway Pressure (BiPAP, a machine that pushes pressurized air into the lungs to help with breathing) treatment was not signed as given for 63 days, and 2. Resident 1's nasal cannula (used to deliver oxygen to patients who need supplemental oxygen) and humidifier (adds moisture to the oxygen) were not dated, her BiPAP mask and tubing were found uncovered on top of the oxygen concentrator (a machine that delivers oxygen) ; and a used nasal cannula was found on the bedside table. These failures had the risk potential to result in Resident 1 developing hypoxia (low oxygen) and infections. Findings: A review of Resident 1's admission records indicated, Resident 1 was admitted to the facility in mid-2023 with multiple diagnoses that included Chronic Obstructive Pulmonary Disease with Acute Exacerbation (lung condition that causes breathing difficulties) and Obstructive Sleep Apnea (sleep related breathing disorder). Resident 1's Minimum Data Set (MDS, an assessment tool) dated 11/15/23, indicated she was cognitively intact. A review of Resident 1's . SBAR [type of assessment tool] Summary dated 12/8/2023, indicated, .writer was called in by family member. [sic] and writer realized with Increased confusion lethargy [deep unresponsiveness and inactivity] and zoning out throughout conversation .MD [Medical Doctor] was called and okayed for resident to be sent out to [Name of Acute Hospital] . A review of Resident 1's Acute Hospital Discharge summary, dated , 12/12/23, indicated, admit date : [DATE] .Patient was found with an altered mental status after going through the night without her CPAP .She had similar symptoms last time she did not have her CPAP at night making acute hypoxic hypercapnic respiratory failure (occurs when there is not enough oxygen in the blood) likely cause of her AMS [Altered Mental Status]. A review of Resident 1's ORDER SHEET dated 8/11/23, indicated, BIPAP per protocol .when sleeping DAY and NOC [night] OSA [Obstructive Sleep Apnea, intermittent airflow blockage during sleep] . A review of Resident 1's Administration Record: VENTILATOR .BiPAP . at bedtime . indicated, the BiPAP treatment was started August 11, 2023. The Administration record dated 10/11/23 through 12/12/23, indicated the BiPAP treatment was not signed as given. There was no documented evidence Resident 1 refused the BiPAP treatment for this period. During a concurrent observation and interview on 12/19/23 at 11:17 a.m., Resident 1 was lying in bed with a nasal cannula attached to the oxygen concentrator. Resident 1's nasal cannula and the oxygen humidifier attached to the oxygen concentrator were not dated to indicate when they were last changed. Resident 1's BiPAP mask and tubing was observed uncovered on top of the oxygen concentrator and, a used and unlabeled nasal cannula was observed on the bedside table. Resident 1 stated she needed her BiPAP from 10:15 p.m. at night until morning. Resident 1 stated, if I do not use the BiPAP I loose oxygen . Resident 1 further stated, she did not know why the staff did not give her the BiPAP. During an interview on 12/19/23 at 11:55 a.m., with Licensed Nurse (LN 1), LN 1 stated, Resident 1 would tell her in the morning that the night nurse did not put on the BiPAP. LN 1 indicated the night nurse would report Resident 1 refused the BiPAP therapy. LN 1 further stated if the Resident refused the treatment, it should be documented in the administration record. During a concurrent interview and record review on 12/19/23 starting from 2:50 p.m., with the Director of Nursing (DON), the DON verified Resident 1's BiPAP treatment administration record was not signed as given from 10/11/23 through 12/12/23. The DON also verified that there was no documentation of the reason why the BIPAP therapy was not given and no documentation the resident had refused it. The DON stated that the order was there, but the staff did not sign it. She further stated that if the administration record was not signed, there was no evidence that it was done. A review of the facility's Policies and Procedure titled, . BiPAP Support , revised, 3/2015, indicated, .Document the following in the resident's medical record: .Time [BiPAP] was started and duration of the therapy .Notify the physician if the resident refuses the procedure . 2. A review of Resident 1's Physician's order indicated, Oxygen at .2 LPM [liters per minute] via .NC [ nasal cannula] .continuous every shift. During a concurrent observation and interview on 12/19/23 at 11:55 a.m., LN 1 verified Resident 1's BiPAP mask and tubing was on top of the oxygen concentrator. LN 1 stated, it should not be there, it should be kept in the bag. LN 1 also verified, there was a used nasal cannula on the bedside table. LN 1 stated, it's probably an extra tubing. LN 1 was observed removing the nasal cannula from the bedside table and proceeded to throw it in the garbage bin. LN 1 also verified Resident 1's nasal cannula and humidifier were not dated and stated the nasal cannula and humidifier should have contained the date when last changed. She further stated the nasal cannula should be changed at least weekly and the humidifier bottle changed when empty. During an interview and record review on 12/19/23 starting from 2:50 p.m. with the DON, the DON stated the BiPAP mask and tubing should be kept in a bag if it's not in use. The DON further stated the bag was to protect it from being contaminated. The DON also stated the used nasal cannula on Resident 1's bedside table was probably an old one and should have been discarded. The DON further stated the nasal cannulas should be changed once a week and the staff should label the tubing with the date it was changed. A copy of policy for Oxygen Equipment/ Changing of Oxygen equipment was requested from the DON on 12/22/23 at 11:50 a.m. and 1/4/24 at 11:39 a.m. but was not provided. A review of the NIH National Library of Medicine website document, titled, Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Infections in Health Care dated 2014 indicated, .Equipment used for respiratory therapy (e.g. items that come into contact with mucous membranes) is considered semicritical; such items should be cleaned . Store equipment dry in closed packages . https://www.ncbi.nlm.nih.gov/books/NBK214361/

Dec 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 F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, Licensed Nurse 1 (LN 1) failed to ensure the correct type and dos...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, Licensed Nurse 1 (LN 1) failed to ensure the correct type and dose of insulin (a medication used to control blood sugar levels) was administered to one of three sampled residents (Resident 1). This failure had the potential to result in hypoglycemia (low blood sugar) for Resident 1. Findings: A review of the Skilled Nursing admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included, Type 1 Diabetes Mellitus (a disease involving inappropriately elevated blood glucose levels). During an interview with the Director of Nursing (DON) on 11/22/23 at 10 a.m., the DON stated on 10/6/23 at approximately 7:45 p.m., LN 1 administered 50 units of Lispro (a rapid acting insulin used to control blood sugar) instead of 50 units of Lantus (a long-acting insulin used to control blood sugar). LN 1 had discovered the error approximately 30 minutes later and notified the Physician. LN 1 was then instructed to monitor Resident 1's blood sugar (BS) every 15 minutes and send him to the hospital for evaluation. Resident 1 returned from the hospital approximately 1 hour later. A review of Resident 1's physician's orders, dated 2/16/23, indicated an order for Lantus 50 units subcutaneously (to inject using a needle into the fatty tissue) at bedtime and Lispro 10 units subcutaneously with meals. A review of the Progress Note, dated 10/6/23 at 11:57 p.m., indicated on 10/6/23 at approximately 7:20 p.m., Resident 1's BS was 170 milligrams per deciliter (mg/dL, a unit of measurement) and was due for 50 units of Lantus at bedtime. At approximately 7:44 p.m., LN 1 realized Resident 1 was given 50 units of Lispro instead of 50 units of Lantus. Resident 1 was given orange juice and his BS was checked every 15 minutes. LN 1 then notified the physician and was told to send Resident 1 to the emergency room for evaluation. At 9 p.m., the ambulance had arrived, and Resident 1's BS had dropped to112 mg/dL. A review of the facility's policy titled, Insulin Administration revised 9/2014 under preparation #3 indicated, The type of insulin dosage requirements, strength, and method of administration must be verified before administration, to ensure that it corresponds with the order on the medication sheet and the physician's order.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview, and policy review, the facility failed to ensure one of 3 sampled residents (Resident 1) was treated with respect and dignity when the staff did not provide privacy du...

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Based on observation, interview, and policy review, the facility failed to ensure one of 3 sampled residents (Resident 1) was treated with respect and dignity when the staff did not provide privacy during care. This failure decreased the potential to ensure Resident 1's right to privacy was maintained. Findings: A review of the clinical record indicated Resident 1 was admitted to the facility with diagnoses including chronic respiratory failure with hypoxia (a serious condition that makes it difficult to breathe) and tracheostomy status (a surgical procedure to create an opening into the trachea [windpipe] from outside the neck to help oxygen reach the lungs). During an observation on 11/14/23 starting at 10:30 a.m., Resident 1 was suctioned (removal of secretions to keep the windpipe clear) by the Respiratory Therapist (RT) through her tracheostomy with the privacy curtain open. In an interview on 11/14/23 at 10:35 a.m., the RT confirmed she did not close the privacy curtain prior to suctioning Resident 1. In an interview on 11/14/23 at 12:28 p.m., the Director of Nursing (DON) stated her expectation was for staff to draw the curtains closed to provide privacy when a resident is being suctioned. In an interview on 11/14/23 starting at 12:40 p.m., the Supervisor Nurse (SN) stated the staff should close the curtain when suctioning a resident to provide privacy. A review of the facility's policy titled, Resident Rights revised February 2021 indicated, Employees shall treat all residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .privacy .

Oct 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0675 (Tag F0675)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) attained the highest mental and psychosocial well-being whe...

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Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) attained the highest mental and psychosocial well-being when the residents were concerned about their medication supplies after they missed their routine medications due to medication delivery delays. This failure resulted in Resident 1 to start keeping her own medication administration log to remind staff to reorder her medications timely and Resident 2 was more depressed and experienced uncontrolled pain, high stress, and anxiety. Findings: 1. Resident 1 was admitted to the facility with diagnoses that included atrial fibrillation (an irregular and often rapid heart rate that could lead to blood clots), lung problems and high blood pressure. In a concurrent observation and interview on 10/5/23 at 11:15 a.m., Resident 1 was in the bed in her three shared bedroom. Resident 1 reported she did not receive her blood thinner and heart medications because the facility ran out of the medications. The resident stated she worried about the medication supplies so she started keeping her own medication administration log and reminded staff to reorder her medications in time and showed her medication administration logbook to the Department. It was a hand drawn grid log with check marks and the names of the medications. The resident stated the facility should have her medications on hand at all times and voiced it was not her job to remind staff to reorder her medications. Review of Resident 1's clinical record included physician orders, dated 9/2/23, for apixaban (a blood thinner to prevent forming blood clots), to administer 5 mg (milligram) twice a day for the irregular heart rate and for bumetanide (a diuretic, a water pill to treat fluid retention and high blood pressure) to administer 1 mg once a day for heart problems. Review of Resident 1's Medication Administration Record (MAR) for September 2023 indicated Resident 1 missed two doses of the blood thinner on 9/13/23 p.m. and 9/14/23 a.m. and also missed the water pill on 9/17/23. In a concurrent interview and record review on 10/5/23 at 12:09 p.m., the Director of Nursing (DON) verified the missed doses of the blood thinner and the water pill for Resident 1 and stated the medications were not available for administration then. The DON stated missing such medications could place the resident at risk for blood clots and fluid overload and acknowledged the medications should have been administered as ordered. 2. Resident 2 was admitted to the facility in the Summer of 2023 with diagnoses that included skin infection to her lower limbs, major depressive disorder, and anxiety disorder. In a concurrent observation and interview on 10/5/23 at 11:32 a.m., Resident 1 was in her wheelchair in her three bed shared bedroom. Resident 2 stated the facility did not have her Oxycodone (a narcotic pain medication) for three days and her pain was not under control then. The resident complained staff did not communicate well with her what the problem was instead staff told her, It's [Oxycodone] not here, it's not here and gave her Tylenol which did not take care of her pain. Resident 2 stated, My stress level was high, anxiety level was high and my depression .more depressed due to the lack of communication. Resident 2 recited her pain was not under control. Review of Resident 2's September 2023 MAR indicated the resident had a physician order, dated 9/14/23, for two tablets of Oxycontin ER (Extended Release, the time-release version of Oxycodone) 10 mg every 12 hours for pain in the leg for 15 days; however, the MAR indicated the medications were not administered on 9/14/23 at 11 p.m. and 9/15/23 at 11 a.m. Review of Resident 2's clinical record, Progress Notes, indicated Oxycontin ER were not given to the resident due to the medications were not available for administration. LNs entered notes on 9/15/23 at 1:05 a.m., Awaiting delivery and another note on 9/15/23 at 12:04 p.m., Awaiting for pharmacy for reasons LNs not able to administer Oxycontin ER for the resident. In an interview on 10/5/23 at 11:55 a.m., LN 1 stated she experienced medications were not available for administration during her shift. LN 1 stated when it happened it made both staff and residents frustrated. In a concurrent interview and record review on 10/5/23 at 12:09 p.m. with the Director of Nursing (DON), the DON verified Resident 2 did not receive her routine pain medication because the medications were not available to administer. The DON stated Resident 2 was already in pain due to the infection in the legs and acknowledged not knowing the medication status would increase her anxiety.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmacy services timely for three of three sampled residen...

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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 pharmacy services timely for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when prescription medications were not available for administration. This failure resulted in Resident 1, Resident 2, and Resident 3 to not receive their routine medications as prescribed and placed the residents at risk for adverse consequences. Findings: 1. Resident 1 was admitted to the facility with diagnoses that included atrial fibrillation (an irregular and often rapid heart rate which could lead to blood clots), lung problems and high blood pressure. Review of Resident 1's clinical record included physician orders, dated 9/2/23, for apixaban (a blood thinner to prevent forming blood clots), to administer 5 mg (milligram) twice a day for the irregular heart rate and for bumetanide (a diuretic, a water pill to treat fluid retention and high blood pressure) to administer 1 mg once a day for heart problems. Review of Resident 1's Medication Administration Record (MAR) for September 2023 indicated Resident 1 missed two doses of the blood thinner on 9/13/23 p.m. and 9/14/23 a.m. In addition to the omitted blood thinner, Resident 1 missed the water pill on 9/17/23. Review of Resident 1's clinical record, Progress Notes, indicated apixaban was not administered because the medication was not available. Licensed Nurses (LN) documented the reasons for not administering the blood thinner as waiting for delivery on 9/13/23 at 5 p.m., and Med [medication] on order on 9/14/23 at 9:23 a.m. The progress notes included a LN's note on 9/17/23 at 8:37 a.m., that the water pill was not administered due to the medication was on, pending delivery. In a concurrent interview and record review on 10/5/23 at 12:09 p.m., the Director of Nursing (DON) verified the missed doses of the blood thinner and the water pill for Resident 1 and stated the medications were not available for administration then. 2. Resident 2 was admitted to the facility in the Summer of 2023 with diagnoses that included skin infection to her lower limbs. Review of Resident 2's September 2023 MAR indicated the resident had a physician order, dated 9/14/23, for two tablets of Oxycontin ER (an opioid, Extended-Release to control pain) 10 mg every 12 hours for pain in the leg for 15 days; however, the MAR indicated the medications were not administered on 9/14/23 at 11 p.m. and 9/15/23 at 11 a.m. Review of Resident 2's clinical record, Progress Notes, indicated Oxycontin ER was not given to the resident due to the medications were not available for administration. LNs entered notes on 9/15/23 at 1:05 a.m., Awaiting delivery and another note on 9/15/23 at 12:04 p.m., Awaiting for pharmacy for reasons unable to administer Oxycontin ER to the resident. In a concurrent interview and record review on 10/5/23 at 12:09 p.m., the DON verified Resident 2 did not receive her routine pain medication because the medications were not available to administer. 3. Resident 3 was admitted to the facility in September 2023 with diagnoses that included fractures of the left upper arm, left rib, hip bone, shoulder blade and the left shoulder. Review of Resident 3's clinical record, Order Summary Report, included a physician order, dated 9/21/23, for Oxycontin ER 10 mg 2 tablets (20 mg) to administer every twelve hours for mild to severe pain. Review of Resident 3's MAR for September 2023 indicated the resident did not receive her first scheduled dose of Oxycontin ER on [DATE] at 8 p.m. In a concurrent interview and record review on 10/5/23 at 12:09 p.m., the DON verified Resident 3 was admitted on [DATE] at 2:10 p.m. and stated the resident did not receive her scheduled 8 p.m. Oxycontin ER dose on that day. The DON explained the resident missed the dose because the medication had not been delivered by then. The DON stated it was facility practice to administer pain medications for residents within 4 hours upon admission. The DON stated Oxycontin should have been available for administration by 8 p.m. Review of the facility's policy and procedure, Pharmacy Services-Role of the Provider Pharmacy, revised April 2019, stipulated the contracted pharmacy was to provide regular and reliable pharmacy services to residents, including medications . In an interview on 10/5/23 at 11:55 a.m., LN 1 stated there were occasions that she was not able to administer medications because the pharmacy did not deliver the medications on time. In an interview on 10/5/23 at 1:19 p.m., the DON acknowledged the pharmacy services should have been prompt so the residents could have received their routine medications as prescribed.

Sept 2023 10 deficiencies

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure smoking safety for one of 24 sampled residents (Resident 97) when the initial smoking assessment was delayed and the smoking care pl...

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Based on interview and record review, the facility failed to ensure smoking safety for one of 24 sampled residents (Resident 97) when the initial smoking assessment was delayed and the smoking care plan was inconsistent with the assessment. This failure placed the resident at risk for injuries related to smoking and had the potential for non-smoking residents to be exposed to smoking hazards. Findings: Review of Resident 97's medical records, admission Record, indicated the resident was admitted to the facility early 2023 with diagnoses that included mental issues and lung problems. Review of Resident 97's smoking assessment, Smoking Safety, completed on 6/20/23, indicated it was the initial smoking assessment since the resident's admission in January 2023. The assessment identified the resident was an independent smoker and recommended, Resident may smoke independently. Review of Resident 97's care plan for smoking, initiated on 6/20/23, indicated the resident's smoking goal was The resident will not smoke without supervision . as opposed to the smoking assessment specified the resident was an independent smoker. The resident's care plan included interventions pertinent to supervised smokers, as to Observe clothing and skin for signs of cigarette burns .Notify charge nurse immediately if it is suspected resident has violated facility smoking policy .Instruct the resident about smoking risks and hazards. However, one of the smoking interventions list in the care plan emphasized, The resident can smoke UNSUPERVISED, which was inconsistent with the smoking goals and other interventions implemented in the care plan. Review of the facility's policy and procedure, Resident Smoking, implemented 6/1/23, stipulated it was the facility policy to apply safety protections to smoking and non-smoking residents to ensure a safe and healthy environment related to smoking. The policy indicated, All residents will be asked about tobacco use during the admission process .Residents who smoke will be further assessed .to determine whether or not supervision is required for smoking. The policy stipulated all safe smoking measures were to be documented on each resident's care plan. In a concurrent interview and record review on 9/13/23 at 1:02 p.m., the Director of Nursing (DON) verified Resident 97's admission date, the initial smoking assessment date and the inconsistent care plan goals and interventions with the smoking assessment. The DON stated it was the facility policy to complete the smoking assessment immediately after residents' admission. The DON stated the initial smoking assessment for Resident 97 was late and it should have been completed shortly after the resident's admission. The DON indicated the resident care plan for smoking did not match with the smoking assessment and stated the care plan should have been consistent with the assessment.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure professional standards were met when two of 24 sampled resid...

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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 professional standards were met when two of 24 sampled residents (Resident 170 and Resident 173) received medications without identifying irregularities of the indications for use. This failure had the increased potential for medication errors and placed the residents at risk for erroneous diagnoses and inaccurate medications. Findings: a. Review of Resident 170's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included lung problems and infection. The resident's admission Record indicated the resident had neither depression nor anxiety disorder in the DIAGNOSIS INFORMATION section. Review of Resident 170's Order Listing Report included a physician order, dated 9/7/23, for an anti-depressant medication, Fluoxetine 20 mg (milligram, a unit of measurement) 1 tablet by mouth once a day. The physician order prescribed the indication for use of Fluoxetine was for Anxiety M/B [manifested by] restlessness . On 9/12/23, review of Resident 170's Medication Administration Record (MAR) for September 2023, indicated Fluoxetine was administered daily since 9/7/23 and there were four different Licensed Nurses (LNs) that initialed that they administered Fluoxetine to the resident since the admission. In a concurrent interview and record review on 9/13/23 at 10:20 a.m., LN 2 verified the physician order for Fluoxetine for Resident 170 had an inaccurate indication for use. LN 2 stated Fluoxetine was for depression to lift up the resident's mood, not for anxiety to suppress mood. LN 2 stated the Fluoxetine order should have been clarified with the physician and changed to the accurate indication for use. LN 2 verified four LNs initials and acknowledged there were at least four opportunities to identify the irregularity of the order and to correct it. LN 2 explained the pharmacy verified the accuracy of the physician order prior to initial administration of the medications and it should have been caught at that time as well. In a concurrent interview and record review on 9/13/23 at 12:49 p.m., the Director of Nursing (DON) verified the physician order for Fluoxetine for Resident 170 contained irregularity of the indication for use and it should have been noted by LNs. The DON acknowledged the potential harm for erroneous diagnoses and wrong medication administration to the resident. The DON stated it was the facility practice to send residents medication list to the pharmacy to ensure medications and diagnoses were met prior to LNs administering any medication. The DON indicated the pharmacy should have caught the irregularity at the initial drug regimen review. b. Review of Resident 173's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included lung problem and diabetes. The admission Record did not indicate the resident had a diagnosis of an elevated level of lipids in the blood such as high cholesterol and high triglycerides (fats in the blood). Review of Resident 173's medication list included a physician order, dated 9/2/23, for Atrovastatin Calcium (medication to treat high cholesterol and triglycerides) 20 mg 1 tablet by mouth with an indication for, DM [diabetes] type 2. On 9/12/23, review of Resident 173's September 2023 MAR indicated Atrovastatin was administered daily and six LNs initialed that they administered the medication for the residents since the admission. In a concurrent interview and record review, LN 2 verified the Atrovastatin order for Resident 173 included an incorrect indication for use of the medication. LN 2 explained Atrovastatin was to treat high lipid blood level, not for diabetes. LN 2 stated LNs who administered the medication should have caught the inaccurate indication for use of the medication and corrected the order. LN 2 acknowledged the potential harm could cause to the residents if the resident did not have the medical diagnoses and administered the medication with inaccurate indication for use for the residents. In a concurrent interview and record review on 9/13/23 at 12:47 p.m., the DON verified the physician order for Atrovastatin order for Resident 173 had incorrect indication for use. The DON acknowledged it was the professional standards for LNs to identify the irregularity of the medication order, notify the physician and make appropriate changes.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to; 1. Identify signs and symptoms of opioid (a controlle...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to; 1. Identify signs and symptoms of opioid (a controlled medication used to treat moderate to severe pain) overdose (a life-threatening condition characterized by lessened alertness and small pupils) and to develop a care plan to accurately assess and monitor one of three sampled residents (Resident 47), and 2. failed to ensure Licensed Nurses (LN) provided quality of care in accordance with professional standards of practice for Resident 171 when: a. No comprehensive person-centered care plan with interventions that reflected his Peripherally Inserted Central Catheter, PICC (a thin, soft, long catheter inserted into the arm, neck, or leg's vein); b. No physician order about routine care and maintenance of PICC line; and c. LN 7 did not verify blood return (withdraw blood into the syringe) prior to use to confirm the location within the vein. These failures had the potential to affect the health and safety of Resident 171 and resulted in additional opioid administration and admission to the acute care hospital for Resident 47. Findings: 1. A review of the clinical record indicated Resident 47 was initially admitted to the facility early 2022 with diagnoses including chronic pain and osteomyelitis of the vertebra (spinal infection characterized by chronic back pain). A review of Resident 47's Minimum Data Set (MDS- an assessment tool) dated 5/30/23, indicated Resident 47 had moderate cognitive impairment and had a tracheostomy tube (a surgical hole in the neck created for breathing) attached to a mechanical ventilator (a machine which moves air into and out of the lungs). A review of Resident 47's Medication Administration Records (MAR), dated 8/1/2023 - 8/31/2023, indicated, Oxycodone (an opioid, controlled medication used to treat moderate and severe pain) HCl Oral Tablet 10 mg (milligram, unit of measurement) and Fluoxetine (medication for depression) HCl Capsule 20 mg were given on 8/28/23 at 8:00 a.m. A review of Resident 47's Order Summary report indicated, Narcan [a life-saving medication that can reverse an overdose from opioids] Liquid 4 MG/0.1ML (Naloxone HCl) 1 spray Alternating nostrils as needed for opioid overdose drug overdose SEEK immediate emergency medical help. If response is not obtained after 2-3 min administer 2nd dose using new device in other nostril until emergency help arrive. A review of Resident 47's eINTERACT Change in Condition Evaluation note, dated 8/28/23, indicated, Acute change in the mental status since7AM [sic] this morning. Not responding to questions but tracks at times. At baseline, he is able to respond and follow commands. he is not answering any questions. Patient assessed by MD [Medical Doctor] during her rounds, Exam +ve [positive] for pin point pupils, on oxycodone [an opioid medication] q6 [every 6 hours]. As per MD order intranasal spray 4mg twice given without any benefit. Per Md transfer to ER . A review of Resident 47's Physician's Discharge summary, dated [DATE], indicated, Assessments: -Acute change in mental status since 7 AM- Exam +ve for pin point pupils B/L [bilateral]- is on oxycodone q6. Narcan twice is without any benefit. He us [sic] tracking at times but otherwise is not responding to verbal commands .R/O [rule out] infection also but no s/s [signs and symptoms] of infection recently . A review of Resident 47's Acute hospital discharge summary indicated, Date of admission: [DATE] .Date of discharge: [DATE] .Hospital Course and Significant Findings: .The patient was admitted with impression of unintentional opiate overdose complicated by .infection .Multifactorial Encephalopathy [damage or disease that affects brain], likely from opioid effects. Patient reported with small pupils on exam, given and responded appropriately . There was no documented evidence of monitoring for signs and symptoms of opioid overdose prior to the change in condition on 8/28/23. During a concurrent observation and interview on 9/13/23 at 9:15 a.m., in Resident's 47's room, Resident 47 was observed lying in bed, awake with tracheostomy tube attached to mechanical ventilator. Resident 47 was able to mouth some words along with hand gestures. During a concurrent interview and record review on 09/13/23 starting at 9:45 a.m., with the Licensed Nurse (LN) 8, the LN 8 stated on 8/28/23 at around 7:15 a.m., the LN 9 nurse informed her that Resident 47 was alert but nonverbal. The LN 8 stated, she then went and assessed Resident 47. She tried to converse with Resident 47 and the resident did not respond and was just looking around and staring at the tv. LN 8 stated she informed the MD (Medical Director) at around 8:00-8:30 a.m., when the MD came for his rounds. The MD ordered to administer Naloxone and to send Resident 47 out to the acute hospital. The MAR was reviewed with the LN 8 and LN 8 verified that the oxycodone was administered on 8/28/23 at 8:04 a.m. The LN 8 stated she did not initially realize that the resident was exhibiting opioid overdose when he was not responding as usual. She thought the patient was not responding because he was upset and did not realize that he was overdosed. The LN 8 confirmed Resident 47 did not have a Care plan for opioid overdose monitoring. LN 8 stated Resident 47 had no monitoring for signs and symptoms opioid overdose. During an interview on 9/13/23 at 12:07 p.m., with the Director of Nursing (DON), The DON stated, the importance of care planning is to know your goals and interventions, if there is no care planning you will miss a lot of monitoring, assessments, and adverse effects. During a telephone interview on 9/13/23 at 2:28 p.m. with Pharmacy Consultant (PC), the PC stated, Resident 47 needs to be monitored for any signs of opioid overdose such as shortness of breath, not responding and sleepiness. The PC confirmed Resident 47 had no monitoring for signs and symptoms of opioid overdose. She stated, if Residents are taking opioid medication(s) Residents should be monitored for signs and symptoms of overdose. The PC further stated, nursing should have a parameter to hold the opioid medication. During a telephone interview on 9/13/23 at 2:53 p.m., with the Medical Director (MD), He stated, at around 9 a.m., on 8/28/23 the licensed staff informed him that Resident 47 was very drowsy, sleepy and was not communicating. He stated on assessment Resident 47 had pinpoint pupils, he ordered to give Narcan and repeated another dose of Narcan because Resident 47 did not respond initially. The MD stated, if a resident had a change in condition, he expects the licensed staff to inform him within 15 minutes and to monitor for signs and symptoms of opioid overdose. The MD further stated, if the resident is too sleepy per nursing judgement, they can call the MD to hold the medication. During a telephone interview on 9/14/23 at 12:27 p.m., with the Licensed Nurse (LN) 9, she stated, on 8/28/23 at 8 a.m., she noticed Resident 47 did not respond when she asked him if he was in pain. The LN 9 stated Resident 47 usually communicates with mouthing words and during her assessment Resident 47 was just staring at the tv. LN 9 further stated, she checked Resident 47's vital signs, and it was all within normal limits. The LN 9 confirmed she gave Resident 47's medications at 8 a.m. (which included oxycodone and fluoxetine). She stated she did not check Resident 47's eyes and she did not consider the resident was having opioid overdose. A review of the SAMHSA Substance Abuse and Mental Health Services Association website document, titled, Opioid Overdose Prevention TOOLKIT indicated, .Opioid overdose can be due to many factors . It can .occur when opioids are taken with other medications-for example, prescribed medications such as .psychotropic medications that are used in the treatment of mental disorders . that may have adverse interactions with opioids .(https://www.samhsa.gov/) A review of the NIH National Library of Medicine website document, titled, Risk of Opioid Overdose Associated With Concomitant Use of Oxycodone and Selective Serotonin Reuptake Inhibitors published, 2/24/22 indicated, . In .US adults, initiating oxycodone in patients treated with .fluoxetine was associated with a small increased risk of opioid overdose .(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8874341/) 2. Resident 171 was admitted recently, with diagnosis of back surgical site infection, intraspinal abscess (infection inside the spine) and Osteomyelitis (infection of the bone) of vertebra. Per physician's order, he was receiving an antibiotic, intravenously, IV (given through the vein) for his surgical site infection from 9/7/23 to 10/16/23. Resident 171 has a PICC to his right upper arm. During a concurrent observation and interview on 9/12/23 at 9:30 a.m., Resident 171 was scheduled to receive his IV antibiotic, through his PICC. While in resident's room, LN 7 prepared the medications to be infused, and after sanitizing the end of the PICC, LN 7 flushed the PICC of Resident 171 with 10 ml (milliliter measurement) normal saline (NS) without checking it for blood return. When asked, LN 7 confirmed she did not check the PICC for blood return before infusing the antibiotic, and stated if the cannula is not in the vein, it will cause redness, swelling and pain on Resident 171's right upper arm. She also confirmed there was no care plan created and no physician order about routine care and maintenance of PICC line. LN 7 further stated, there should be a physician's order for maintenance care of the resident's PICC line. During an interview on 9/13/23 at 10:30 a.m., the Director of Nursing, DON stated, LNs should check the PICC for blood return before infusing the antibiotic to make sure the cannula (plastic needle) is in the vein. She further confirmed there was no care plan, routine care, and maintenance of PICC line for Resident 171. Once a PICC line is inserted, there should be a physician's order on how to perform a routine care and maintenance for PICC line called IV set order, and this will guide the nurses on how to care for the PICC, and LNs should have initiated a care plan once the PICC was inserted, as stated by the DON. Review of the facility's policy and procedure titled Comprehensive Care Plans, date implemented, 3/1/23, indicated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of the facility's policy and procedure titled, Care and Maintenance of Central Venous Catheter, undated, indicated, .The facility will adhere to accepted standards of practice regarding the care and maintenance of central venous catheters.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, Resident 44 failed to maintain his usual body weight, losing 38 pounds (lbs.) and 18% of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, Resident 44 failed to maintain his usual body weight, losing 38 pounds (lbs.) and 18% of his body weight since admission. This had the potential of leading to decreased independence due to muscle loss, as well as reduced ability to fight off infections. Findings: During the lunch meal rounds on 9/11/23 at approximately 1 p.m., Resident 44 was visited. While discussing his dislike of facility prepared meals, he reported that he had lost weight during his 2 years at the facility. He expressed anger and frustration by the continued weight loss. During a chart review of Resident 44 on 9/13/23 at 11:52 a.m., he was noted to have a diagnosis including failure to thrive, malnutrition, anemia, and a vitamin deficiency. His diet order included a controlled carbohydrate diet (used to control blood sugar levels) with a shake twice a day. Abbreviated Weight History as follows: 8/17/23=171lbs. (a loss of 38 lbs. or 18.2% of his body weight since admission). 7/23=not available 6/22/23=183 lbs. 5/24/23=173 lbs. 4/18/23=169 lbs. (a loss of 12 lbs. or 6.6% of his body weight which is severe over 1 month). 3/17/23=181lbs. 2/23=not available 1/12/22=186 lbs. 12/15/22=187.6 lbs. 11/14/22=195.5 lbs. 10/19/22=194 lbs. 9/12/22=205 lbs. 8/13/21=209 lbs. on admission. During a review of Resident 44's minimum nutrition assessment, he was noted to be in the normal status on 5/24/22 and 8/18/22. This changed to at risk for malnutrition as of 9/27/22 and remained there for the 12/27/22 and 3/21/23 assessments. During a review of his nutritional assessment, dated 12/27/22, he was noted to have lost 40 lbs. or 17.9% of his body weight during the previous 6 months. The Registered Dietitian (RD) noted weight loss highly likely related to fair by mouth intake and multiple meal refusals. Diet was listed as a regular diet with large portions and a supplemental shake daily. Intake was reported as 50% of meals. RD recommendations were to add a shake (no added sugar) with lunch and dinner. During a review of his nutritional assessment, dated 3/21/23, he was noted to have lost 34 lbs. or 18% of his body weight during the previous 6 months. Diet was listed as a regular diet with large portions and a supplemental shake daily, plus 2 house shakes, and a protein enhanced dessert. Intake was reported as 60% of meals. No additional RD recommendations were made. During a review of his nutritional assessment dated [DATE], he was noted to have lost 20.5 lbs. or 10.5% of his body weight during the previous 7 months. The RD noted patient with inadequate oral intake per recorded intake stating 'I don't like the food'. Diet now listed as controlled carbohydrate without supplementation. Intake reported at 25-50% of meals. RD recommendation was to add two sugar free shakes per day. Review of Nutrition Care Plans from 11/11/21 and 6/23/23, were similar in that the focus was on nutrition/hydration with a goal of the resident eating 75-100% of his meals. Suggested interventions included encouraging family to provide healthy foods, honoring food preferences, liberalizing the diet (removing therapeutic diet restrictions), and offering HS (hour of sleep) snacks. During an interview with the RD on 9/13/23 at 1:45 p.m., she discussed the procedure for weight loss in residents. She stated care plan interventions may include updating food preferences, liberalizing the diet, or changing the diet texture (if appropriate), and ordering supplements. During a review of Resident 44's nutrition recommendations, the RD did not find the nutrition assessment recommendations listed on his care plan nor did she see evidence of follow up as to whether or not the interventions had been effective. While reviewing the chart, she found no documentation of updated food preferences. During an interview with the Director of Nursing (DON) on 9/14/23 at 9:19 a.m., she concurred that the care plan had not been personalized for resident 44. During a review of facility provided policy titled Nutrition Management (The Compliance Store, LLC. 2023), bullet 4 discussed care plan implementation indicating the following: b. Interventions will be individualized to address the specific needs of the resident. c. Real food will be offered first before adding supplements. Review of bullet 5 described monitoring and revision of the care plan which indicated: a. Monitoring of the resident's condition and care plan interventions will occur on an ongoing basis . c. The care plan will be updated as needed, such as when a resident's condition changes, goals are met or . interventions are determined to be ineffective . Review of facility provided policy titled Weight Change Protocol (Healthcare Menus Direct, LLC. 2023) under the Assessment section, it indicated to Determine if the meals sent to the resident meet their needs, goals and preferences. Under the Monitors section, it indicated A care plan is to be developed stating the problems, the goal, and the approaches, interventions to accomplish the goal .The care plan must be revised as the goals and interventions change. The goals, interventions in the care plan should match the latest assessment. Under the Evaluation section, it indicated that Interventions are changed if not effective. The care plan is reviewed in all areas and changes made, as needed.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with the facility policy for one of 24 sampled residents (Resident 12) when o...

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Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with the facility policy for one of 24 sampled residents (Resident 12) when oxygen tubing, oxygen mask for nebulizer (to administer liquid medicine into a mist through a mask to inhale the medication) treatment and the Bi-pap (the machine supplies pressurized air into the lungs) bag were outdated or not dated at all. These failures increased potential for respiratory infection for Resident 12 who already had compromised lung function. Findings: Resident 12 was admitted to the facility in the Spring of 2023 with diagnoses that included lung disease and mental issues. In an observation on 9/11/23 at 8:45 a.m., Resident 12 was out of her room in a 4-bed shared room. Next to the resident's bed which was close to the door, the oxygen concentrator was observed in operation with the oxygen flow rate set at 4 liters/minute. The nasal cannula (a plastic tubing that delivers the oxygen from the concentrator to the nostrils) was connected to the concentrator and placed on the night table next to the bed. Next to the nasal cannula, a nebulizer mask with tubing connected to the mask was placed on the night table unbagged. The date, 8/25/23 on the nebulizer mask was visible. In addition to the nasal cannula and the nebulizer mask, there was Bi-pap equipment in the bag. In a concurrent observation and interview on 9/11/23 at 8:50 a.m., Licensed Nurse 1 (LN 1) verified the oxygen concentrator was running and stated it should have been turned off when not in use. LN 1 stated the nasal cannula was undated and it should have been dated. LN 1 verified the date on the nebulizer mask and stated it was outdated and should have been changed weekly. LN 1 stated it was the facility practice to store the nebulizer mask in the bag when not in use for infection control issues. LN 1 indicated the bag contained Resident 12's Bi-pap equipment which also should have been dated to ensure infection control related to respiratory care. Review of the facility's policy and procedure, dated 5/1/23, for Oxygen Administration Infection Prevention stipulated the procedures for prevention of infection associated with respiratory therapy. For infection control considerations related to oxygen administration, the policy stipulated, Change the oxygen cannula and tubing every seven (7) days, or as needed .Keep the oxygen cannula and tubing used PRN [as needed] in a clean bag when not in use. For infection control consideration related to medication nebulizers/continuous aerosol procedures, the procedure indicated, Store the circuit in bag, marked with date and resident's name .Discard the administration set-up every seven (7) days. However, the policy and procedure did not include how to take care for the Bi-pap gears. In an interview on 9/13/23 at 12:58 p.m., the Director of Nursing stated it was the facility practice to change the breathing tubing weekly and as needed and to store in a bag when not in use as it posed infection control issues.

CONCERN (E)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to maintain resident's right to privacy of personal and medical records when residents' meal tickets were discarded in the facil...

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Based on observation, interview, and record review, the facility failed to maintain resident's right to privacy of personal and medical records when residents' meal tickets were discarded in the facility kitchen garbage bin for the 98 residents who ate facility prepared meals. This failure had the potential for unauthorized access of residents' personal and medical records. Findings: During a concurrent observation and interview on 9/11/23 at 9:40 a.m. with Dietary Aide (DA) 1 in the dishwashing area, DA 1 was observed throwing uneaten food, used napkins, and residents' meal tickets left on the meal trays into the garbage bin. DA 1 confirmed the observation. During a concurrent observation and interview on 9/11/23 at 9:42 a.m. with the Dietary Services Supervisor (DSS) in the dishwashing area, the DSS confirmed that DA 1 threw the residents' meal tickets into the garbage bin. The DSS also confirmed that multiple residents' meal tickets were returned with their meal trays to the kitchen. During an observation on 9/12/23 at 9:22 a.m. with DA 3 in the dishwashing area, DA 3 was observed scraping uneaten food and used napkins and throwing residents' meal tickets left in the meal trays into the garbage bin. A review of a facility's meal ticket indicated the meal ticket contained residents' information such as the residents' complete name, residents' identification number, where the resident usually eats his/her meal, residents' unit, room, and bed number, residents' diet order, resident's allergies, resident's food notes and alerts, residents' standing food order, resident's likes and dislikes, the date and type of meal. During an interview on 9/14/23 at 9:19 a.m. with the Director of Nursing (DON), the DON stated only direct care staff should have access to resident's information. The DON also stated the residents' meal tickets should have been shredded after the resident finished eating, and if the meal ticket was returned to the kitchen, the kitchen staff should shred them. The DON further stated, There's already a process in place .It's [throwing resident's meal tickets into the garbage bin] a HIPAA (Health Insurance Portability and Accountability Act- a federal law that requires the creation of national standards to protect sensitive patient health information from being disclosed) violation, anybody can see the information. A review of the facility's policy and procedure titled, Safeguarding of Resident Identifiable Information, dated 3/1/2023, indicated, It is the facility's policy to implement reasonable and appropriate measure to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against .unauthorized release of information and records 2. Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure expired biological supplies found in Station 1 ...

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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 expired biological supplies found in Station 1 and 2 Medication Rooms (MR) were not available for use, and failed to ensure proper labeling of drug when, 1. Resident 47's oxycodone (an opioid, controlled medication used to treat moderate to severe pain) had no change in order label on the bubble pack; and 2. Expired medical supplies in the medication rooms were not removed and discarded, for a census of 111 residents. These failures placed Resident 47 at risk for receiving more than the prescribed dose of the opioid medication and had the potential for the expired biological supplies to be used for residents, compromising the accurate findings of their laboratory results, and may have subsequently led to misdiagnosis or prescribing wrong medications and treatments. Findings: 1. A review of the clinical record indicated Resident 47 had diagnoses that included chronic pain and long-term use of opiate analgesic. Further review of Resident 47's clinical record indicated a physician order dated [DATE] for oxycodone HCl (hydrochloride) 10 mg (milligram, unit of measurement) 1 tablet via G-tube (gastrostomy, tube inserted directly into the stomach to provide nutrition and medication) every 6 hours for chronic pain. In a concurrent observation and interview on [DATE] starting at 9:23 a.m. with Licensed Nurse (LN) 1, Resident 47's oxycodone HCl bubble pack indicated 10 mg, 1 tablet via G-tube every 12 hours as needed for breakthrough pain and take 1 tablet every 6 hours for chronic pain. The LN 1 stated the oxycodone order was changed to every 6 hours routinely and the 'as needed' order every 12 hours was discontinued when Resident 47 came back from the hospital. The LN 1 further stated the licensed staff usually put a direction change sticker in the bubble pack and in the controlled drug record. The LN 1 confirmed there was no direction change sticker placed on both the bubble pack and the controlled drug record. An interview with the Director of Nursing (DON) was conducted on [DATE] at 10:27 a.m. The DON stated, if there was a change in the medication order, the licensed staff can place a change in direction sticker so that licensed staff will not make a mistake in administering the medication. The DON further stated, her expectation was for the medication label in the bubble pack to match the order in the Medication Administration Record (MAR), if not, the licensed staff should place the change in direction sticker to prevent any mistakes. A review of the facility policy titled, Medication Labels, dated [DATE], indicated, .If the physician's directions for use change or the label is inaccurate, the nurse may place a change of order label on the container indicating there is a change in directions for use . 2. During a concurrent observation and interview with the Assistant Director of Nursing, ADON, on [DATE] starting at 12:05 p.m., the ADON acknowledged: a. Seven swab sticks found in Station 1 MR (used for collection and transportation of biological specimens from the patient to the laboratory) expired on 2023-8-11; b. One urinary catheter found in Station 2 MR (female external catheter) expired on 2020-12-28; c. All of the following vacutainers (blood collection tubes) were found in Station 2 MR: Three BD vacutainers expired on 2020-8-31; Two BD vacutainers expired on 2020-11-30; Three BD vacutainers expired on 2020-02-29; Three BD vacutainers expired on 2020-10-31; One BD vacutainer expired on 2020-12-31; One BD vacutainer expired on 2020-01-31; and One BD vacutainer expired on 2019-12-31. She stated, these biological supplies shouldn't be available in the MR or mixed with medical supplies that are not expired. The ADON confirmed that the Licensed Nurses (LNs) will get medical supplies or medications needed for the residents from the MR. During an interview with LN 12 on [DATE] at 7:25 a.m., he stated, the medical supplies and medications were kept locked in the MR, and LNs can access the room. LN 12 confirmed that he takes medical supplies or medications from the MR if it is not available in his cart, and assumed the supplies are not expired. During a review of the facility's policy and procedure titled, Specimen Collection, date implemented, [DATE], indicated, .The facility will ensure that the specimen collection items such as blood collection devices, vacutainers, blood culture tubes, vials, or bottles: b. Are used within their appropriate time frames, checking expiration dates, discarding those that have expired and replacing the item(s) with newer stock .

CONCERN (E)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to serve residents' therapeutic diet (a diet ordered as part of treatment for a disease or clinical condition, or to eliminate, ...

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Based on observation, interview, and record review, the facility failed to serve residents' therapeutic diet (a diet ordered as part of treatment for a disease or clinical condition, or to eliminate, decrease, increase, or provide specific nutrients in the diet) as prescribed by the physician when the prescribed controlled carbohydrate diet (CCHO- a diet focused on having the same amount of carbohydrates; fiber, starches and sugars, every day) for 14 out of 32 residents (Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 97, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76) were not followed. This failure has the potential for Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 97, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76 to experience fluctuating and/or uncontrolled blood sugar levels which may lead to serious medical complications. Findings: A review of Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76's clinical records indicated the residents had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in the blood which can cause multiple health problems). A review of Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 97, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76's clinical record indicated an active diet order which included CCHO. A review of the facility's fall menu titled, Good For Your Health Menus, for dates 9/11-17/2023, indicated a lunch meal on 9/12/23 which included pasta with creamy Italian sauce. During a tray line observation on 9/12/23 which started at 11:46 a.m. in the kitchen, Facility [NAME] (FC) 2 was observed plating penne pasta with cream sauce on Resident 81, Resident 78, Resident 33, Resident 52, Resident 10, Resident 121, Resident 171, Resident 114, Resident 97, Resident 107, Resident 570, Resident 122, Resident 44, and Resident 76's plates using a scoop with grey handle. A review of a facility document titled, Scoop Size, undated, indicated a scoop with grey handle has a portion size of 1/2 cup. A review of a facility's cook's spreadsheet titled, FALL MENUS, for dates 9/12/23, 10/10/23, and 11/7/23, indicated residents with prescribed small and regular portion CCHO diet should receive 1/4 cup of pasta with creamy Italian sauce. During an interview on 9/14/23 at 9:19 a.m. with the Director of Nursing (DON), the DON stated, Whatever that diet order is, that should be the one being delivered. The DON also stated if the diet order for residents with CCHO diet is not followed, their blood sugar would be affected and might fluctuate which could lead to medical complications, or worst a potential death. The DON further stated, .If [a resident is] given a wrong food [portion], we have to inform the doctor, and monitor residents . During an interview on 9/14/23 at 10:25 a.m. with the Dietary Services Supervisor (DSS), the DSS stated, The scoop used is for a regular diet . The DSS further stated if a resident on CCHO diet was given 1/2 cup of pasta with creamy Italian sauce instead of the recommended 1/4 cup, they would have been given too much carbohydrate which could affect the resident's health status. A review of the facility's policy and procedure titled, CONTROLLED CARBOHYDRATE DIET (CCHO), dated 2020, indicated, A controlled carbohydrate diet, (CCHO), is a meal plan .for diabetic residents the carbohydrates are evenly, systematically and consistently distributed through three meals and H.S. [hour of sleep] snack in an effort to maintain a stable blood sugar level throughout the day.

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 provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with profe...

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Based on observation, interview, and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 98 residents who ate facility prepared meals when: 1. A package of ground sausage with ice crystals built-up was found open and exposed to air in the freezer; 2. Two out of two dry storage logs were not filled in four out of 11 entries; 3. A food preparation sink lacked an air gap (a backflow prevention device that prevents contaminated water from re-entering the sink); 4. Five large steam table pans, three medium steam table pans, one small steam table pan (with food particles), two water pitchers and covers, and two medium measuring containers were all found stored wet; 5. One baking soda container was found open to the air and past the used-by date, one spice was found with an unreadable use-by label, and two gravy mixes, a box of corn starch, and a seasoning salt were found opened and exposed to air; 6. A metal pipe was found chipped with yellowish build-up, one serving spoon was found covered with white deposits on its inner surface, one out of two air conditioning units was found with grey particles on front surface and power cord plug, one electric ceiling fan was found with grey particles on the back surface, window blinds found with grey particles and scattered black spots, the ceiling above the food preparation area found with dark brown spots, and the top of the dishwasher was found covered with white deposits; 7. A can opener was found with metal blade worn and had a dark brown build-up; 8. Two out of two resident refrigerators had temperatures above the safe food range; 9. Three containers of food and two beverages were found in the resident refrigerator not labeled and dated; and 10. Ambient temperature foods (room temperature food such as tuna) were not monitored for cool down to ensure temperature control after preparation. These failures had the potential to put residents at risk for foodborne illnesses. Findings: 1. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 8:27 a.m., with the Dietary Services Supervisor (DSS) in the freezer, a package of ground sausage with ice crystals was found opened and exposed to air. The DSS confirmed this and stated, .it's [package of ground sausage] supposed to be tightly resealed after opening. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated she would not use a frozen food item with ice crystals. The DSS further stated, It [ice crystals build-up] affects the flavor, texture, and quality of the food .it's a food safety [issue]. A review of the facility's policy and procedure (P&P) titled, PROCEDURE FOR FREEZER STORAGE, dated 2023, indicated, 5. Store frozen foods in airtight moisture-resistant wrapper such as plastic bag or freezer paper to prevent freezer burn (a condition in which ice crystals form on frozen foods as a result of air coming into contact with food). A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 3-302.11, titled, Packaged and Unpackaged Food -Separation, Packaging, and Segregation, 1/18/23 version, indicated, (A) FOOD shall be protected from cross contamination by .storing the food in packages, covered containers, or wrappings . 2. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 8:27 a.m., with the DSS in the kitchen, the dry storage temperature logs for both dry storage for condiments and dry storage for food were not filled in for 4 out of 11 entries. There were no entries made on dates 9/8, 9/9, 9/10, and 9/11. The DSS confirmed the observation. The DSS stated employees should be filling out the dry storage temperature logs daily to check if the storage rooms were within the recommended temperatures. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated, .if the [dry storage temperature] logs are not updated, we cannot monitor the temp [temperature] if it gets too high or low, and it will affect the food . A review of the facility's P&P titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, indicated, .Thermometers should be placed in all storage areas and checked frequently . 3. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 9:01 a.m., with the DSS in the kitchen, the food preparation sink located in the middle of the kitchen lacked an air gap. The DSS confirmed the observation. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated, .I'm not aware of how the plumbing should be. That's something I want to bring up to maintenance and administrator. The DSS agreed that there should be a visual break in the pipeline to prevent contaminated water from re-entering the sink. A review of the US FDA 2022 Food Code, section 5-202.13, titled, Backflow Prevention, Air Gap., 1/18/23 version, indicated, .Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow . 4. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 9:01 a.m., with the DSS in the kitchen, five large steam table pans, three medium steam table pans, one small steam table pan (with food particles), two water pitchers and covers, and two medium measuring containers were all found stored wet. The DSS confirmed the observations. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated all kitchen equipment and utensils were supposed to be air dried properly so bacteria would not grow on them. A review of the facility's P&P titled, DISHWASHING, dated 2023, indicated, 5. Dishes are to be air dried in racks before stacking and storing. A review of the US FDA 2022 Food Code, section 4-901.11, titled, Equipment and Utensils, Air-Drying Required., 1/18/23 version, indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow 5. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 9:01 a.m., with the DSS in the kitchen, a box of baking soda found open to the air and labelled 8/22. The DSS confirmed the observation. A review of the facility's P&P titled, DRY GOODS, dated 2023, indicated opened baking soda are to be stored for 6 months only. The P&P further indicated, .Keep them [dry goods] dry and tightly covered. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 9:01 a.m., with the DSS in the kitchen, one container of ground oregano was found with an unreadable opened-date label, and a container of seasoning salt, a pack of chicken gravy mix, a pack of country gravy mix, and a box of corn starch were all found stored opened and exposed to the air. The DSS confirmed the observations. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated she expected all opened items to be labeled clearly. The DSS further stated, We should seal them [opened spices and food mixes] properly, such as in Ziplock bags .The quality and their [spices and food mixes] flavor is affected [if left open to air]. A review of the facility's P&P titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, indicated, 9. Dry food items which have been opened, such as .spices .etc., will be tightly closed, labeled and dated . A review of the US FDA 2022 Food Code, section 3-305.13, titled, Vended Time/Temperature Control for Safety Food, Original Container., 1/18/23 version, indicated, The possibility of product contamination increases whenever food is exposed .Once the original seal is broken, the food is vulnerable to contamination. 6. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 9:01 a.m., with the DSS in the kitchen, a six-foot long black metal pipe next to the steam table and food preparation sink was found with chipped sides and with scattered yellowish build-up. Also, a serving spoon hanging next to the stove counter was found covered with white deposits on the inner surface. An air conditioning unit facing the food preparation area was found with a 1/8 to ¼ inch buildup of thick grey particles on the front surface and power cord plug. An electric ceiling fan being used to air-dry the washed dishes and utensils was found with 1/8-inch-thick grey particles on the back surface. The window blinds next to the food preparation area were found with 1/8 to ¼ inch thick grey particles and were covered with scattered pinpoint to half-a-penny sized black spots. The ceiling directly above the food preparation area was found with scattered pinpoint to a penny sized dark brown spots. And the top of dishwasher was found covered with white deposits. The DSS confirmed the observations. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated all equipment, fixtures and walls in the kitchen should be clean. The DSS further stated the dirt could get into the food which could cause bacteria growth and disease. A review of the facility's P&P titled, Sanitation, last revised 11/2022, indicated, 2. All utensils, counters, shelves, equipment are kept clean and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . 3. All equipment's, food contact surfaces and utensils are cleaned . A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Non food-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 7. During a concurrent observation and interview on 9/11/23, within the initial kitchen tour at 9:01 a.m., with the DSS in the kitchen, a can opener was found with the metal blade worn and had a dark brown build-up. The DSS confirmed the observation. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated when the metal blade of a can opener is worn out, the metal might go into the food which could injure the residents. A review of the facility's P&P titled, Sanitation, last revised 11/2022, indicated, 2. All .equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils are cleaned . A review of the facility's P&P titled, CAN OPENER AND BASE, dated 2023, indicated, Proper sanitation and maintenance of the can opener .is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade . 1. The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently . 6. Replace blade on can opener, as needed. A review of the US FDA 2022 Food Code, section 4-501.11, titled, Good Repair and Proper Adjustment, 1/18/23 version, indicated, The cutting or piercing parts of can openers may accumulate metal fragments that could lead to food containing foreign objects and, possibly, result in consumer injury. 8. During an observation on 9/11/23 at 3:15 p.m. at nurse's station 1 medication room, the inside thermometer (a device that measures temperature) of the food refrigerator was noted to have a temperature reading of 50 degrees Fahrenheit (F- unit of measurement). The surveyor's thermometer was left inside the refrigerator and was checked after 15 minutes; temperature was at 46 degrees F. A review of the resident food refrigerator's temperature log at nurse's station 2 medication room titled, Temperature Log for Refrigerator- Fahrenheit, for the month of September 2023, indicated temperature readings of 45 degrees F and 44 degrees F on 9/2, 43 degrees F and 42 degrees F on 9/3, 44 degrees F on 9/4 and 9/5, 46 degrees F and 45 degrees F on 9/6 and 9/7, 45 degrees F on 9/8, 43 degrees F on 9/9, 44 degrees F and 43 degrees F on 9/10, and 46 degrees F on 9/11. During an observation on 9/12/23 at 1:14 p.m. with Certified Nurse Assistant (CNA) 2 at nurse's station 1 medication room, the inside thermometer of the food refrigerator was noted to have a temperature reading of 45 degrees F. The surveyor's thermometer was left inside the refrigerator and was checked after 5 minutes; temperature was at 46 degrees F. CNA 2 verified the observation. During an observation on 9/12/23 at 1:16 p.m. with Licensed Nurse (LN) 6 at nurse's station 2 medication room, the inside thermometer of the food refrigerator was noted to have a temperature reading of 45 degrees F. The surveyor's thermometer was left inside the refrigerator and was checked after 7 minutes; temperature was at 45 degrees F. LN 6 verified the observation. During an interview on 9/14/23 at 9:19 a.m. with the Director of Nursing (DON), the DON stated the temperature of the resident food refrigerator were checked daily and every night shift. The DON also stated they had guide posted together with the temperature log for the nurses to know what to do in case the refrigerator temperature was not suitable for food storage. The DON further stated if the refrigerator temperature was not suitable for food storage, they would throw everything out from the refrigerator because the food might get spoiled which might cause diarrhea, nausea or vomiting, or other side effects to the residents. A review of the facility's P&P titled, Date Marking for Food Safety, dated 3/1/2023, indicated, 1. Refrigerated, ready-to-eat/temperature control for safety food .shall be held at a temperature of 41 degrees F or less . A review of the facility's P&P titled, Resident Refrigerators, dated 3/1/2023, indicated, 1. Maintenance staff shall record refrigerator temperatures weekly on a temperature log . b. Temperature will be at or below 41 degrees F . 9. During an observation on 9/11/23 at 3:15 p.m. with LN 5 at nurse's station 1 medication room, the resident food refrigerator contained one small container of white sauce with white lid- not labeled and dated, one medium container of food with red lid- not labeled and dated, one medium glass jar of preserved fruit and vegetables- not labeled and dated, one half-drank 500 milliliter (unit of measurement) water bottle- not labeled and dated, one opened half & half- not dated. LN 5 confirmed the observation. LN 5 stated all residents' food stored in the resident food refrigerator should be labeled with the residents' name and room number and the date it was received. LN 5 further stated they would keep the residents' food in the refrigerator for no more than three days. During an interview on 9/11/23 at 3:28 p.m. with CNA 1 at nurse's station 2 medication room, CNA 1 stated they would label all the residents' food stored in the resident food refrigerator with the residents' room number and the date it was received. CNA 1 further stated they would usually keep the residents' food in the refrigerator for two to three days and it would be the nurses who would check which food needs to be thrown out. During an interview on 9/14/23 at 9:19 a.m. with the DON, the DON stated she would expect all residents' food stored in the resident food refrigerator to be labeled with the residents' name and room number and the date it was received. The DON stated if the residents' food were not labeled and dated properly, they would not know who the food is for and when it should be discarded which might cause foodborne illness to the residents. A review of the facility's P&P titled, Use and Storage of Food Brought in by Family or Visitors, dated 3/1/2023, indicated, 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated . b. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by the facility staff. A review of the facility's P&P titled, BRINGING IN FOOD FOR A RESIDENT, dated 2023, indicated, Foods in unmarked or unlabeled containers will be marked with the current date and the resident's name. 10. During an interview on 9/12/23 at 9:22 a.m. with the DA 3 in the kitchen, DA 3 stated when they make tuna salad, they would get the ingredients from the storage room and store the prepared tuna salad in the refrigerator after preparation. DA 3 further stated they do not check ambient food temperature cooldown. During an interview on 9/12/23 at 4:09 p.m. with DA 4 in the kitchen, DA 4 stated when they make ambient food such as tuna salad, they would get the canned tuna in the storage room and would also get mayonnaise and relish from storage room when there was not an opened container in the refrigerator. DA 4 further stated, No, we don't do them [checking ambient food temperature cooldown] since it's canned, and we get it from storage room. A review of facility's dry storage for food temperature log titled, DRY FOOD STORAGE TEMPERATURE LOG, for the month of September 2023, indicated temperature readings of 60 degrees F on 9/1, 59 degrees F and 60 degrees F on 9/2, 60 degrees F and 61 degrees F on 9/3, 60 degrees F on 9/4, 9/5, and 9/6, and 58 degrees F and 59 degrees F on 9/7. There were no entries made on dates 9/8, 9/9, 9/10, and 9/11. A review of facility's dry storage for condiments temperature log titled, DRY FOOD STORAGE TEMPERATURE LOG, for the month of September 2023, indicated temperature readings of 80 degrees F on 9/1 and 9/2, 81 degrees F and 82 degrees F on 9/3, 70 degrees F on 9/4, 70 degrees F and 80 degrees F on 9/5, and 80 degrees F on 9/6, and 9/7. There were no entries made on dates 9/8, 9/9, 9/10, and 9/11. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated, We should implement a cooldown [monitoring] for the ambient food . The DSS further stated if an ambient food is not properly cooled down, it would be a risk for bacteria growth on the food. The facility's cooldown log for ambient food was requested but none were provided. A review of the facility's P&P titled, Record of Food Temperatures, dated 3/1/2023, indicated, 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. A review of the US FDA 2022 Food Code, section 3-501.14, titled, Cooling, 1/18/23 version, indicated, .(B) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled within 4 hours to .41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted FOODS and canned tuna .

CONCERN (E)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the facility when two cockroaches were observed in the facility kitchen. This...

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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for the facility when two cockroaches were observed in the facility kitchen. This failure has the potential for contamination of resident's food, soilage of kitchen utensils and surfaces, and possible spread of disease or infection. Findings: During a concurrent observation and interview on 9/11/23 at 9:01 a.m. with the Dietary Services Supervisor (DSS) in the kitchen, a 3/4 sized dead cockroach was found upside down in the food preparation sink. The DSS confirmed the observation. During a concurrent observation and interview on 9/11/23 at 9:15 a.m. with the DSS in the kitchen, a 1/2 sized cockroach was seen running on the floor from the southern wall of the kitchen going under the steam table and kitchen counter holding hot water, coffee dispenser and cutting boards. The DSS confirmed the observation and stepped on the cockroach to kill it. During an interview on 9/14/23 at 10:25 a.m. with the DSS, the DSS stated It's not good to have them [cockroaches] in the kitchen . [the kitchen is] supposed to be clean. The DSS further stated the cockroaches could get into the residents' food which could cause the food to get contaminated and/or spoiled and would also be a risk for the spread of bacteria or infection. A review of the facility's policy and procedure titled, Pest Control Program, undated, indicated, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 6-501.111, titled, Controlling Pests., 1/18/23 version, indicated, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES .

Sept 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide the necessary care for one of three sampled residents (Resident 1) and failed to notify the physician immediately of ...

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Based on observation, interview, and record review, the facility failed to provide the necessary care for one of three sampled residents (Resident 1) and failed to notify the physician immediately of Resident 1's change of condition (COC), when the resident complained of chest pain. In addition, the facility failed to assess Resident 1 and monitor him for his complaint of chest pain. These failures resulted in Resident 1's calling 911 due to the delay for needed medical attention and placed the resident at risk for harm when his condition was not evaluated. Findings: A review of Resident 1's admission record indicated the facility admitted the resident in 2022 with multiple diagnoses, including quadriplegia (loss of movement and sensation affecting resident's torso, upper and lower extremities and making him unable to move in a bed), heart failure (a condition when the heart is unable to pump enough blood for body's needs), and high blood pressure. A review of Resident 1's care plan titled, Resident has quadriplegia, dated 3/25/22, indicated resident's goal to remain free of complications and discomfort. The care plan interventions directed facility staff to manage resident's pain per physician's order. A review of Resident 1's chronic pain care plan, dated 4/4/22, directed nurses to administer pain medications and notify physician if the medication was ineffective and, if current complaint is a significant change from resident's past experience. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 3/28/23, indicated the resident was cognitively intact. The MDS indicated Resident 1 was completely dependent on facility staff for bed mobility, toileting and bathing. A review of Resident 1's clinical records contained a nursing progress (NP) note, dated 7/29/23 at 3:50 p.m. which indicated, Writer was called to pt [patient's] room. Fire Dept [Department] is there with [patient] on gurney. They wanted to inform nurse in charge that they are taking [patient] to [name of the hospital] for chest pain. He is alert, responsive, no s. s [signs, symptoms] of acute distress observed. The nurse documented that Resident 1 left facility at approximately 3:31 p.m. A review of a NP note, dated 7/29/23, at 4:04 p.m., indicated, Received report from morning nurse that [patient] c/o [complained] of chest pain. A review of Resident 1's clinical records showed no documented evidence of a nursing note or other record of the resident's complaint of chest pain identified by the morning shift nurse nor documentation a physician was informed of the resident's chest pain. There was no documented evidence of Resident 1's chest pain assessment. Resident 1's records indicated the resident's blood pressure and heart rate were checked on 7/29/23 at 11:51 a.m. Per the resident's clinical records, 7/29/23 at 12:21 a.m., was the last time nursing staff checked his temperature and oxygen saturation level, which indicated it was more than 12 hours prior to Resident 1's complaint of chest pain. During an observation and interview on 8/10/23, at 2:15 p.m., Resident 1 was laying in his bed. Resident 1 stated he had been living in the facility for almost two years and recently had a scary experience when he had chest pain and nobody checked on him. Resident 1 explained on 7/29/23 around noon, he woke up from his nap and needed help with personal care, so he pushed his call light button to call for assistance. Resident 1 stated he also waited for his lunch, but nobody brought his lunch tray that day. Resident 1 added, I had my call light on .for more than two (2) hours but nobody came .CNA [Certified Nursing Assistant] was attending to both of my roommates, [but] ignored me .I kept calling the front desk, but then she [receptionist] was transferring my calls to the nursing station and .they just ignored the phone calls, the same as call lights. Resident 1 stated his, chest right in the middle started hurting and nobody came .Chest pain was getting worse; my left arm was hurting by that time, but nobody checked on me. My call light was still on. Resident 1 stated he heard his nurse, LN 1 (Licensed Nurse 1) talking to his roommate, but she did not check on him before leaving the room even though his call light was still on. Resident 1 stated he yelled for help a few times, but nobody came to check on him. Resident 1 added, I have heart failure and I when nobody came after I pushed my call button and yelled for help, I started panicking that I might die here .I had no choice but to call 911. They took me to ED [Emergency Department] and I was hospitalized for three days. During an interview on 8/10/23 at 2:55 p.m., LN 1 stated she was assigned to Resident 1 on 7/29/23 morning shift. LN 1 stated after Resident 1 had his bed bath after 9 a.m., he fell asleep. LN 1 stated around 1 p.m., she administered medications to the resident's roommate, but Resident 1 was asleep. During a continued interview, LN 1 confirmed it was, possible Resident 1 did not receive his lunch because, he refused his CNA. LN 1 explained the resident barely eats the facility's food and orders food to be delivered from restaurants. LN 1 stated she did not bring the resident's lunch tray to his room. LN 1 stated she did not assess Resident 1 for chest pain because she was not aware that Resident 1 had chest pain. LN 1 stated, I don't remember if his call light call was on .Not aware about chest pain. As I was leaving, I saw the fire department staff were entering the building .assumed .[Resident 1] called them. During a concurrent interview and record review on 8/10/23 at 3:50 p.m., the Director of Nursing (DON) stated after Resident 1 was readmitted after a brief hospitalization for chest pain, he complained nobody came to check on him and nobody helped with chest pain. The DON stated the resident's complaint of chest pain was new and acknowledged it was a change of condition (COC). The DON stated, The resident was mad .and started complaining of chest pain right before shift change. Our PM [afternoon] shift nurse went to assess him .but he was already on the phone calling 911. During a continued interview and record review on 8/10/23 at 5 p.m., Resident 1's Situation, Background, Assessment, and Recommendation (SBAR, a communication technique for communication between facility's staff and physician to notify of changes in resident's condition), completed on 7/29/23 at 7:26 p.m., was reviewed with the DON. The DON reviewed the SBAR and confirmed Resident 1's blood pressure and heart rate were checked at 11:51 a.m., which was about three hours before the resident called 911 and more than two (2) hours before the afternoon shift nurse came on duty. The DON acknowledged there was no documented evidence LN 1, who was working day shift or a Registered Nurse assessed Resident 1's chest pain characteristics (if the pain was radiating down resident's arm, neck, jaw and what made the chest pain worse). The DON stated her expectation for nursing staff was to assess resident's chest pain immediately, assess for presence of shortness of breath, and administer oxygen if needed. The DON stated the resident's physician should have been notified of the resident's chest pain immediately. The DON acknowledged per the SBAR documentation, Resident 1's physician was not notified until four hours after the resident's blood pressure and heart rate were checked at 4 p.m., and 30 minutes after the resident left to emergency room (ER). The DON stated Resident 1 had history of heart failure and high blood pressure which placed him at increased risk for heart attack. The DON agreed a delay in chest pain assessment and delay in informing Resident 1's physician of resident's change of condition could have caused harm to the resident's health. A review of the facility's Pain assessment and Management policy, dated October 2022, indicated the purpose of the policy was, to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs. The policy directed staff to, assess the resident whenever there is a suspicion of new pain .monitor the resident for the presence of pain and the need for further assessment when there is a change of condition. A review of the facility's policy titled, Acute Condition Changes - Clinical Protocol, dated March 2018, indicated, Assessment and Recognition .The nurse shall assess and document/report the following baseline information: vital signs; neurological status; current level of pain, and any recent changes in pain level; level of consciousness .onset, duration, severity .Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician .phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including resident's .current symptoms .The nursing staff will contact the physician on the urgency of the situation. For emergencies, they will call .and request a prompt response .the attending physician will respond in a timely manner.

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from neglect when Resident 1 did not receive incontinence care, was not t...

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Based on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from neglect when Resident 1 did not receive incontinence care, was not turned and not repositioned for over five hours. This failure resulted in Resident 1's feeling uncomfortable, itching and had the potential to worsen his skin rash. Findings: A review of Resident 1's admission record indicated the facility admitted the resident in 2022 with multiple diagnoses, including quadriplegia (loss of movement and sensation affecting resident's torso, upper and lower extremities and making him unable to move in a bed), heart failure (a condition when the heart is unable to pump enough blood for body's needs), and high blood pressure. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/28/23, indicated the resident was cognitively intact. The MDS indicated Resident 1 was incontinent for bladder and bowel and was completely dependent on facility staff for ADLs, including bed mobility, toileting, personal hygiene, and bathing. The MDS section for the resident's, preferences for customary routine and activities indicated it was, very important to him to choose between a .shower, bed bath, or sponge bath. A review of Resident 1's skin care plans, dated 7/28/23, indicated the resident had scattered open areas called Moisture Associated Skin Damage (MASD, incontinence-associated skin rash) on his right and left buttocks and tailbone. The care plan goals indicated the MASD areas will heal without complications through the next care plans review date of 9/25/23. The nursing interventions directed staff to, always keep [resident's] skin clean and dry and turn and reposition the resident frequently. During an interview on 8/10/23 at 2:06 p.m., Certified Nursing Assistant (CNA 3) stated she was familiar with Resident 1's care. CNA 3 stated Resident 1 was totally dependent on staff with his care, turning, and repositioning and it took a longer time, sometimes up to 45 minutes to assist him with his personal hygiene. CNA 3 stated other CNAs would be responsible for attending to her other assigned residents, if they were not busy. CNA 3 stated Resident 1 had open areas on his bottom, was incontinent, and needed to be changed at least 3 times a shift. During an observation and interview on 8/10/23, at 2:17 p.m., Resident 1 was observed lying in bed awake. Resident 1 stated the facility was frequently short on CNAs and brought in CNAs from staffing registries who were not familiar with his routine. Resident 1 stated on 7/29/23, no CNA came to provide his morning care after the shift started. Resident 1 stated LN 1 informed him later he had one of the registry CNAs assigned to him. Resident stated he became upset because he had issues with this particular CNA in the past and had requested multiple times not to be assigned to that specific CNA. Resident 1 stated he notified LN 1 he needed to be changed but was told he had to wait because the assigned CNA was late to work. Resident 1 continued, Then the registry CNA came and helped two of my roommates, but she didn't check on me, totally ignored me. I didn't get my breakfast. Later, when [LN 1] brought my medications, she said according to that CNA, she's not supposed to work with me. When I asked [LN 1] what I was supposed to do .she said - 'I don't know what to do with you' .She [LN 1] did not help me and did not send any other CNA to change me. Resident 1 added by the time he asked LN 1 what he was supposed to do, Resident 1 was soaking wet, uncomfortable, and itchy. Resident 1 stated he had skin issues related to his incontinence briefs not being changed as frequently as he needed. In a further interview, Resident 1 stated he called the front desk and asked to for them to send one of the Restorative Nursing Assistants (RNA) to come and assist him with his personal care. Resident 1 added, He changed me, gave me a bed bath instead of the shower I was supposed to get that day, and gave me breakfast at 9:45 a.m. It [food] was cold, but I was hungry .so I had to eat. Resident 1 stated he had his call light on from around noon time and he did not receive his lunch and no other staff checked on him until the end of the shift. During an interview on 8/10/23 at 2:55 p.m., LN 1 stated she was assigned to Resident 1 on 7/29/23 morning shift. LN 1 explained there were no regular CNAs staff assigned to the hall where Resident 1 lived, and he had a registry CNA assigned to him. LN 1 stated the CNA did not provide his care the entire day shift because he refused her. LN 1 added, Other registry CNA who was working that section, did not want him .Nobody wants to work with him .it's very time consuming to work with him .I talked to the resident and told him I didn't know what to do with him. LN 1 stated she did not know who would provide personal care for him and change him. LN 1 stated she consulted the Director of Nursing (DON) and the facility's staffer. LN 1 stated the RNA came, and Resident 1 had his bed bath after 9 a.m., and fell asleep after that. During a continued interview, LN 1 confirmed that it possible that Resident 1 did not receive his lunch because he refused his CNA. LN 1 explained the resident barely eats the facility's food and orders food from outside restaurants. LN 1 confirmed she did not bring the resident's lunch tray to his room and did not provide personal care after the resident had his bed bath around 9:45 a.m. A review of Resident 1's flow sheet (where CNAs document personal hygiene and bathing), indicated Resident 1 did not receive personal hygiene, including brushing teeth, shaving, washing face and no assistance with toileting for the entire morning shift on 7/29/23, and no assistance with personal hygiene was provided for evening shift on 7/18/23, 7/24/23, and 7/30/23. There were 18 days during the month of July 2023 where CNAs documented Resident 1 was independent with ADLs tasks and did not require any help or staff oversight. During an interview on 8/10/23 at 3:25 p.m., the treatment nurse (TN) stated Resident 1 had open areas on his bottom on and off. TN stated at present Resident 1 had a MASD on his inner buttocks and tailbone. When TN was asked if resident's MASD was from not having timely changes of his briefs, the TN replied it could be from sweat, urine, and stool. During a concurrent interview and record review on 8/10/23 at 3:50 p.m., the DON stated her expectation for staff answering call lights should be as soon as they see it and briefs should be changed at least three times per shift and as needed. The DON stated if a resident was calling, asking to be changed because he/she was uncomfortable in soiled briefs, it was an unacceptable practice to wait for hours. The DON described Resident 1 as very choosy, especially with CNAs who he wants and who he doesn't want .very persistent with his requests. The DON stated on 7/29/23 Resident 1 refused his assigned registry CNA and the facility were not able to provide another CNA to care for his needs. The DON stated Resident 1 did not get his shower on 7/29/23, but he had a bed bath given by the RNA. The DON did not answer when she was asked if the resident had incontinence care, had his briefs changed, was repositioned on 7/29/23 later in the day, after he had his bed bath around 9 a.m. A review of the facility's policy titled, Abuse and Neglect - Clinical Protocol, dated March 2018, indicated the neglect was defined as the failure of the facility, its employees .to provide .services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

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 F0725 (Tag F0725)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain sufficient staff to provide nursing and rela...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain sufficient staff to provide nursing and related services to meet the residents needs for census of 116, when Resident 2 had to wait for over an hour to be assisted with cleaning, multiple residents complained of extended wait time for assistance with their needs, and the facility failed to meet State staffing requirements for Certified Nursing Assistants (CNAs) for 10 of 10 sampled days. These failures resulted in inadequate availability of CNAs to attend to Residents 2 and other residents requiring assistance needs, had the potential to place residents at risk for skin breakdown, and negatively affect residents' physical and psychosocial well-being. Findings: A review of Resident 2's admission record indicated the facility admitted the resident in the beginning of this year with multiple diagnoses which included after stroke care, aphasia (difficulty with communication), muscle weakness, and lack of coordination. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/28/23, indicated he was cognitively intact and did not reject personal care. The MDS assessment indicate that Resident 2 had bladder and bowel incontinence and required extensive assistance with all Activities of Daily Living (ADLs), including bed mobility, personal hygiene, toileting, and bathing. A review of Resident 2's ADL [Activities of Daily Living] Care Plan, dated 1/27/23, indicated the resident had an ADL self-care performance deficit. One of the nursing interventions indicated to encourage the resident to use bell to call for assistance. A review of Resident 2's care plan titled, The resident has a communication problem r/t [related to] unclear speech, dated 1/31/23 indicated, Resident is able to: Inform staff of his needs daily. One of the interventions directed staff to, anticipate and meet [resident's] needs. During an observation on 8/10/23, at 1:50 p.m., a blinking light above the door to room [ROOM NUMBER] was observed. There were no staff nearby. During an observation on 8/10/23, at 2 p.m., a blinking light outside of room [ROOM NUMBER] was observed. Resident 2 was lying in his bed on his right side holding tightly onto call light button and continuously pressing on the button. Resident 2's speech was slightly garbled, but he answered appropriately. Resident 2 stated he had a bowel movement and needed to be changed. Resident 2 stated, I pushed my call button a while ago, more than half an hour. CNA came and told me to wait. I don't know her name .I waited and then pushed my call button again. It's uncomfortable to lay in soiled diaper. My bottom hurts. Resident 2 stated a different CNA came, turned the call light off, and left the room. Resident 2 added, She didn't say anything, just turned it off. I waited and when nobody came, I pushed it on again. Still waiting. Sometimes have to wait an hour or longer. Sometimes I push call button and wait, and by the time they come, I forget what I needed. Some of them get inpatient and upset that I can't tell what I needed. During an interview on 8/10/23, at 2:06 p.m., CNA 3 stated she was assigned to Resident 2. CNA 3 stated the resident was incontinent for bowel and bladder and was wearing briefs. CNA 3 stated Resident 2 had no open wounds on his bottom but had diaper rash. CNA 3 stated the last time she changed the resident was earlier this morning around 9-10 a.m., after the resident ate his breakfast. CNA 3 stated she was busy providing care to other residents and did not have a chance to check on him earlier. CNA 3 stated other CNAs would be responsible for attending to her other assigned residents. During an observation on 8/10/23, at 2:15 p.m., Resident 2's call light above his door was blinking and beeping. Resident 2 was still laying on his right side, holding onto call light button. Resident 2 stated, Nobody changed me yet. Different people came in turned the light off and have told me she will be back and never came. During an observation and interview on 8/10/23, at 12:58 p.m., Resident 3 was in his bed, awake and alert. Resident 3's speech was slow, but he responded to all questions appropriately. During an interview Resident 3 stated sometimes he had to wait for his CNA longer, from 30 minutes to an hour. Resident 3 stated, They are always busy here, always in a rush, and they don't stay here [in the facility] long. Come and leave in a month or two. I heard they are shorthanded and have hard time finding CNAs. During an interview on 8/10/23, at 1:10 p.m., CNA 1 stated normally her assignment consisted of 8- 9 residents, but sometimes when the facility was short, she had more residents on her assignment. CNA 1 stated when two CNAs called in sick on weekends and it was very hard to find a replacement, the rest of the CNAs ended up taking a bigger load. CNA 3 added, It's hard to take care of residents' needs when we understaffed . and sometimes residents have to wait longer for call lights answered and needs taken care of and we don't have enough time to chart. During an observation and interview on 8/10/23, at 1:24 p.m., Resident 4 was observed lying in her bed, awake, alert and oriented to person, place, and time. Resident 4 stated she was dependent on staff for all ADLs and used her call button the call for assistance. Resident 4 stated call light response time depended on how busy the staff were and added the longest she had to wait was one hour. Resident 4 stated, Too many patients needing help and too little employees. CNAs don't stay here for long - they come and go. When 2 - 3 CNAs call in sick, extra pressure is placed on the remaining CNAs. Hard to find registry to work weekends and they have to spread their CNAs, so every patient is taken care of . if they are short-handed, we have to wait. During an interview on 8/10/23, at 1:45 p.m., Resident 5 stated during shift change or during lunch/dinner, or when they were shorthanded, wait time for assistance could be up to an hour because CNAs have lots of patients, have to check on all of them, or feeding their patients. During an interview on 8/10/23, at 1:55 p.m., CNA 2 stated she was called from a different hall to help another CNA with resident's care. CNA 2 stated some days and on weekends there were lots of staff calling in sick and it was harder on other CNAs. CNA 2 stated, When someone calls in-sick, we have no choice but to take over their residents which makes a larger load for us to provide care. Some residents require a longer time to attend to their needs and resident's care must be rushed. CNA 2 stated her responsibilities included passing breakfast and lunch, assist some residents with feeding, collect trays, and answer call lights. CNA 2 stated she checked on her residents and changed them at least three times during her shift. During an interview on 8/10/23, at 2:06 p.m., CNA 3 stated she had 9 residents on her assignment and had to give two showers. CNA 3 stated sometimes it would take her an hour or longer to assist some of her residents with a shower because the residents required two CNAs and a mechanical lift device for transfer. CNA 3 stated other CNAs would be responsible for attending to her other assigned residents. CNA 3 stated some days her shifts were super busy when she had more residents on her assignment due to some staff calling in sick. A review of facility's document titled Direct Care Service Hours Per Patient Day (DHPPD, calculations that determine the number of clinical staff required for resident's care according to the number of resident census) was reviewed for 10 sampled days in July 2023. The document indicated the following dates were less than 2.4 hours for Certified Nursing Assistants and the facility was not in compliance with state requirements: 7/1 - 2.08 7/2 - 2.33 7/8 - 2.01 7/9 - 2.31 7/15 - 2.17 7/16 - 2.03 7/22 - 2.34 7/23 - 2.29 7/29 - 2.29 7/30 - 2.35 During an interview on 8/10/23, at 3:35 p.m., the Staffing Coordinator (SC) stated there were days when the facility was short staffed for CNAs. The SC stated the facility used registry CNAs when the facility's regular staff called in sick, and sometimes had difficulties finding CNAs and ended up short on CNAs, especially on weekends. The SC confirmed on some days the facility's DHPPD were lower and did not meet the State requirements for CNAs. A review of California Department of Public Health All facilities letter (AFL) 20-32.2, titled, Suspension of Regulatory Enforcement of Specified Skilled Nursing Facility Requirements, dated 3/17/2021, indicated the skilled nursing facilities were to comply with 2.4 staffing requirement for CNAs. During a concurrent interview and record review on 8/10/23, at 3:50 p.m. the DON stated call lights should be answered as soon as possible, as soon as they [staff] see it and the briefs should be changed at least three times per shift and as needed. The DON stated if a resident was calling, asking to be changed because he/she was uncomfortable in soiled briefs, it was an unacceptable practice to wait for more than 30 minutes. The DON stated she was not aware of resident's complaints of call lights not answered in a timely manner. The DON stated the facility staffing was not bad, but was occasionally short if regular staff call in sick and were unable to find registry CNAs. The DON was asked if the facility was in compliance with the State requirements. The DON stated she was not sure what were the DHPPD numbers, and added, need to ask our staffer.

Jul 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0839 (Tag F0839)

Could have caused harm · This affected 1 resident

Based on interview, record review, and facility document review, the facility failed to ensure one of five professional staff, Certified Nursing Assistant (CNA) 1, was certified while working in the f...

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Based on interview, record review, and facility document review, the facility failed to ensure one of five professional staff, Certified Nursing Assistant (CNA) 1, was certified while working in the facility. This failure had the potential to negatively impact the care of the facility's residents. Findings: Review of CNA 1's Time Card Report for the weeks of 12/1/2022 to 12/15/2022, 12/16/2022 to 12/31/2022, 1/1/2023 to 1/15/2023 and 1/16/2023 to 1/31/2023 indicated CNA 1 provided care to residents. During a telephone interview on 7/17/23 at 12:35 p.m., with the Director of Nursing (DON), she confirmed they were not able find any documentation that CNA 1 was certified and confirmed CNA 1 worked with residents during the above timeframe. Review of the facility's Job Description: Certified Nursing Assistant, undated, indicated under Experience: Must be a licensed Certified Nursing Assistant in accordance with laws of this state.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide privacy and dignity for one of three (Resident 1) sampled residents when Resident 1's urinary catheter (tube inserted...

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Based on observation, interview, and record review, the facility failed to provide privacy and dignity for one of three (Resident 1) sampled residents when Resident 1's urinary catheter (tube inserted into bladder to drain urine) bag was uncovered. This failure caused Resident 1's privacy to be compromised. Findings: A review of Resident 1's admission Record indicated he was initially admitted to the facility in May 2021 with multiple diagnoses including osteomyelitis (infection of the bone) of thoracic vertebra (middle section of the spine), autistic disorder (condition characterized by challenges with social skills, behaviors, and communication), schizophrenia (mental disorder causing disordered thinking and behavior), bipolar disorder (disorder associated with mood swings), severe intellectual disabilities, and neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problem). A review of Resident 1's Minimum Data Set (MDS- an assessment tool) Cognitive Patterns, dated 2/23/23, indicated Resident 1 had short and long term memory problems and was severely impaired to make decisions for tasks of daily life. A review of Resident 1's MDS Functional Status, dated 2/23/23, indicated Resident 1 was totally dependent for toilet use including management of urinary catheter. A review of Resident 1's MDS Bladder and Bowel, dated 2/23/23, indicated Resident 1 had an indwelling urinary catheter. During an observation on 5/11/23 at 12:17 p.m., observed Resident 1's urinary catheter bag uncovered, exposed, and attached to the bed frame. During a concurrent observation and interview on 5/11/23 at 12:30 p.m. with Licensed Nurse (LN) 1, LN 1 acknowledged that Resident 1's urinary catheter bag was uncovered. LN 1 stated the catheter bag should be covered or draped. During an interview on 5/11/23 at 12:42 p.m. with LN 2, LN 2 stated, Dignity bag should be used for catheter bag. During an interview on 5/11/23 at 12:49 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that catheter bags should be covered. During an interview on 5/11/23 at 1:05 p.m. with the Director of Nursing (DON), the DON confirmed that urinary catheter bags should be covered with a dignity bag (catheter bag cover). During an interview on 5/11/23 at 3:07 p.m. with LN 3, LN 3 started that urinary catheter bags are to be covered. A review of the facility's policy titled Dignity, revised 2/21, 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 .Staff are expected to promote dignity and assist residents .helping the resident to keep urinary catheter bags covered .

May 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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to ensure infection prevention and control program guidelines and practices were maintained for a census of 114, when a Certified...

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Based on observation, interview and record review, the facility failed to ensure infection prevention and control program guidelines and practices were maintained for a census of 114, when a Certified Nursing Assistant (CNA) entered an isolation contact precautions room without sanitizing hands and without wearing gown and gloves. This failure had the potential to result in transmission and spread of infection for a vulnerable population. Findings: During a review of an undated facility signage, titled CONTACT PRECAUTIONS, the signage indicated, Put on gloves before entry .Put on gown before entry. During an observation on 4/26/23, at 2:15 p.m., CNA 1 entered an isolation precautions room holding two cans of soda without sanitizing hands and without putting any PPE (personal protective equipment, gowns and gloves). The room door had a signage, CONTACT PRECAUTIONS, and had PPE available outside the room. On further observation, CNA 1 touched items inside the room and handed the two cans of soda to Resident 2 with his bare hands. During an interview on 4/26/23, at 2:18 p.m., with CNA 1, CNA 1 stated, Yes, I know. I should have sanitized my hands and wore gloves and gown when I entered the room. I forgot. The room is on contact precautions. There are a lot of residents in the sub-acute unit and most of them are on isolation precautions. During an interview on 4/26/23, at 2:24 p.m., with Licensed Nurse 1 (LN 1), LN 1 stated, All the time, we need to follow infection control protocol .On isolation precautions, staff should follow the signage, wash hands before and after entering the room and wear the appropriate PPE to prevent the spread of infection. During an interview on 4/26/23, at 2:35 p.m., with the Director of Nursing (DON), the DON stated, Staff should follow the isolation precaution signs on the door, wash hands before going in and out of the room, and wear appropriate PPE. During a review of the facility's policy and procedures (P&P) titled, Handwashing/Hand Hygiene, revised 8/19, the P&P indicated, The facility considers hand hygiene the primary means to prevent the spread of infection .Use and alcohol-based hand rub .or alternatively, soap and water .before and after entering isolation precaution settings. During a review of the facility's P&P titled, Isolation - Initiating Transmission-Based Precautions, revised 8/19, the P&P indicated, The facility makes every effort to use the less restrictive approach to managing individuals with potentially communicable infections .the Infection Preventionist ensures that protective equipment .(gowns, gloves, masks .) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment. During a review of the facility's P&P titled, Policies and Practices - Infection Control, revised 10/18, the P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with dignity and respect when the Certified Nursing Assistant 1 (CNA 1) walked out of Resident...

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Based on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with dignity and respect when the Certified Nursing Assistant 1 (CNA 1) walked out of Resident 1's room in the middle of providing care, for a census of 106. This failure resulted in Resident 1's decrease level of satisfaction with his care. Findings: A review of the admission Record indicated Resident 1 was admitted with diagnoses including quadriplegia (paralysis of all four extremities). Further review of Resident 1's clinical records indicated a Minimum Data Set (MDS, an assessment tool) dated 12/22/22. The MDS indicated Resident 1 was cognitively intact with a score of 15 out of 15 in the Brief Interview for Mental Status (BIMS, a test of cognition) and Resident 1 was totally dependent on staff for Activities of Daily Living (ADL) including toilet use and personal hygiene. During an interview with Resident 1 on 1/20/23 at 11:12 a.m. Resident 1 stated the CNA 1 assigned to him was upset when he reminded CNA 1 on how he wanted his care to be provided. CNA 1 told Resident 1 to keep quiet and CNA 1 walked out of Resident 1's room. In an interview on 1/20/23 at 1:05 p.m., the Infection Preventionist (IP) stated on 1/1/23 at around 9:45 p.m., Resident 1 called the front desk nurse's station. The IP answered the phone and Resident 1 requested for the IP to come to his room. The IP asked Resident 1 what happened and Resident 1 stated, CNA 1 got upset and walked out on him when he was telling CNA 1 on how to properly clean him. Resident 1 further told the IP, CNA 1 worked with him the other day when he had loose stools, and CNA 1 changed his brief without cleaning him all the way. In a concurrent interview on 1/20/23 starting at 2:37 p.m., CNA 2 and CNA 3 stated they do not get upset with their residents and they need to treat them [residents] with respect and dignity. In a telephone interview on 1/24/23 at 9:11 a.m., CNA 1 admitted she had an argument with Resident 1, and she walked out of Resident 1's room. In a telephone interview on 1/24/23 at 11:16 a.m., the Licensed Nurse (LN) stated he was the charge nurse when Resident 1 was having frequent bowel movement. The LN further stated at around 10:20 p.m., Resident 1 had another bowel movement, CNA 1 got frustrated and walked out. The LN stated he talked to the CNA 1 who was mad at that time and LN offered for another CNA to help but CNA 1 said she got it. CNA 1 went back and changed Resident 1 then Resident 1 had another bowel movement and that was when CNA 1 said she was done and left Resident 1's room. The LN confirmed CNA 1's response to the situation with Resident 1 was not appropriate. In a telephone interview on 1/27/23 at 10:34 a.m., the Director of Staff Development (DSD) stated her expectation was for CNAs to provide quality of care to residents. The DSD further stated the CNAs should have good nursing customer service and professionalism. A review of the facility's policy titled, Resident Rights revised February 2021, indicated, .These rights include the resident's right to .be treated with respect, kindness, and dignity. A review of the facility's policy 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, level of satisfaction with life, and feelings of self-worth and self-esteem .The facility culture supports dignity and respect for residents by honoring resident .preferences .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents .promptly responding to a resident's request for toileting assistance .

Jun 2021 5 deficiencies

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan within seven days after completion of a comprehens...

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Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan within seven days after completion of a comprehensive assessment that met one of 24 residents' (Resident 397) identified incontinence (inability to control bowel or bladder) needs. This failure had the potential to lead to delayed and inaccurate provision of care. Findings: Review of Resident 397's clinical record indicated the following documents: An admission Record indicated the resident was admitted to the facility in 2021, with diagnoses including congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), kidney disease, and muscle weakness. A Minimum Data Set (MDS - a comprehensive assessment tool), dated 5/20/2021, indicated Resident 397 was frequently incontinent of urine. An Order Summary Report, indicated a physician's order, dated 5/17/2021, for Furosemide (a diuretic medication to help rid the body of excess fluid by increasing the amount and frequency of urine the body makes) Tablet 40 milligrams (mg - a measurement) once per day for edema (swelling in the body caused by excess fluid). A Plan of Care, dated 6/8/2021, indicated the resident was incontinent of bowel and bladder related to diagnoses of congestive heart failure and diuretic medications. The plan of care was initiated 19 days after the completion of the MDS. An interview with Resident 397 was conducted on 6/9/2021 at 8:47 a.m. Resident 397 stated she was frustrated because her medication caused her to urinate frequently and she did not think staff knew this because she was always wet, and left soiled for extended periods of time. Resident 397 stated she pressed her call light when she would have an episode of incontinence, but by the time staff came to change her, I have soaked the whole bed. A concurrent interview and record review was conducted with the Director of Nurses on 6/10/2021 at 12:45 p.m. The DON confirmed Resident 397 was frequently incontinent and the care plan for incontinence should have been initiated immediately after admission to the facility. A facility policy titled Care Plan, Comprehensive, dated 12/2017, indicated Care Plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs. Care Plans are based on using fundamental information gathered by the MDS, CAA's [Care Area Assessment's] and information gathered through observation and evaluation.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview, record review, and facility policy review, the facility failed to ensure that a treatment was consistently provided for 1 of 24 sampled residents (Resident 397) when skin observati...

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Based on interview, record review, and facility policy review, the facility failed to ensure that a treatment was consistently provided for 1 of 24 sampled residents (Resident 397) when skin observations and physician orders related to skin care were not consistently documented as completed. This failure had the potential to cause unrecognized and further worsening of skin conditions. Findings: Review of Resident 397's clinical record indicated the following documents: An admission Record indicated the resident was admitted to the facility in 2021 with diagnoses including congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and muscle weakness. A plan of care for Potential for impaired skin integrity related to incontinence [inability to control bowel and bladder function] and impaired mobility, dated 5/18/2021, contained an intervention listed for House Barrier Ointment [a topical cream used to prevent skin breakdown], initiated on 6/8/2021. An Order Summary Report, indicated a physician's order, dated 5/19/2021, for redness on coccyx [tailbone area], clean with Ns [normal saline - a sterile cleaning solution], pat dry, apply barrier cream, monitor if gets worse notify MD [MD - Medical Doctor] every shift until healed. A Treatment Administration Record (TAR), dated 6/1/2021-6/30/2021. The TAR indicated the physician's order for barrier cream to be applied to the redness on the coccyx every shift and to monitor for signs and symptoms of worsening. The TAR had no documented evidence to indicate the cream was applied for the day shift on 6/2/2021; evening shift on 6/2/2021, 6/3/2021, 6/4/2021, and 6/7/2021; and night shift on 6/4/2021 and 6/7/2021. A concurrent interview and record review was conducted with the Director of Nurses (DON) on 6/10/2021 at 12:45 p.m. The DON confirmed Resident 397 was frequently incontinent and had redness on the coccyx area on admission to the facility. The DON confirmed the resident required barrier cream as ordered by the physician and it was documented inconsistently on the administration record. A facility policy titled Skin Integrity, dated December 2016 was reviewed. The policy indicated, Care plan implementation of a preventative program to maintain skin integrity will be implemented at time of admission for at risk residents. The policy further indicated, Application of skin moisturizers/barriers to occur daily as necessary.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to permanently affix the cabinet containing con...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to permanently affix the cabinet containing controlled medications (medications that may lead to physical or psychological dependence) for destruction to a surface. This failure had the potential to result in the diversion of controlled medications, which could jeopardize the health and safety of both staff and residents. Findings: During a concurrent observation and interview on [DATE], at 2:15 p.m., with the Assistant Director of Nursing (ADON) and the Consultant Pharmacist (CP), in the Director of Nursing's office, the controlled medications for destruction were kept in a four-drawer tall filing cabinet in the bottom drawer. The outside of the drawer was locked, and there was a loose silver lockbox inside. The ADON and the CP both acknowledged that the filing cabinet was not permanently affixed to the wall or floor and was able to be moved. During a review of facility policy titled, 8.2 Disposal/Destruction of Expired or Discontinued Medications, revised [DATE], indicated Before destruction Facility should secure controlled substances under Double Lock at all times. 'Double Lock' can mean a locked cabinet in a locked room or a double locked cabinet. Double Lock can also mean a sealed container in a locked cabinet or room until the sealed container is picked up by a licensed waste disposal company. The facility policy did not reflect current federal regulatory standards which stated, The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse .

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment when the facility laundry room was observed to have a water leak, nonfunctional sinks, c...

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Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment when the facility laundry room was observed to have a water leak, nonfunctional sinks, corroded walls, and flooring in disrepair. This failure had the potential to cause injury/harm to laundry room staff, and caused resident's linens and personal items to be washed in an unsanitary environment. Findings: A concurrent observation and interview was conducted of the facility laundry room on 6/9/2021 at 2:18 p.m., with the Housekeeping Supervisor (HS). Two sinks were present on the wall adjacent to the industrial-sized wash machines. HS attempted to turn on the water in both sinks, and no water came out of either faucet. HS stated maintenance was just in here, and was not sure why the water was not working. In the same observation and interview, a large section of drywall below the sinks was observed to have wet a large wet spot. A section of the drywall near the floor was observed to be corroded with sections missing. A black substance was observed in a large puddle of water collecting below the sink area on the floor. Large sections of the flooring was broken and/or missing, exposing the concrete subfloor below. HS stated she was not sure why the floor was wet, but the wall and floor had been like that, for approximately six to seven months. A concurrent observation and interview was conducted of the facility laundry room on 6/9/2021 at 2:28 p.m., with Plant Operations Manager (POM) and the Infection Preventionist (IP). POM acknowledged the wet floor and turned a dial in the wall to allow water to run in the sink. POM stated, I just fixed the plumbing. IP also acknowledged the large puddle of water, put his hand on the drywall below the sink and stated the wall was soaked. The POM walked to the access area behind the wall and stated I see the problem, a pipe is broken. IP confirmed a large section of pipe was broken. An interview was conducted with the facility Administrator on 6/09/21 at 3:31 p.m. The Administrator acknowledged the water on the floor, the wet and missing sections of drywall, and the flooring in disrepair, and stated they were working to fix them.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to follow infection control guidelines for 4 residents for a census of 105, when: 1) Licensed Vocational Nurse 1 (LVN 1) did not...

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Based on observation, interview, and record review, the facility failed to follow infection control guidelines for 4 residents for a census of 105, when: 1) Licensed Vocational Nurse 1 (LVN 1) did not sanitize (to clean or disinfect) a small bin used to carry her blood pressure cuff (a medical device that wraps around the arm to measure blood pressure), pulse oximeter (a medical device used to measure oxygenation of red blood cells), and thermometer after they were used on Resident 62 and placed back into the bin; 2) LVN 1 touched a plastic drinking cup inside the rim with bare hands and Resident 11 drank from the cup; 3) LVN 2 did not change gloves and performed hand hygiene between administering an inhalation medication and eye drops to Resident 58; 4) LVN 3 touched a small plastic medication cup inside the rim with bare hands, which made contact with Resident 23's mouth; and 5) LVN 3 did not perform hand hygiene after doffing (removing) gloves. These failures had the potential to spread infection among residents and staff. Findings: 1) During a medication administration observation on 6/8/2021 at 7:58 a.m., LVN 1 gathered vital signs (clinical measurements that indicate the state of a person's essential body functions) from Resident 62 and placed the used blood pressure cuff, pulse oximeter, and thermometer into a small bin to carry them. LVN 1 then removed the soiled objects, cleaned them with disinfecting wipes, and placed them back into the small bin without disinfecting the bin. During an interview with LVN 1 on 6/8/2021 at 12:41 p.m., she acknowledged that the bin should be cleaned between uses and per resident. During an interview with the Infection Preventionist (IP) on 6/8/2021 at 1 p.m., he stated that the little boxes on the top of the medication carts should be cleaned between uses and/or residents. A review of the, Infection Prevention Manual for Long Term Care, (undated), the, Cleaning, disinfection, and sterilization, section indicated, Supplies and equipment will be cleaned immediately after use. 2) During a medication administration observation on 6/8/2021 at 8:08 a.m., LVN 1 used her bare hands to grab a plastic drinking cup inside the rim of it, pour water into the cup, and administer it to Resident 11. During an interview with LVN 1 on 6/8/2021 at 12:41 p.m., she stated she was not aware of another way to grab the cups when they are stacked together. During an interview with the IP on 6/8/2021 at 1 p.m., he agreed that cups should not be handled by the rim from which a resident would drink. 3) During a medication administration observation on 6/8/2021 at 8:31 a.m., LVN 2 administered [Brand Name] inhalation medication to Resident 58. She then asked Resident 58 to swish water in his mouth and spit it into a cup. After, LVN 2 proceeded to administer eye drops in Resident 58's eyes without doffing her gloves, performing hand hygiene, and donning (to put on) new gloves between medication administrations. During an interview with LVN 1 on 6/8/2021 at 1:05 p.m., she acknowledged that gloves should have been changed and hand hygiene should have been performed between the two medication administrations. During an interview with the IP on 6/8/2021 at 1 p.m., he stated gloves should be changed frequently and hand hygiene should be performed more often. A review of facility policy titled, Hand Hygiene, revised November 2017, stated, Staff must perform hand hygiene (even if gloves are used) at a minimum: Before and after contact with the resident; . After contact with blood, bodily fluids . and, after removing personal protective equipment (e.g., gloves, gown, facemask). The policy further stated, Handwashing/ hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. 4) During a medication administration observation on 6/8/2021 at 11:30 a.m., LVN 3 gathered vital signs from Resident 23, removed her gloves, and grabbed a small plastic medication cup inside the rim with her bare hands. She then used the cup to administer medications to Resident 23. During an interview with LVN 3 on 6/8/2021 at 12:35 p.m., she acknowledged she should not touch medication cups by the rim. During an interview with the IP on 6/8/2021 at 1 p.m., he agreed that cups should not be handled by the rim where the resident would place their mouth to drink. 5) During a medication administration observation on 6/8/2021 at 11:30 a.m., LVN 3 changed gloves on three occasions without performing hand hygiene between each one. During an interview with LVN 3 on 6/8/2021 at 12:35 p.m., she acknowledged that hand hygiene should have been performed more often during her medication administration. During an interview with the IP on 6/8/2021 at 1 p.m., he stated gloves should be changed frequently and hand hygiene should be performed more often. A review of facility policy titled, Hand Hygiene, revised November 2017, stated, Staff must perform hand hygiene (even if gloves are used) at a minimum: Before and after contact with the resident; . After contact with blood, bodily fluids . and, after removing personal protective equipment (e.g., gloves, gown, facemask). The policy further stated, Handwashing/ hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections.

CAPITAL POST ACUTE

The Good

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The Ugly 63 deficiencies on record

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CAPITAL POST ACUTE

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