How many inspection deficiencies does PIONEER HOUSE have?

PIONEER HOUSE has 59 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at PIONEER HOUSE?

PIONEER HOUSE has a three-star staffing rating from CMS with 0.71 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 PIONEER HOUSE located?

PIONEER HOUSE is located in SACRAMENTO, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does PIONEER HOUSE have?

PIONEER HOUSE has 50 certified beds.

Who owns PIONEER HOUSE?

PIONEER HOUSE is a for profit - limited liability company facility and is part of the CYPRESS HEALTHCARE GROUP chain.

What questions should families ask when visiting PIONEER HOUSE?

Families visiting PIONEER HOUSE 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 PIONEER HOUSE compare to other nursing homes?

PIONEER HOUSE 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.

PIONEER HOUSE

Name: PIONEER HOUSE
Address: 415 P STREET, SACRAMENTO, CA, 95814, US
Telephone: (916) 442-4906
Rating: 2.0

415 P STREET, SACRAMENTO, CA 95814 · (916) 442-4906

For profit - Limited Liability company 50 Beds CYPRESS HEALTHCARE GROUP Data: November 2025

Trust Grade

35/100

#880 of 1155 in CA

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PIONEER HOUSE nursing home in SACRAMENTO, CA - Photo 1 of 2

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Last Inspection: November 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Pioneer House in Sacramento has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #880 out of 1155 in California, placing it in the bottom half of nursing homes in the state, and #35 out of 37 in Sacramento County, showing limited local options for better care. Although the facility has improved from 13 issues in 2024 to 3 in 2025, it still has a high total of 59 concerns, which could pose potential harm to residents. Staffing is average with a 3 out of 5 rating, and the turnover rate is 47%, which is consistent with the state average. Notably, there are no fines on record, and the facility has good RN coverage, exceeding that of 81% of California facilities. However, specific incidents of concern include a dietary aide failing to practice proper hand hygiene while washing dishes, improperly stored food items that could lead to cross-contamination, and unsecured dumpsters that pose a risk for pest infestations. While there are some strengths, families should carefully weigh these serious issues when considering Pioneer House for their loved ones.

Trust Score: F
In California: #880/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for California. RNs are trained to catch health problems early.
Violations: 59 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 13 issues

2025: 3 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below California average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 47%

Near California avg (46%)

Higher turnover may affect care consistency

Chain: CYPRESS HEALTHCARE GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 59 deficiencies on record

Sept 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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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 protect the rights to be free from physical abuse for two of four sampled residents (Resident 2 and Resident 3), when: 1. Resident 1 entered Resident 2's room, touched Resident 2's belongings, ate his food, and swung her arms at Resident 2 when Resident 2 tried to intervene; and2. Resident 1 approached Resident 3 in the dining room and hit her on the back. These failures resulted in Resident 2 and Resident 3 sustaining pain and injury from physical contact and voicing their safety concerns.Findings:1. During a review of Resident 1's admission Record (AR), dated 9/5/25, the AR indicated Resident 1 was admitted to the facility in mid-2025 with diagnoses which included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and dementia with behavioral disturbance (a condition where cognitive decline is accompanied by significant behavioral changes). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 7/14/25, the MDS indicated Resident 1 had severe impaired cognition. During a review of Resident 1's care plan (CP), initiated on 8/25/25, the CP indicated, [Resident 1] has a change in condition: pt [patient] hit another resident.Resident's change in condition will improve or resolve by next review. During a review of Resident 1's CP, initiated on 6/9/25, the CP indicated, [Resident 1] at risk for altered nutritional status r/t [related to]: dementia, wanders around facility & snacks often. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for August of 20025, the MAR indicated, Monitor patient Q shift [every shift] for wandering.Start date 06/09/2025. During a review of Resident 1's Nursing Progress Notes (NPN), dated 8/29/25 at 7:30 p.m the NPN indicated, [At] 1930 [Resident 2] called staff that this [Resident 1] was touching all of his belongings and this res tried to scratch him, and [Resident 2] tried stopping this [Resident 1] and came outside the room and asked for staff help. Per [Resident 1] I don't know, no, I don't remember. Staff immediately redirected the [Resident 1]. Upon assessment [Resident 1] alert and verbally responsive to care. During a review of Resident 2's AR, dated 9/5/25, the AR indicated Resident 2 was admitted to the facility in mid-2025 with diagnoses which included depression and chronic pain. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had intact cognition. During a review of Resident 2's NPN, dated 8/29/25 at 7:30 p.m., the NPN indicated, [At] 1930 [Resident 2] called this writer that someone [Resident 1] is in his rm [room] touching all his belongings and eating his chips and that [Resident 1] tried to scratch him when he was trying to let her stop what [Resident 1's] been doing. This writer went to the room and saw [Resident 1] picking up the chips on the floor and eating it.skin check was done on [Resident 2], slight redness noted on [Resident 2's] right neck. [Resident 2] asked for a PRN [as needed pain medication]. During a concurrent observation and interview on 9/5/25 at 9:40 a.m. in Resident 2's room, Resident was alert and verbally responsive, and stated that about five days ago, as he entered his room, he saw his grocery bags open and Resident 1 eating his [Resident 2's] chips. Resident 2 stated that he asked Resident 1 to get out of his room, but Resident 1 approached him and started swinging her arms at him. Resident 2 further stated that Resident 1 moved her arms erratically and hit him on his face and neck, and it was burning afterwards, but he backed out of the room and called for help. Resident 2 further stated that he felt that he was abused, and he was scared whenever Resident 1 was around. Resident 2 stated that he had to refrain from activities more and stay in his room to ensure his safety and the security of his belongings. During a phone interview on 9/5/25 at 11:06 a.m. with Licensed Nurse 1 (LN 1), LN 1 indicated that on 8/29/25 he was in a different room providing care to another resident as Resident 2 called for help, and stated Resident 1 was in his room. LN1 stated that when he came to Resident 2's room, he saw Resident 1 inside the room eating chips. LN 1 further stated that Resident 2 was stating that Resident 1 tried scratching him. LN 1 stated that when he assessed Resident 2, he saw redness on his neck. LN 1 confirmed that Resident 1 had instances of aggression and was known to wander around. During an interview on 9/5/25 at 1:59 p.m. with the Director of Nursing (DON), the DON confirmed that Resident 1 was known to be moving around and entering different residents' rooms, and she had prior incidents of aggressive behavior. The DON confirmed that Resident 1 entered Resident 2's room on 8/29/25, and Resident 2 was found with redness to the neck after the incident. The DON further stated that she expected residents to be free from physical and verbal abuse. 2. During a review of Resident 3's AR, dated 9/5/25, the AR indicated Resident 3 was admitted to the facility in the middle of 2024 with diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and depression. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 had a moderate cognitive impairment. During a review of Resident 1's NPN, dated 9/4/25 at 14:20, the NPN indicated, Staff notified that [Resident 1] slapped back of the other res head [Resident 3] . During a review of Resident 3's NPN, dated 9/4/25, the NPN indicated, [At] 1420 Staff notified that other res [Resident 1] was touching res bag, activity director tried redirecting [Resident 1], when res [Resident 3] tried stopping res [Resident 1] to stop touching her belongings, [Resident 1] slightly slapped back of [Resident 3's] head, other staff immediately came to redirect [Resident 1].[Resident 3] c/o [complained of] pain to back of head, administer PRN [as needed] pain med. During an interview on 9/5/25 at 10:35 a.m. with the Activities Director (AD), the AD stated that yesterday, around 2:30 p.m. in the dining room, Resident 3 was sitting on a wheelchair as Resident 1 came behind her and slapped her on the back of her head. The AD further confirmed that Resident 1 had prior incidents of aggression and slapping and was under special monitoring. During a concurrent observation and interview on 9/5/25 at 10:51 a.m. with Resident 3 in the dining room on her wheelchair. Resident 3 was able to communicate using words and short phrases, and with the help of hand gestures. Resident 3 indicated that yesterday she was hit on the back by another resident, and she was still hurting, and her hand was also hurting. Resident 3 stated that she did not feel safe and wanted to go home. During a review of Resident 4's AR, dated 9/5/25, the AR indicated Resident 4 was admitted to the facility in the late 2024 with diagnoses which included paraplegia (loss of movement in the legs), and end stage renal disease (ESRD - irreversible kidney failure). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had intact cognitive abilities. During an interview on 9/5/25 at 10:20 a.m. in Resident 4's room, Resident 4 stated that yesterday he saw in the dining room how Resident 3 was sitting in the wheelchair and Resident 1 walked up to her and started touching her bags, and when Resident 3 told her to stop, Resident 1 slapped Resident 3 on the back with a loud, audible slap. Resident 4 further stated that Resident 1 often wandered around unsupervised, entering other residents' rooms, and that he [Resident 4] often had to stay in his room's entrance monitoring to make sure that Resident 1 did not enter. Resident 4 further stated that the facility did not provide enough staff to sufficiently supervise Resident 1. During an interview on 9/5/25 at 11:18 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 indicated Resident 1 was known to have wandered and had aggressive behavior, and she was on special monitoring by staff, but she was not monitored at all times. CNA 1 further stated she had to get Resident 1 out of other residents' rooms on a daily basis. During an interview on 9/5/25 at 11:56 a.m. with LN 3, LN 3 confirmed that Resident 1 was known to wander around and had instances of aggression towards other residents. LN 3 stated that direct care staff were busy providing care to other residents, and the facility did not provide sufficient staff to monitor Resident 1 at all times. During an interview on 9/5/25 at 1:59 p.m. with the Director of Nursing (DON), DON confirmed that Resident 1 was known to be moving around and entering different residents' rooms, and she had prior incidents of aggressive behavior. The DON confirmed that Resident 1 was seen physically touching Resident 3 in the dining room yesterday. The DON further stated that she expected residents to be free from physical and verbal abuse. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:. b. other residents.

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 F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure one out of two sampled residents, Resident 1, was provided a therapeutic diet as ordered by the physician. This failure had the potential for Resident 1 to experience malnutrition and weight loss. Findings: A review of Resident 1's admission Record indicate Resident 1 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (a broad term for any brain disease that alters brain function or structure) and dysphagia (difficulty swallowing). A review of Resident 1's Order Summary Report (OSR, physician orders) indicated an order for a regular diet, soft and bite sized texture (foods that are soft, and chopped into bite-sized pieces) with a start date of 2/7/25. During a concurrent observation and interview on 2/18/25 at 12:05 p.m. in Resident 1's room, with Certified Nurse Assistant (CNA) 1, Resident 1's lunch and lunch tray card were observed. Resident 1's tray card indicated mince moist (foods that are soft, moist and minced to size) as the diet. Resident 1's meal included a green food item that was pureed (a food item that is smooth and free of lumps, holds their shape, without being too firm or sticky and will not weep). Resident 1 stated, I don't know what this green stuff is, I'm supposed to be getting a different diet, not this pureed stuff. CNA 1 confirmed Resident 1's lunch included an unidentified pureed food item and a lunch tray card that indicated Resident 1 should be receiving foods with a mince moist texture. CNA 1 confirmed Resident 1's lunch tray card and pureed food item on the lunch tray was incorrect. During a concurrent observation, interview and record review on 2/18/25 at 12:54 p.m. with Licensed Nurse (LN) 1, Resident 1's tray card, meal served and OSR were reviewed. LN 1 confirmed Resident 1's diet order was incorrect and did not match the lunch tray card or the food item that was served. During a concurrent observation, interview and record review on 2/18/25 at 2:02 p.m. with [NAME] (CK) 1, Resident 1's tray card, meal served and OSR were reviewed. CK 1 confirmed Resident 1's diet order did not match the lunch tray card or the food item that was served. CK 1 stated, Those diets [the mince moist and soft, bite sized] are two different orders. During a concurrent observation, interview and record review on 2/18/25 at 2:32 p.m. with the Director of Nursing (DON), Resident 1's tray card, meal served and OSR were reviewed. The DON confirmed Resident 1's diet order did not match the tray card or the food that was provided during lunch. The DON acknowledged they should have provided the correct diet that was indicated on the physician's order. A review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised October 2017, indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes .Diet order should match the terminology used by the food and nutrition services department.

Jan 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 F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe discharge for one of three sampled residents (Resident 1), when Resident 1 was discharged to a room and board facility (a home that offers housing accommodations, may offer meals, but does not provide personal care services) and did not have care needed for activities of daily living (ADL). This failure resulted in Resident 1 living in an unsafe environment that could not meet Resident 1's needs which prompted a transfer to the hospital. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in September 2024 with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke- disrupted blood flow to the brain causing brain tissue death), right leg above the knee amputation, bipolar disorder (mental health condition causing extreme mood swings that include emotional highs and lows) and chronic obstructive pulmonary disease (lung disease that blocks air flow and makes it difficult to breathe). A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool). Cognitive Patterns, dated 12/18/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's MDS, Functional Abilities, dated 12/18/24, indicated Resident 1 used a wheelchair, required substantial assistance for toileting, showering, dressing, bed mobility, and transfers. Resident 1's MDS, Bladder and Bowel, dated 12/18/24, indicated Resident 1 was always incontinent of bladder and bowel. A review of Resident 1's MDS, Functional Abilities-Discharge, dated 1/7/25, indicated Resident 1 required substantial assistance for toileting, showering, dressing, bed mobility, and transfers. A review of Resident 1's MDS, Bladder and Bowel, dated 1/7/25, indicated Resident 1 was always incontinent of bladder and bowel. A review of Resident 1's PT [Physical Therapy] Discharge Summary, dated 10/7/24, indicated Resident 1 was minimum assist for bed mobility and moderate assist for transfers. A review of Resident 1's OT [Occupational Therapy] Discharge Summary, dated 10/10/24, indicated Resident was minimum assist for lower body dressing and moderate assist for toileting. A review of Resident 1's Order Summary Report indicated order dated 1/7/25, Resident may discharge with current medications and belongings when ready. A review of Resident 1's Progress Note, dated 1/7/24, indicated .Resident is set to discharge today 01/07/25, with all proper orders in place. This writer met with resident to ensure she is prepared to be discharged and answer any questions if any .Resident will discharge to [name] Room & Board .Resident declined all HH [Home Health] Services . During an interview on 1/24/25 at 1:40 p.m. with the Director of Nursing (DON), the DON stated Resident 1 was discharged to room and board on 1/7/25 with Resident 1's consent. The DON stated the Social Service Director (SSD) handled the discharge. During an interview on 1/24/25 at 1:48 p.m. with the SSD, the SSD stated Resident 1 decided to move to a room and board. The SSD stated the manager from a room and board came to talk to the resident on 1/6/25 and Resident 1 went to the room and board on 1/7/25. The SSD stated Resident 1 was able to transfer to wheelchair with help using a transfer pole. The SSD stated she was not present in the room when the room and board manager came to interview Resident 1 and was not aware what Resident 1 told the room and board manager about ability to care for himself or what assistance was needed. The SSD stated Resident 1's insurance and healthcare provider was arranging for In Home Supportive Services (IHSS- program that provides in home assistance to eligible aged, blind, or disabled individuals). The SSD acknowledged she did not document her conversation on 1/6/25 with the room and board manager. During a telephone interview on 1/24/25 at 2:41 p.m. with the Room and Board Representative (RBR), the RBR stated he met with Resident 1 on 1/6/25 who indicated he could stand and mobilize with the wheelchair. The RBR stated he relied on Resident1's assessment of his abilities. The RBR stated that Resident 1 reported he had applied for IHSS. The RBR stated he relied on Resident 1's reporting that IHSS had been applied for and was going to provide care. The RBR stated he believed that IHSS was in place based on what Resident 1 told him. The RBR stated he expected IHSS to be in place when Resident 1 arrived, but no IHSS caregiver came to see him. The RBR stated that in a room and board the resident needs to be very independent. The RBR stated, In my opinion, [Resident 1] needs help. The RBR stated Resident 1 was managing on day 1 and day 2, not doing well on the 3rd day, then on the 4th day, Resident 1 was not able to care for self and went to the hospital. During an interview on 1/24/25 at 2:53 p.m. with the SSD, the SSD stated she was aware that IHSS was not in place when Resident 1 was discharged to the room and board. The SSD stated she was not present during Resident 1's discussion with the RBR on 1/6/25 but relied on a conversation with the RBR on 1/6/25 that Resident 1 had the assistance needed. The SSD stated Resident 1 indicated the RBR could provide the help he needed. The SSD stated she did not confirm IHSS was in place. During an interview on 1/24/25 at 3:09 p.m. with Licensed Nurse (LN) 1, LN stated Resident 1 was able to transfer self with much assistance. LN 1 stated if discharged to room and board, and no one to help, he should have stayed in the facility. During an interview on 1/24/25 at 3:18 p.m. with LN 2, LN 2 stated Resident 1 was dependent for transfers, for changing briefs due to incontinence, and needed help with ADLs. During a concurrent interview and record review on 1/24/25 at 3:33 p.m. with the DON, the DON acknowledged that Resident 1's MDS on 1/7/25 indicated Resident 1 needed substantial assistance for transfers and ADL care. The DON acknowledged that the SSD did not document on 1/6/25 any discussion with the RBR regarding Resident 1's functional ability and the room and board's ability to provide care. The DON acknowledged that IHSS was not confirmed prior to Resident 1's discharge on [DATE]. The DON stated, IHSS should have been confirmed prior to discharge. Review of the facility's Policy and Procedure (P&P) titled Transfer or Discharge, Preparing a Resident for, revised 12/16, indicated .Residents will be prepared in advance for discharge .A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and /or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility . Review of the facility's P&P titled Discharging the Resident, revised 12/16, indicated .The resident should be consulted about the discharge .If the resident is being discharged home, ensure that resident and /or responsible party receive teaching and discharge instructions .

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to make sure that an inventory of personal belongings sheet was completed, and a copy was given upon admission to one of three sampled residents (Resident 1.) This failure had the potential for the resident ' s personal belongings being lost or stolen. Findings: During a review or Resident 1 ' s admission Record (AR), the AR indicated, Resident 1 was admitted in late 2024 with diagnoses which included anxiety. During a review of Resident 1 ' s Inventory of Personal Effects (IPE – inventory sheet), dated 12/2/24, the IPE did not have the Resident 1 ' s signature on the ' Certification of Receipt ' portion of the document. During a review of Resident 1 ' s closed record, there was no documented evidence that Resident 1 signed the inventory sheet and was given a copy upon admission on the nurse ' s notes or admission record. During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) Section C, dated 12/5/24, the MDS indicated, Resident 1 was cognitively intact. During a telephone interview on 12/26/24 at 11:00 a.m.with Resident 1, Resident 1 stated that an inventory of his belongings was not done upon his admission, and he was not given a copy of the inventory sheet during his admission. During an interview on 12/26/24 at 12:26 p.m.with Director of Nursing (DON), DON stated that during admission an inventory sheet for resident ' s belongings should be done and either the resident or responsible party for the resident would sign it and a copy would be given to them. During an interview on 12/26/24 at 2:45 p.m.with Director of Nursing (DON), DON stated that the facility cannot provide a documentation that Resident 1 was given a copy of the inventory sheet upon admission. The DON indicated there wasno documentation on the chart or in the notes. During a review of the facility ' s policy and procedure (P&P) titled, Admitting the Resident: Role of the Nursing Assistant, dated September 2013, the P&P indicated, When all personal items have been inventoried and recorded on the Inventory of Personal Effects Record, sign your name and title and instruct the family member that witnessed the inventory to also sign the form .provide the resident and/or family member with a copy of the completed and signed inventory record.

Dec 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect two sampled residents (Resident 3 and Resident 2) from abuse, when, Resident 3 was verbally threatened and punched by Resident 1 in the face and neck and Resident 2 experienced multiple episodes of sexual inappropriateness from Resident 1, who had a known history of verbal aggression and sexual inappropriateness. These failures resulted in Resident 3's physical injury and emotional distress and feeling dirty for Resident 2. Findings: A review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Program, revised 4/2021, indicated, Residents have the right to be free from abuse .This includes . freedom from . verbal, mental, sexual or physical abuse. According to the admission record, the facility admitted Resident 1 in the fall of 2024 with diagnoses which included multiple fractures of left leg. A review of Resident 1's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 10/3/24 indicated the resident scored 15 out of 15 on the assessment and was cognitively intact. A review of Resident 1's Order Summary Report' contained two physician's orders dated 9/27/24 and 11/12/24 for psychiatric evaluation. A review of Resident 1's care plan dated 10/31/24 and revised 12/11/24 indicated, The resident is/has potential to be sexually inappropriate to staff .to other residents r/t [related to poor impulse control .The resident will verbalize .need to control behavior. The interventions included, monitoring behaviors, documenting observed behaviors and attempted interventions, monitoring resident's whereabouts every 30 minutes, and arrange for psychiatrist consult. A review of Resident 1's care plan dated 11/15/24 indicated, The resident is reported to be verbally aggressive and threatened peer .The resident will not harm self or others. The interventions directed staff to monitor for irritability . monitor/document any s/sx [signs and symptoms] of resident posing dangers to others . intervene before agitation escalates . A review of the nursing progress notes (NPN) indicated Resident 1 had been having history of multiple episodes of verbal and physical aggression and sexually inappropriate behaviors. There was no documented evidence that the resident had been referred or had been evaluated by a psychiatrist as was ordered by the resident's physician on 9/27/24 and 11/12/24 and as indicated in Resident 1's care plan. A review of the NPN dated 10/31/24, at 11:15 a.m., indicated Resident 1 made inappropriate sexual comments toward a female staff. A review of the NPN dated 11/8/24, at 3:42 p.m., indicated that Resident 1 was noted with increased behaviors . continues to make false, accusatory, and paranoid/delusional statements . The NPN indicated the physician was notified and the psychiatric consult was requested. A review of the social services note dated 11/15/24, at 11:56 a.m., indicated that Resident 1 has had verbal altercation with another resident from across his room and continued to go back to his room and is threatening the other resident, all verbal only. A review of the NPN dated 12/9/24, at 7:22 p.m., indicated that Resident 1 was witnessed by staff entering Resident 3's room. Per NPN, Resident 1 started yelling at Resident 3, and then was noted . charging toward [Resident 3], hitting him [Resident 3] in the head. A review of Resident 1's 'Change in Condition Evaluation' dated 12/10/24 at 3:29 p.m., indicated, Resident [1] made unwanted sexual advances multiple times towards another resident. A review of the admission record indicated the facility admitted Resident 3 earlier this year with multiple diagnoses which included hemiplegia (total paralysis of the arm, leg, and trunk of the left side of the body). A review of Resident 3's quarterly BIMS assessment dated [DATE] indicated that Resident 3 scored 15 out of 15 and was cognitively intact. A review of the NPN note dated 12/9/24, at 7:09 p.m., indicated Resident 3 was verbally threatened and then was hit in the head by Resident 1. The nurse documented that Resident 3 was assessed after the incident and complained of severe headache. Per NPN, Resident 3 rated the pain as an 8 on a scale from 1 to 10, where 8 indicated a severe pain. A review of Resident 3's care plan dated 12/9/24 indicated, Peer to Peer - Resident received episode of physical aggression by another resident. A review of the admission record indicated the facility admitted Resident 2 earlier this year with multiple diagnoses which included left-sided hemiplegia and above the knee amputation (AKA- surgical removal of the portion of right leg above the knee). A review of Resident 2's BIMS dated 9/22/24 indicated that Resident 2 scored 13 out of 15 and was cognitively intact (had sufficient judgement). A review of Resident 2's care plan dated 10/6/24 indicated the resident used anti-anxiety medication related to anxiety disorder. One of the interventions directed staff to monitor the resident for safety. A review of Resident 2's 'Change in Condition' document dated 12/10/24, at 4:04 p.m., indicated, Resident verbalized to charge nurse .about 6-8 days ago [Resident 1] came to me again and made sexual advances towards me. He said, 'I want you to come lay in my bed so I can .you and you can suck my .Lately nothing has happened but 3-4 more advances .I didn't want to do it .I didn't tell anyone because I was uncomfortable. A review of Resident 2's 'PSYCHO-SOCIAL/WELL BEING' care plan dated 12/10/24 indicated, [Resident 2] recently experienced unwanted sexual advances. At risk for altered wellbeing [and] reduced sense of well-being . The interventions included, Daily psychosocial visit from Social Services for next 3 days & [and] as needed . Determine if mood endangers the resident and intervene if necessary .Identify relationships that the resident could draw on. The care plan did not contain any interventions to show how the facility will ensure Resident 2's safety. During an interview on 12/19/24, at 1:20 p.m., Restorative Nursing Assistant (RNA 1) stated she and another staff assisted Resident 3's roommate with care when they overheard Resident 1 in the hall screaming and yelling loudly calling Resident 3's name. RNA 1 stated both staff attempted to unsuccessfully calm down Resident 1 before he quickly barged into room and hit Resident 3 in the head. RNA 1 stated Resident 3 did not argue or talk back during all this time and it all happened so fast, the staff was not able to stop Resident 1 from hitting Resident 3. During a continued interview with RNA 1 on 12/19/24, at 1:20 p.m., RNA 1 stated that she was aware of Resident 1's inappropriate sexual advances towards Resident 2. RNA 1 described Resident 2 as alert and oriented. RNA 1 stated that a few days after Resident 2 reported the alleged incident, the resident approached RNA 1 and talked about the incident with Resident 1. RNA 1 stated that Resident 2 verbalized to her that she was weary of [Resident 1's] behaviors. During an observation and interview on 12/19/24, at 1:35 p.m., Resident 3 was observed lying in his bed. Resident 3 stated he was eating dinner when he heard Resident 1 yelling loudly. Resident 3 continued, I don't remember what he was saying, it was very quick. He came here and hit me in the face and my neck with his fist . It hurt bad. Resident 3 demonstrated the area on his face and neck where he was hit and continued, That guy is always mean and angry. We were in the same room before, across the hall and he always yelled at me. He even threatened to kill me, said he is going to smash my head with a fan. Resident 3 added that he complained about Resident 1 and the facility moved him to a different room. Resident 3 stated, Every time I hear his voice I cringe because I'm still scared of him. I cannot walk and cannot defend myself. I am safe when he's not around. During an interview with CNA 1 on 12/19/24, at 1:50 p.m., CNA 1 stated Resident 1 had lots of behaviors and described him as very short tempered and irritable. CNA 1 stated Resident 1 had frequent arguments with Resident 3 in the past when they were roommates. CNA 1 stated that Resident 1 had history of saying sexual things and making sexual advances towards female staff and the staff was aware of it. During a concurrent interview and record review on 12/19/24, at 2:10 p.m., the Assistant of Director of Nursing (ADON) validated that on 12/9/24 Resident 1 yelled at Resident 3 and then physically assaulted him in the face. The ADON stated she was aware that Resident 1 and Resident 3 were not getting along when they were roommates. The ADON stated was not aware of Resident 1's threats to Resident 3 and not aware if they had physical altercations prior. The ADON stated she was not sure what happened .and what triggered to move [Resident 3] to a different room. During a continued interview on 12/19/24, at 2:10 p.m., the ADON stated she was present when Resident 2 reported the sexual allegation incident with Resident 1 on 12/10/24. The ADON stated that Resident 2 did not report alleged encounter with Resident 1 right away and reported the incident 6 - 8 days after the incident happened. The ADON stated that Resident 2 reported that Resident 1 made 3 or 4 more advances after the first incident and put his arm around Resident 1 and that she [Resident 2] was uncomfortable with that. The ADON added, I asked . if she was scary of him and if she felt safe. She said she was okay. During an interview on 12/19/24, at 2:20 p.m., Resident 2 stated that Resident 1 had been having inappropriate conversations and sexual suggestions on many occasions when they were in the hall, dining room or outside. Resident 2 stated, [Resident 1] would put his arm around me and even tried to put his hand into my pants . I've told him to stop, but he did not listen .I did not like what he was doing . I didn't want to talk to anyone about it because it was so gross, and I felt dirty. Resident 2 stated she decided to report Resident 1 when the incidents became more frequent. Resident 2 continued, They moved him away from me, but he continues talking to me and even yelled at me when I was outside . I'm okay if other people around but not comfortable to be alone with him. Resident 2 stated she did not report to anyone that Resident 1 continues talking to her inappropriately when they are outside after she reported it first on 12/10/24. A joint interview with Resident 2, Social Services Director (SSD), and Administrator (ADM), was conducted on 12/19/24, at 2:40 p.m. SSD stated that Resident 1 was moved to a different hall and had been on frequent monitoring every 30 minutes since the incident was reported. The SSD and ADM assured that the staff did not observe any further incidents of Resident 1 being inappropriate. During the interview, Resident 2 explained that Resident 1 continues talking inappropriately when they are outside and when there are no other residents around and added that she did not talk to anyone about this. During an interview on 12/19/24, at 2:55 p.m., Resident 1 was asked about the incident of physical aggression toward Resident 3. Resident 1 stated, We were not getting along when we were living in the same room; he always called me words and racial slurs . That day I was in the hall talking on the phone . He overheard me and started calling me . word again .I lost it . went to his room and slapped him. During a continued interview on 12/19/24, at 2:55 p.m., Resident 1 was asked regarding alleged incident with Resident 2. The resident denied the allegations and stated, it's false, it's all lie. I have never said or done anything like that. During a joint interview with Director of Nursing (DON) and ADM on 12/19/24, at 3:25 p.m., the DON validated that Resident 1 had history of verbal altercations with another resident prior to the incident with Resident 3. The DON acknowledged that Resident 1 had a known episodes of sexually inappropriate behaviors toward the staff, but no incidents towards the residents prior to Resident 2's report. The ADM stated the facility will implement additional steps to ensure Resident 2's safety and the ADM added, It is our goal for everyone to feel safe here. We are responsible for protecting our residents. A review of the facility's policy titled, Safety and Supervision of Residents, with the revision date of 7/2017, indicated, Resident safety and supervision . are facility-wide priorities . Resident supervision is a core component of the systems approach to safety.

Nov 2024 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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews the facility failed follow physician orders for one resident out of five sampled residents (Resident 1) when Resident 1 ' s weight was not measured at admission. This failure had the potential for facility to be unable to recognize if Resident 1 experienced unexpected weight loss. Findings: A review of Resident 1 ' s admission records indicate Resident 1 was admitted to the facility in October 2024 with diagnoses including dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (critical deficiency in protein and calories in the diet). During a review of Resident 1 ' s Order Summary Report (OSR, physician orders), dated 10/31/24, an order for admission weight was noted. During a concurrent interview and record review on 11/26/24 at 4:03 p.m., with the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Nurse Consultant (NC), the following documents were reviewed: 1. Resident 1 ' s OSR, 2. Progress Notes, dated 10/31/24 – 11/17/24 and, 3. Weights and Vitals Summary, dated 10/31/24 – 11/13/24. The ADON, DON and NC confirmed there was no admission weight for Resident 1 per the OSR and no way to track weight loss. A request for the facility ' s policy and procedure (P&P) for their admission Assessment, which included documentation of a resident ' s admission weight was requested on 11/26/24 and 11/27/24. The facility did not provide the requested P&P.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews the facility failed to ensure one resident out of five sampled residents (Resident 1), who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene, when Resident 1 did not receive showers as scheduled. This failure had the potential for Resident 1 to experience a decrease in hygiene and psychosocial wellbeing. Findings: A review of Resident 1 ' s admission records indicate Resident 1 was admitted to the facility in October 2024 with diagnoses including cerebral infarction (blood flow to the brain is blocked, causing brain cells to die) and muscle weakness. A review of Resident 1 ' s Order Summary Report (OSR, physician orders), dated 10/31/24, indicated Resident 1 had the capacity to understand and make his own health care decisions. During a review of Resident 1 ' s 48 Hour Baseline Care Plan, (a document that provides person centered instructions for a resident's care), dated 10/31/24, indicated Resident 1 was dependent on staff for grooming and hygiene care, needed the assistance of one to two staff members for bathing and had a preference for showers. A review of Resident 1 ' s Care Plan (a plan that outlines the type of care a resident needs and the steps nurses will take to meet them), dated 10/31/24, indicated Resident 1 was at risk for altered ADLs related to the cerebral infarction, with an intervention that included providing a shower or bathing at least two times a week. During a review of Resident 1 ' s Task: Bathing Performed, dated 10/31/24 to 11/16/24, indicated Resident 1 ' s bathing task was completed on 11/5/24 and 11/7/24. There were no bathing tasks completed from 11/8/24 to 11/16/24. During a concurrent interview and record review on 11/26/24 at 4:03 p.m., Resident 1 ' s 48 Hour Baseline Care Plan, Care Plan, and Bathing Tasks were reviewed with the Assistant Director of Nursing (ADON), the Director of Nursing (DON) and the Nurse Consultant (NC). The ADON, DON and NC confirmed Resident 1 was dependent on staff for grooming and hygiene needs and he did not receive showers as indicated. The CN stated, The CNA (Certified Nursing Assistant) should have told the nurse why that specific task wasn ' t done. A review of the facility ' s policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Nov 2024 6 deficiencies

CONCERN (D)

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews the facility failed to ensure one out of 16 sampled residents (Resident 21), maintained their right to retain and use personal possessions when staff were aware Resident 21's cell phone was taken without his permission. This failure resulted in the unrecovered loss of Resident 21's personal cell phone. Findings: A review of Resident 21's admission record indicated Resident 21 was admitted to the facility in March 2024 with diagnoses including intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and hemiplegia (complete paralysis) and hemiparesis (partial paralysis) to the left dominant side. During an interview on 11/13/24 at 10:23 a.m., in Resident 21's room, Resident 21 stated, They took my cellphone away a few months ago because I called 911 a couple of times because the nurse at night wouldn't come help me when I was in pain. When questioned where the cell phone was currently, Resident 21 stated, I don't know. During a concurrent interview and record review on 11/14/24 at 12:25 p.m. with the Social Services Director (SSD) and the Assistant Director of Nursing (ADON), Resident 21's Inventory of Personal Effects, dated 3/22/23 and Resident 21's progress notes were reviewed. The SSD confirmed Resident 21 was admitted to the facility with 1 Cell/Mobile phone and 2 Chargers as indicated on the resident's inventory sheet. A Nurse Practitioner Progress Note, dated 9/10/24 at 12:46 a.m. indicated, The fire fighters .took [Resident 21's] cell phone when he was not looking. When asked if the SSD knew where Resident 21's cell phone was currently, the SSD stated, The fire department took it months ago, but I don't know where it is now .I never followed up to see what happened to it [the cell phone] or where it ended up. The SSD confirmed this was a violation of the resident's right to have personal property. During a record review on 11/15/24 at 10:33 a.m., Resident 21's Care Plan (CP, a document that summarizes a person's health conditions, care needs, and current treatment) was reviewed. A focus statement dated 9/13/24 indicated, .Fire dept [sic] removed cell phone during one of their visits. No additional documentation was found that discussed the outcome or current location of Resident 21's cell phone. During an interview on 11/15/24 at 10:42 a.m. with the Director of Nursing (DON), the DON was questioned if she knew where Resident 21's cell phone was. The DON stated, I heard the fire fighters took it a while ago, I don't know where it is now. During a review of the facility's policy and procedure (P&P) titled, Personal Property, revised August 2022, the P&P indicated, Residents are permitted to retain and use personal possessions .Resident belongings are treated with respect by facility staff .The facility promptly investigates any complaints of misappropriation or mistreatment of resident property. During a review of the facility's P&P titled, Resident Rights, revised February 2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to .be free from misappropriation of property .retain and use personal possessions to the maximum extent . During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022, the P&P indicated, All reports of resident abuse (including injuries of unknown origin) .theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents .All allegations are thoroughly investigated. The administrator initiates investigations .Witness statements are obtained in writing, signed and dated .The investigator notifies the ombudsman that an abuse investigation is being conducted .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report .The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interviews and record reviews the facility failed to investigate and report an allegation of abuse for one out of 16 sampled residents (Resident 21), when Resident 21 notified a Licensed Nurse (LN) of an allegation of sexual and physical abuse, which included an injury of unknown origin. This failure caused Resident 21 to feel unsafe within the facility. Findings: A review of Resident 21's admission record indicated Resident 21 was admitted to the facility in March 2024 with diagnoses including intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and hemiplegia (complete paralysis) and hemiparesis (partial paralysis) to the left dominant side. During an interview on 11/13/24 at 10:38 a.m. in Resident 21's room, when asked if Resident 21 had concerns with the way the facility addresses his mood, behaviors, and care planning, Resident 21 stated, I keep telling them [I need help], I'm scared I'm going to die here .the staff don't care about me, they're going to let me die here .the [Social Services Director (SSD)] is supposed to help me, but she doesn't. I want to get out of here .they don't listen to me. During an interview on 11/15/24 at 8:53 a.m. with the Activity Director (AD) when asked how Resident 21's mood and activity participation were the AD stated, [Resident 21] would come to activities often when he first got here, he enjoyed the arts and crafts .he stated the Certified Nursing Assistants (CNAs) didn't get him up, but then when [Resident 21] was up, he wanted to go back to bed after a short period of time then [Resident 21] just didn't want to participate anymore. A record review of Resident 21's Behavior Note created 8/2/24 at 3:42 a.m. written by LN 4, indicated, .[LN 4] went to resident's room with 1 CNA for witness .Resident started to claim and shown a bruise purplish on his R posterior hand radial side. Approximately 3x3 cm. No noted open skin noted. Resident claimed that it was inflicted last night (8/1/2024 noc [night]) when he was being changed by 2 CNAs, he described the event as follows. When the CNAs are changing me (the female CNA), she was playing with my [anus] .and the male CNA held my arm down. This is why I have this (pointing to the bruise) . During an interview on 11/15/24 at 1:43 p.m., CNA 4 stated if a resident notified her of an incident of abuse, I would tell the nurse what happened .verbally tell the nurse or any supervisor .ask the person about the situation and then alert the nurse. CNA 4 indicated she would fill out paperwork if requested by the nurse and ask what else needs to be done. CNA 4 was unsure if an abuse binder is available. During an interview on 11/15/24 at 2:03 p.m., LN 2 stated, If I received an allegation of abuse from a resident, I would interview the resident, get details and names, if the resident was willing to tell me .I would notify the Director of Nursing (DON) and Administrator (ADM) .check the policy and procedure (P&P) for abuse reporting .complete a change of condition form, perform frequent checks on the resident .and initiate behavioral monitoring. LN 2 added, I'd let the state [California Department of Public Health (CDPH)] know of the allegation as soon as possible I know there's an abuse binder around here somewhere. During a concurrent interview and record review on 11/15/24 at 2:14 p.m. Resident 21's Behavior Note dated 8/2/24 was reviewed with the DON and ADM. The DON and ADM reviewed the Behavior Note and stated they were unaware of the abuse allegation. DON stated in regards to allegations of abuse, I expected staff to start the 'abuse protocol' . which included notifying the facility's Abuse Coordinator (ADM), complete an SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) and to fax it to the number on form .as well as notify myself and to monitor the resident .notify the Medical Director (MD) and assess for physical injury. The DON added she does not have access to the SOC 341 reports; the ADM does. The ADM stated, I would expect the incident to be reported to me immediately since I'm the abuse coordinator and to the proper authorities .I would complete an investigation with the CNAs named in the allegation, make sure a physical assessment is completed on the resident and file the SOC 341. During a phone interview on 11/15/24 at 3:35 p.m. with LN 4, LN 4 stated she was familiar with the resident and remembered the incident in question. LN 4 added, [Resident 21] reported to me that two CNAs were changing him and the female one was playing with his ass .I didn't see her doing that . and, I'm definitely a mandated reporter [person legally required to report suspicion of abuse or neglect to the relevant authorities] for the residents .for the bruise, I didn't know where he got it so I did a change of condition form .no, I did not do anything for the sexual abuse allegation, it was a non-emergency situation, he wasn't in respiratory distress or anything. When questioned further about the details of the incident LN 4 stated, I don't know when the allegation occurred .I just documented everything [Resident 21] said .I should have notified [DON] about the incident and allegations . A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised September 2022 indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents .All allegations are thoroughly investigated. The administrator initiates investigations .The administrator is responsible for keeping the resident and his/her representative (sponsor) informed of the progress of the investigation . The investigator notifies the ombudsman that an abuse investigation is being conducted .Within five (5) business days of the incident, the administrator will provide a follow-up investigation report.

CONCERN (D)

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

Deficiency F0675 (Tag F0675)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and record reviews the facility failed to ensure one out of 16 sampled residents (Resident 21), was provided with an environment that supported Resident 21's quality of life when Resident 21 received meals in polystyrene containers with plastic utensils. This failure resulted in Resident 21's lack of self-worth, self-esteem, and well-being. Findings: A review of Resident 21's admission record indicated Resident 21 was admitted to the facility in March 2024 with diagnoses including intracerebral hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain) and hemiplegia (complete paralysis) and hemiparesis (partial paralysis) to the left dominant side. During a concurrent observation and interview on 11/14/24 at 12:07 p.m., in Resident 21's room, Resident 21's lunch meal was served in a polystyrene container with plastic utensils. Resident 21 stated, I don't know why [meals are served in polystyrene with plastic utensils], they never told me, but I don't like it. They [staff] don't care about me; I'm going to die here. During a concurrent interview and record review on 11/15/24 at 10:42 a.m. with the Director of Nursing (DON), Resident 21's Order Summary Report (OSR, physician orders) was reviewed. The DON confirmed there were no orders for the use of plastic utensils and polystyrene containers for Resident 21's meals. The DON acknowledged that serving Resident 21's meals in polystyrene with plastic utensils was a dignity issue and Resident 21 had the potential for feeling less than and singled out from his peers. During a concurrent interview and record review on 11/15/24 at 12 p.m. with the Dietary Manager (DM), Resident 21's dietary order was reviewed. The DM confirmed there was no order for the use of plastic utensils and polystyrene containers. The DM stated, I don't know why [Resident 21] receives his meal tray like that, it's just always been done that way .it's not specified on the meal ticket. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised February 2021, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .p. be informed of, and participate in, his or her care planning and treatment.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review the facility failed to ensure medications were stored in their original containers and in a safe manner for 16 sampled residents. This failure had the potential for medications to be incorrectly identified and misused. Findings: During a concurrent observation and interview on 11/14/24 at 9:01 a.m. with Licensed Nurse (LN) 3, at Medication Cart 1 (Med Cart 1). LN 3 opened the top drawer to Med Cart 1 where there were three 30 mL (milliliters, a unit of measurement) plastic cups observed, stacked on top of one another, in the top drawer. Each plastic cup had two or more items in it, unlabeled and unidentified. LN 3 confirmed the plastic cups were not labeled and included the following: 1. One plastic cup had one pink pill and one red liquid-gel pill, 2. One plastic cup had two orange-colored pills, 3. One plastic cup had seven red and white liquid-gel pills. LN 3 acknowledged the medications should not be removed from their original packaging; this is a safety concern. During an interview on 11/15/24 at 10:42 a.m. with the Director of Nursing (DON), the DON confirmed medications are not to be removed from their original packaging. The DON stated, The next nurse who takes over the medication cart won't know what these pills are .this is a safety hazard. A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised February 2023, indicated, Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Medications may not be transferred between containers.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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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 food was prepared and stored in a safe and sanitary manner for a census of 42 residents who received food prepared from the kitchen, when: 1. Expired half-gallon of milk, opened salad dressing and creamer containers without open dates labeled, and full egg crates without received or expiration dates labeled were found in the kitchen refrigerators; 2. No temperature monitoring logs for resident food freezer section and for the dry storage room; 3. Ice and water dispensers in the dining room were not clean; and, 4. Lids used for covering prepared food on the steam table were stored on top of the unclean oven top. These failures decreased the facility's potential to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings: 1. During a concurrent observation and interview on 11/12/24 commencing at 8:39 a.m. with the Dietary Manager (DM) the initial tour of the kitchen was conducted. Half-gallon opened container of milk was found in the beverage refrigerator with manufacturer's label, BEST BY [DATE]. DM confirmed that the milk was expired and should have been thrown away. Further inspection of walk-in refrigerator found four (4) crates of eggs, containing 30 eggs per crate, were found without received date or expiration date labeled, one gallon (unit of volume) of Creamy Caesar Dressing and a 56 fluid ounces (units of volume) bottle of opened French Vanilla coffee creamer found open without opened on date labeled. DM confirmed observations and stated the salad dressing and coffee creamer should be labeled with open dates and eggs should have a date labeled. A review of facility's list of residents receiving food from the kitchen titled Resident Listing Report, dated 11/13/24 (print date), indicated 42 residents were receiving food from the kitchen. A review of facility's policy and procedure titled, Food Receiving and Storage, revised November 2022, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices . All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date) . Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded . Other opened containers are dated and sealed or covered during storage . 2. During a concurrent observation and interview on 11/12/24 commencing at 2:18 p.m. with DM in the dining room, a refrigerator with a freezer section on top, that was used for storage of resident foods, was observed with no temperature log for the freezer section which contained frozen foods. DM confirmed observation and stated that freezer section should have a temperature log for monitoring. During a concurrent observation and interview on 11/13/24 at 9:14 a.m. with DM in the dry storage room in the basement, no temperature log was observed in the room. DM confirmed there was not a temperature log for the room and acknowledge one needs to be placed for temperature monitoring. A review of facility's policy and procedure titled, Food Receiving and Storage, revised November 2022, indicated, Foods shall be received and stored in a manner that complies with safe food handling practices . Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements . 3. During a concurrent observation and interview on 11/12/24 at 2:18 p.m. with DM in the dining room, ice and water dispensers of the ice machine were observed with white and brown residue on the surface. DM confirmed that ice and water dispensers were not clean. A review of facility's policy and procedure titled, Ice Machines and Ice Storage Chests, revised January 2012, indicated, Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice . Clean and sanitize the tray and ice scoop daily . Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions . 4. During an observation on 11/13/24 at 10:26 a.m. [NAME] (CK1) was observed in the kitchen preparing food. CK1 took tray cover from the top of the oven and placed it over a food tray containing food on the steam table. Surface on top of oven was observed with dusty sticky residue. During a concurrent observation and interview on 11/13/24 at 10:45 a.m. with DM in the kitchen by the oven. DM confirmed the top of the oven surface was unclean with food tray lids, used to cover foods, were stored on the dirty surface. DM added staff needed to clean the dirty surface. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Environmental Surfaces, revised on August 2019, indicated, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard . Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. A review of Resident 42's admission record indicated Resident 42 was admitted to the facility in September 2024 with diagnoses which included spina bifida (a birth defect in where the spinal cord fails to develop properly) and paraplegia (the loss of muscle function in the lower half of the body, including both legs). A review of Resident 42's Order Summary Report (OSR, physician orders) indicated Resident 42 had the following orders: a) Bilateral nephrostomy tubes (a flexible tube that drains urine directly from the kidney through an opening in the skin of the lower back); cleanse tube site with normal saline, pat dry, apply dry dressing and secure, every day; b) A treatment order for a left sacral unstageable wound to be changed daily; and, c) Enhanced Barrier Precautions (EBP). During a concurrent observation and interview on 11/13/24 at 9:15 a.m. outside of Resident 42's room, an EBP sign was noted outside of the resident's room and Personal Protective Equipment (PPE, gowns, gloves, masks) were observed hanging on the door facing outside of the resident's room, into the hallway. CNA 5 was observed entering Resident 42's room without a gown. During a wound care observation on 11/13/24 from 9:28 a.m. to 9:48 a.m. in Resident 42's room, LN 1 did not wear a gown during Resident 42's wound care for his left sacral unstageable wound or when changing the dressings to his bilateral nephrostomy tubes. During a follow up interview on 11/13/24 at 1:41 p.m. with CNA 5, CNA 5 admitted he did not use PPE while he provided personal care to Resident 42. CNA 5 acknowledged the EBP sign outside of the resident's door and stated, I should have gowned up. During an interview on 11/13/24 at 1:49 p.m. with LN 1, LN 1 acknowledged the EBP sign outside of Resident 42's door and admitted she should have gowned up during wound care. During an interview on 11/14/24 at 2:14 p.m. with the IP, the IP confirmed Resident 42 was on EBP and staff need to wear gowns when providing personal care and wound care. A review of the facility's P&P titled, Enhanced Barrier Precautions, dated August 2022, the P&P indicated, Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high contact resident care activities .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and wound care (any skin opening requiring a dressing) .EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 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: 1. Housekeeping staff dipped contaminated gloves into mop bucket sanitizing solution; 2. Laundry room did not contain a hand washing station, and laundry room staff did not use gown for handling dirty laundry, did not sanitize equipment after handling dirty laundry, did not perform hand hygiene after glove removal, did not perform hand hygiene between resident room visits, and hung contaminated clothes hangers back on the clean linens cart; 3. Facility unable to provide evidence of timely corrective action following positive legionella tests in the water systems; 4. Licensed Nurse 1 (LN 1) did not perform hand hygiene when going in and out of residents' rooms while passing lunch trays; 5. Certified Nursing Assistant 2 (CNA 2) and CNA 3 did not perform hand hygiene when going in and out of residents' rooms while passing lunch trays; and, 6. LN 1 did not follow Enhanced Barrier Precautions (EBP, an infection control intervention that involves wearing gowns and gloves during high-contact patient care activities to reduce the spread of multidrug-resistant organisms for residents with wounds or indwelling medical devices, regardless of whether they are known to be infected or colonized) when providing wound care for Resident 42. These failures had the potential to result in infection among a facility census of 41 residents. Findings: 1. During an observation on 11/14/24 commencing at 10:08 a.m. Housekeeper (HK 1) was observed cleaning room [ROOM NUMBER]. HK 1 used gloved hands to wipe table tops and doorknobs with rags soaked in sanitizer solution. After completing wiping process HK 1 moved on to moping without changing gloves and dipped gloved hands into the mop bucket solution to take out mop pad that was soaked in it and squeezed out extra sanitizing solution out of the mop pad. HK 1 went on to mop the room, and after completing mopping the room HK 1 used gloved hands to remove dirty contaminated mop pad by rolling it off the mop and disposing of it in a separate container on the cleaning cart. HK 1 did not change gloves and dipped his hands into the bucket second time to take fresh mop pad for mopping restroom. In an interview on 11/14/24 at 10:08 a.m. HK 1 confirmed that he did not change gloves after wiping or when changing mop pads while cleaning room [ROOM NUMBER], he also agreed that this practice did contaminate the bucket with floor sanitizer. In an interview on 11/15/24 at 9:32 a.m. Infection Preventionist (IP) agreed that during room cleaning process not changing gloves after wiping and removal of contaminated mop pads and dipping contaminated gloved hands into the floor sanitizer bucket constituted cross-contamination and was not expected practice. A review of facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, indicated, Environmental surfaces will be cleaned and disinfected according to current CDC [ Centers for Disease Control and Prevention] recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard . 2. During a concurrent observation and interview on 11/14/24 commencing at 11:59 a.m. with the HK 2 in the laundry room. HK 2 demonstrated how she processed laundry. No hand washing sink was observed in the room. HK 2 in gloved hands and wearing no gown, opened a bin of dirty laundry and loaded it into the washing machine. HK 2 stated that using gown was not necessary because laundry did not come from the isolation rooms. After loading the dirty laundry HK 2 used automatic detergent dispenser to add detergent to the washing machine and closed the lid and using gloved hands without changing gloves prior, and pushed buttons on the machine to start washing. HK 2 did not sanitize exterior of the washing machine after loading dirty laundry, and she stated that she uses sanitizing wipes to wipe down equipment surfaces couple of times during her shift [not every time after dirty laundry loading]. HK 2 removed gloves and without performing hand hygiene took cart with clean clothes to bed delivered to six different resident rooms (614, 613, 612, 610, 605, and 604). HK 2 did not perform hand hygiene prior to entering these rooms, while in the rooms she touched closet doors and took empty hangers from residents' closets and hung them on the clean clothing cart. HK 2 confirmed that she did not perform hand hygiene after handling dirty laundry and removing gloves nor between different resident rooms, she had taken hangers from resident rooms and hung them on the cart with clean clothes, and the laundry room did not have a hand washing sink. In an interview on 11/15/24 at 9:32 a.m. the IP stated that staff must use gowns when handling dirty laundry and remove gloves and perform hand hygiene after handling dirty linens and in-between room visits. The IP clarified, empty hangers from residents rooms are potentially contaminated and should not go back to the clean linen cart without prior sanitation. The IP added, the washing machine needed to be sanitized after loading dirty laundry and confirmed the laundry room did not currently have a handwashing sink, due to maintenance issues. A review of facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, revised August 2019, indicated, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard . A review of facility's P&P titled, Departmental (Environmental Services) - Laundry and Linen, revised January 2014, indicated, .Wash hands after handling soiled linen and before handling clean linen . Consider all soiled linen to be potentially infectious and handle with standard precautions . Employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected . A review of facility's P&P titled, Handwashing/Hand Hygiene, revised October 2023, indicated, .Environmental measures are taken to reduce contamination associated with sinks and sink drainage, including: hand washing sinks that are constructed and installed according to health department codes; sinks that are dedicated to handwashing, when possible . Hand hygiene is indicated . after contact with blood, body fluids, or contaminated surfaces . after touching the resident's environment . immediately after glove removal . The use of gloves does not replace hand washing/hand hygiene . 3. During a review of facility's water management plan on 11/14/24 at 3:30 p.m., facility's water management plan binder contained a positive legionella (a waterborne opportunistic lung pathogen) testing report dated 11/2/23, which indicated that four facility locations tested positive for legionella. The binder did not contain evidence the facility took corrective action following the positive legionella tests nor was re-testing, of all involved locations, performed. In an interview on 11/15/24 at 7:59 a.m. Facility's Administrator (ADM) confirmed that no evidence of corrective action or retesting of all involved legionella positive locations following the 11/2/23 report was available. During a concurrent interview and record review on 11/15/24 at 9:32 a.m. with IP, water flush logs dated 10/15/24 were reviewed. The IP stated water flushes were used as an intervention to control legionella. However, the IP confirmed there was no documented evidence that water flushes or retesting, of all involved positive locations reported on 11/2/23, were performed. IP confirmed he expected interventions and retesting to be completed, documented, and documentation should be available in the water management binder. A review of facility's document titled, Water Management Program, dated 6/7/2024, indicated, The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease [a lung disease caused by Legionella] . The water management program that the facility will use is based on the CDC recommendations for the facility's water management program . Facility will hire [Water testing company name] to test samples of water throughout the facility on an annual basis . The binder called Water Management Program kept in the Administrator's office will consist of the program, the annual results sample test . The facility water management team will meet annually to review the program or sooner if . the control limits are consistently not met . 4. During observation on 11/12/24 at 11:50 a.m., lunch dining cart arrived on hallway B, observed LN 1 leaving hallway A, sitting at nursing station performing computer data entry, then going to hallway B's dining cart and started passing out lunch trays to residents. LN 1 did not perform hand hygiene, before handling lunch trays or when entering and exiting residents' rooms. During an interview on 11/12/24 at 12:05 p.m., standing in hallway B near nursing station, LN 1 acknowledged leaving hallway A, going behind the nurse's station, touching the computer, and not washing or sanitizing hands before going to dining cart on hallway B and passing out lunch trays. LN 1 stated .[sanitizing hands] is important to prevent infection between residents. During a concurrent interview on 11/12/24 at 12:50 p.m., near hallway B's nursing station, the ADM stated that hand sanitizing between residents' rooms was important to prevent the spread of infection and added, I will talk to my staff about that. 5. During an observation on 11/13/24 at 11:59 a.m., the lunch dining cart arrived on hallway A, CNA 2 and CNA 3 were observed not performing hand hygiene prior to removing lunch trays from dining cart or when going in and out of residents' rooms. During an interview on 11/13/24 at 12:05 p.m., standing in hallway A near dining cart, CNA 2 and CNA 3 both acknowledged not performing hand hygiene between rooms when delivering lunch trays. CNA 2 stated when I don't wash my hands, it could cause infection. CNA 3 stated sanitizing stops germs between the patients but when you have 50 million things on your mind to do in a day, sometimes you forget. During an interview on 11/13/24 at 3:55 p.m., the IP stated he expected staff to use hand sanitizer dispensers located conveniently in hallways to prevent spread of infection and residents from becoming sick. A review of facility's policy and procedure (P&P) titled, Alcohol-Based Hand Rub Dispensers, Installation and Use, dated Revised July 2016, indicated, Alcohol-based hand rub dispensers shall be installed in areas that facilitate access by healthcare personnel and maintain a safe environment for the residents and staff.

Jul 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 F0924 (Tag F0924)

Could have caused harm · This affected multiple residents

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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 facility corridors had firmly secured handrails for the two out of two facility corridors (Unit A and Unit B corridors). This failure had the potential to result in increased falls and potential for injury to the residents that used the corridors. Findings: A review of Resident 2's clinical record indicated Resident 2 was admitted April of 2024 and had diagnoses that included difficulty in walking. A review of Resident 2's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 4/11/24, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 7 out of 15 which indicated Resident 2 had severely impaired cognition. During an observation on 7/18/24 at 12:56 p.m. of the Unit A corridor, Resident 2 was observed walking back and forth using a walker. There were no secured handrails on either side of the corridor walls. During a concurrent observation and interview on 7/18/24 at 1:38 p.m. with Resident 2, at Resident 2's room, Resident 2 confirmed that there were no handrails on the walls of Unit A corridor. Resident 2 stated that it would be much safer for him if the corridor had handrails just in case he needed to hold on to a handrail for balance. During an observation on 7/18/24 at 2:56 p.m., two residents were observed going down the Unit B corridor. There were no secured handrails on either side of the corridor. During a concurrent observation and interview on 7/18/24 at 2:59 p.m., with the Maintenance Supervisor (MS), the MS confirmed that there were no secured handrails on either side of the walls on both Unit A and Unit B corridors. The MS stated, Yes, we removed it [handrails] .It's been more than 3 weeks now .We [staff] are painting them [handrails] and fixing things .I don't know when the plan is to put it [handrails] back on . During an interview on 7/18/24 at 4:15 p.m. with the Director of Nursing (DON), the DON stated, Those [handrails] was removed more than a month now, they're being painted .We [staff] have plans to put them [handrails] back but there is no specific date yet . The facility's policy and procedure (P&P) for handrails was requested. During a follow up phone interview on 7/22/24 at 1:07 p.m. with the DON, the DON stated, .To be honest, I don't know exactly when it was removed but since I started working here [in the facility], the handrails are not there anymore .I started working last 4/31/24 . The DON agreed that without handrails, the risk of falls and injuries was increased for all residents that use the corridors. The DON further stated that they did not have a policy for handrails. A review of the California Code of Regulations [NAME] 22, Chapter 3- Skilled Nursing Facilities, Section 72635, titled, Handrails, indicated, Corridors shall be equipped with firmly secured handrails . https://www.law.cornell.edu/regulations/california/22-CCR-72635 Based on observation, interview, and record review, the facility failed to ensure facility corridors had firmly secured handrails for the two out of two facility corridors (Unit A and Unit B corridors). This failure had the potential to result in increased falls and the potential for injury to the residents that used the corridors. Findings: A review of Resident 2's clinical record indicated Resident 2 was admitted April of 2024 and had diagnoses that included difficulty in walking. A review of Resident 2's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 4/11/24, indicated Resident 2 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 7 out of 15 which indicated Resident 2 had a severely impaired cognition. During an observation on 7/18/24 at 12:56 p.m. of the Unit A corridor, Resident 2 was observed walking back and forth using a walker. There were no secured handrails on either side of the corridor walls. During a concurrent observation and interview on 7/18/24 at 1:38 p.m. with Resident 2, at Resident 2's room, Resident 2 confirmed that there were no handrails on the walls of Unit A corridor. Resident 2 stated that it would be much safer for him if the corridor had handrails just in case he needed to hold on to a handrail for balance. During an observation on 7/18/24 at 2:56 p.m., two residents were observed going down the Unit B corridor. There were no secured handrails on either side of the corridor. During a concurrent observation and interview on 7/18/24 at 2:59 p.m., with the Maintenance Supervisor (MS), the MS confirmed that there were no secured handrails on either side of the walls on both Unit A and Unit B corridors. The MS stated, Yes, we removed it [handrails] .It's been more than 3 weeks now .We [staff] are painting them [handrails] and fixing things .I don't know when the plan is to put it [handrails] back on . During an interview on 7/18/24 at 4:15 p.m. with the Director of Nursing (DON), the DON stated, Those [handrails] was removed more than a month now, they're being painted .We [staff] have plans to put them [handrails] back but there is no specific date yet . The facility's policy and procedure (P&P) for handrails was requested. During a follow up phone interview on 7/22/24 at 1:07 p.m. with the DON, the DON stated, .To be honest, I don't know exactly when it was removed but since I started working here [in the facility], the handrails are not there anymore .I started working last 4/31/24 . The DON agreed that without handrails, the risk of falls and injuries was increased for all residents that use the corridors. The DON further stated that they did not have a policy for handrails. A review of the California Code of Regulations [NAME] 22, Chapter 3- Skilled Nursing Facilities, Section 72635, titled, Handrails, indicated, Corridors shall be equipped with firmly secured handrails . https://www.law.cornell.edu/regulations/california/22-CCR-72635

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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure two of 44 sampled residents' (Resident 2 and Resident 4), call lights were within reach and easily accessible. This failure placed Resident 2 and Resident 4 at risk of not being able to ask staff for assistance. Findings: Resident 2 was admitted to the facility in late 2023 with diagnoses which included dementia (loss of memory), history of falling and glaucoma (vision loss). Resident 4 was admitted to the facility in early 2024, with diagnoses which included dementia (loss of memory), chronic kidney disease, stage 3 (kidney damage) and hypertension (high blood pressure). During an observation on 4/2/24 at 2 p.m. in Resident 2's and Resident 4's room, the call lights were observed to be bundled up and placed in a black basket above the bedside dresser. During a concurrent observation and interview on 4/2/24 at 2:30 p.m. with Certified Nurse Aide (CNA) 1, in Resident 2's and Resident 4's room, CNA 1 confirmed the call lights were in the basket out of reach of the Residents and stated, We usually put the call lights within reach. So, that the residents feel safe and can call us. During an interview on 4/2/24 at 2:25 p.m. with the Administrator (ADM), the ADM stated, I would expect the staff to always place the call lights in reach of the residents. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Lights dated 9/2022, the P&P indicated, Ensure that the call light is accessible to the resident when in bed .

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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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), in a census of 43, was free from abuse when Resident 2 punched him in the face. This failure caused Resident 1 to sustain a nosebleed. Findings: Resident 1 was admitted to the facility in the winter of 2023 with multiple diagnoses which included dementia (impaired memory) and schizophrenia (a mental illness characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 12/22/23, the MDS indicated Resident 1 had severe memory impairment and needed assistance with his activities of daily living During a review of Resident 1's admission - Nursing Assessment [NA], dated 12/22/23, the NA indicated Resident was admitted to the facility .started screaming at staff during assessment, telling staff to get out of his room . The NA had no facial injuries documented. During a review of Resident 1's care plan (CP) titled, Resident was a victim of a resident-to-resident altercation .Resident had been being disruptive and frustrated peer assaulted him, causing nosebleed ., dated 12/27/23, indicated, Tx [treatment] as ordered for wounds as needed . During a review of Resident 1's IDT Clinical Review (CR), dated 12/28/23, the CR indicated Resident 1 was Alert and oriented to self only .[had] Verbal outburst[s] .Anger Outburst[s] .Demonstrated obsessive/repetitive behaviors . The CR further indicated, Transfer to .ER [emergency room] for further evaluation due to physically (sic) assault by another resident .bleeding nose . Resident 2 was admitted to the facility in the summer of 2023 with diagnosis which included dementia with agitation and schizophrenia. During a review of Resident 2's CR, dated 10/23/23, the CR indicated, 10/21/23 .Resident to resident altercation. Physically attacked a resident and staff. [Resident 2] is ambulatory and walked into another resident's room and unprovoked assaulted on (sic) resident . During a review of Resident 2's CP titled, Acute, combative, disruptive behavior ., dated 10/23/23, the CP indicated, Remove resident from situation when agitated .MONITOR . During a review of Resident 2's CP titled, The resident uses antipsychotic medications for schizophrenia and dementia with aggressive behaviors ., revised 10/23/23, the CP indicated, Provide non-pharmaceutical interventions for psychotic disorder .redirection . During a review of Resident 2's CR, dated 10/30/23, the CR indicated, 10/29/23 .Altercation with another resident, outside the hallway of resident's room .When is the last time, resident being checked/seen by CNA [Certified Nurses Assistant] .60 minutes before incident .Experiencing hallucinations or delusion .Demonstrates anxious/paranoid or suspicious behaviors . During a review of Resident 2's MDS, dated [DATE], the MDS indicated his memory was moderately impaired and he was able to ambulate independently. During review of Resident 2's Progress Notes [PN], dated 12/27/23, the PN indicated, [Resident 2] observed continuously threatening [Resident 1] across the hall due to excessive shouting and yelling .at 1050[a.m.], [Resident 2] was found on top of [Resident 1's] bed, choking and punching other resident . During an interview on 1/3/23 at 11:09 a.m. with the Director of Nurses (DON), the DON was asked about the incident and said, They didn't share a room but were across the hall from each other. He [Resident 2] went into [Resident 1's] room and punched him in the nose. Per [Resident 1], there was no one there but [himself]. He said [Resident 2] hit him in the nose. He [Resident 2] was fine and had his own room, was calm until he heard the screaming. We didn't have [another] room for him to move to at the time. This was his [Resident 2's] third incident. During an interview on 1/3/23 at 11:25 a.m. with the Activities Assistant (AA), the AA was asked about the 12/27/23 incident and said, [Resident 1] does yell. Anything sets him off .I have seen him yell .[Resident 2] likes things calm and quiet. [Resident 1] has been yelling .[outbursts heard from Resident 1 .grunted indiscernible words loudly]. During a concurrent observation and interview on 1/3/24 at 11:41 a.m. with Resident 1, Resident 1 had a 1/2 by 2 teardrop shaped resolving bruise to the left side of nose but didn't remember what happened. He did not answer simple questions and said, Get me out of the room . During an interview on 1/3/24 at 11:55 a.m. with Resident 1's Conservator, the Conservator said, They alerted me that they took him to the ER .downtown. I saw him the same day when he came back on 12/27/23. I took pictures [viewed on Conservator's phone, full face view] I understand he was punched in the face [outer right side of eye noted to have a small linear bruise or scratch, a very small line (? scratch) to the left upper side of the nose and dried blood at entrance to right nostril.] He just said someone came into the room and started hitting him. He has a history of outbursts and yelling . He recalled it the same day. He didn't know why the other resident hit him and couldn't tell me his name. During an interview on 1/3/24 at 12:09 p.m. with Housekeeper (Hskpr) 1, Hskpr 1 was asked about the 12/27/23 incident and said, It was about 10:48 a.m. on 12/27/23. I was in [room number], dropping off laundry. I heard [Resident 1] screaming but it was different [than the usual outbursts]. He was saying, 'Get out of my room.' I went down to check on him and I found [Resident 2] standing by his bedside. I saw him choking [Resident 1] and punching him on the right side of the face. I ran out of [Resident 1's room] and called, 'Help stat!' It was [MDS Coordinator, MDSC] .who came running. [Resident 2] was walking out of [Resident 1's] room when she got there .screaming and yelling obscenities . During an interview on 1/3/24 at 12:28 p.m. with the Social Services Director (SSD), the SSD was asked about the 12/27/23 incident and said, [Resident 2] got in a mood .He could be very nice and respectful and professional, but then he could turn and become agitated. This was the third incident. SSD was asked about Resident 1 and said, Even after care needs were met, he'd keep screaming . During an interview on 1/11/24 at 12 p.m. with the MDSC, the MDSC was asked about the 12/27/23 incident and said, That was so scary. We didn't know what to do with him [Resident 2] anymore. It was the third incident with him. They were unprovoked attacks. The guy across the hall [Resident 1] was yelling. He said [Resident 2] put his whole hand in his [Resident 1's] mouth .The housekeeper was yelling for help and saying that [Resident 2] was beating [Resident 1] up! I ran down there .I saw him hit the bed with his fist and then he walked out [of Resident 1's room] .He seemed to pick the vulnerable residents who were small and in bed. His mood changed so quickly .he was so unpredictable. He would change within a minute from sweet and kind to unpredictably aggressive. During an interview on 1/11/24 at 1:25 p.m. with Licensed Nurse (LN) 1, LN 1 was asked about the incident on 12/27/23 and said, [Resident 1] had his nose bleeding. He was agitated and upset I mainly noticed the nose bleeding .We never needed to keep our eyes on [Resident 2] constantly .He did have an incident before . During an interview on 1/16/24 at 11:09 a.m. with the Director of Nurses (DON), the DON was asked her expectations and said, Abuse should not happen in the facility. Punching someone in the nose is abuse. During a review of the facility policy and procedure (P&P) titled, Abuse and Neglect, dated 3/18, the P&P indicated, Abuse is defined .as the willful infliction of injury .with resulting physical harm .Instances of abuse of all residents, irrespective of any mental .condition, cause physical harm, pain or mental anguish. It includes .physical abuse .The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse .

Nov 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record the review, the facility failed to prevent physical abuse for 2 of 5 (Resident 2, Resident 3) sampled residents when: 1. Resident 1 threw a container of water at Resident 2, hit Resident 2 on the shoulder, and pushed a wheelchair into Resident 2's bed while Resident 2 was in bed; 2. Resident 1 pushed a wheelchair into Resident 3. This failure resulted in physical injury to Resident 1 and Resident 3 and emotional distress to Resident 2. Findings: 1. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility July 2023 with multiple diagnoses including schizophrenia (disorder characterized by thoughts or experiences out of touch with reality and affects ability to think and behave clearly) and Lewy body dementia (brain disorder that leads to problems with thinking and behavior). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 8/23/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 7 out of 15 that indicated he was severely cognitively impaired. A review of a faxed order for Resident 1 from the physician on 10/11/23, indicated an order .Quetiapine [Seroquel, antipsychotic medication to treat schizophrenia] 25 mg [milligrams, a unit of measure] 3 tabs [tablets] PO [by mouth] q [every] 8hrs [hours] for schizophrenia M/B [manifested by] physical and verbal aggression . A review of information for Resident 1 faxed to the physician on 10/12/23, indicated .Message We are going to attempt a GDR [gradual dose reduction- tapering of medication] of Quatiapine Fumarate 75 mg (current dose) .Orders received from the physician on 10/12/23 indicated .Quetiapine Fumarate 75 mg BID [two times a day] for schizophrenia M/B physical and verbal aggression . A review of Resident 1's Order Summary Report indicated order: Quetiapine Fumarate .25 mg . Give 3 tablets by mouth three times a day for (Schizophrenia) M/B verbal outbursts, and physical aggression towards residents and staff .Order Date 10/23/2023 . A review of Resident 1's Medication Administration Record, for 10/1/23 to 10/31/23 indicated one episode of verbal and physical aggression on 10/21/23 and 10/25/23. A review of Resident 1's Nurse Progress Note, dated 10/21/23, indicated .Resident to resident incident: resident is alert and responsive. said that resident from [Resident 2's room], walked by and called him names. [Resident 1] got mad and went to [Resident 2's room] and assaulted him .he was irritated and angry and eventually got him to calm down. Nurse practitioner was notified verbally, recommends transporting out for further eval [evaluation] due to violence and agitation . A review of Resident 1's Physician Visit Note, dated 10/21/23, indicated .Nursing staff reported that a few hours ago he physically attacked another resident. He is ambulatory and walked into another resident's room and assaulted him. He has a history of physical and verbal aggression towards staff and other residents that we have not been able to manage despite medication .he has hallucinations and verbal and physical outbursts. He is uncooperative and labile [easily changed] mood and unable to share a room with other residents d/t [due to] concern for potential roommate's safety .Confused, auditory and visual hallucinations exhibited .Safety of staff and other residents is of concern at this time . A review of Resident 1's Care Plan, initiated 10/23/23, indicated Focus .Acute, combative, disruptive behavior R/T [related to] .Potential risk for other directed violence related to dementia, combative behaviors .Goal .Resident will not injure self or others daily .Interventions .Request to resume prior dosage of Seroquel .Remove resident from situation when agitated before he becomes as able [sic] . A review of Resident 1's Care Plan, initiated 8/16/23, revised 10/23/23, indicated Focus . The resident uses antipsychotic medications for schizophrenia and dementia with aggressive behaviors. GDR done 10/12/23, failed with episode of aggression toward others on 10/21/23 Interventions .Administer PSYCHOTROPIC [affects the mental state] medications as ordered by physician .Monitor/record occurrence of for target behavior symptoms violence/aggression towards staff/others .and document per facility protocol . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility October 2023 with multiple diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow, makes it difficult to breathe), diabetes (too much sugar in the blood) and congestive heart failure (heart does not pump blood as well as it should). A review of Resident 2's MDS, Cognitive Patterns, dated 10/23/23, indicated Resident 2 had a BIMS score of 13 out of 15 that indicated he was cognitively intact. A review of Resident 2's Nurse Progress Note, dated 10/21/23 at 6:47 p.m., indicated .Resident to resident incident: resident is alert and responsive, said that resident from [Resident 1's] room, walked into his room and assaulted him. Activity staff saw some of the incident and reported it. we separated the two residents. resident stayed in the dining room. he was angry and wanted to make a police report. Assessed resident, said he was hit by [Resident 1's] palm on the right shoulder but no pain and no injuries, water was thrown at him .PD [police department] arrived at 16:50 [4:50 p.m.], got a report from resident . A review of Resident 2's Physician Visit Note, dated 10/21/23, indicated .Recently admitted sitting up in w/c [wheelchair] in activity room, conversant and pleasant. Unfortunately earlier today was victim in an altercation with another resident . A review of Resident 2's Care Plan, initiated 10/23/23, indicated Focus .The resident is at risk for depression r/t aggression from another resident .Interventions .Discuss with the resident any concerns, fears, issues regarding incident between resident . A review of the facility's five day follow up report for incident on 10/21/23, dated 10/26/23, indicated .It was reported that [Resident 1] hit [Resident 2] and slammed his wheelchair into [Resident 2's] bed while [Resident 2] was in his bed .Statements . Activity Assistant .She said she was going room to room passing out new menus when she heard [Resident 1] yelling in his room. After exiting out of another room, she heard more yelling in [Resident 2's room] so she went in there and saw [Resident 1] shoving a wheelchair into [Resident 2]'s bed while he was in it .Charge Nurse .She said she entered the room after the activity assistant called her for help. She noticed items on the floor around [Resident 2]'s bed . [Resident 2] .He said to the charge nurse that [Resident 1] hit him on the arm when he entered the room .Based on the investigation, the facility determined that the alleged physical abuse claim could have occurred . During an interview on 11/1/23 at 11:00 a.m. with the Director of Nursing (DON), the DON stated that on 10/21/23 Resident 1 reported that Resident 2 was saying things about his wife and Resident 1 took it upon himself to deal with the situation. The DON stated Resident 1 went to Resident 2 and started shaking his wheelchair. Resident 2 reported that Resident 1 hit him in the head. The DON stated Resident 1 had another altercation with a different resident on 10/29/23. DON stated Resident 1 had been at acute care hospital in August 2023 for 10 days due to aggressiveness to staff and auditory hallucinations. The medication Seroquel was ordered by the acute care upon discharge on [DATE]. DON stated Resident 1 had a GDR one week prior to incident on 10/21/23 and had Seroquel reduced to two times a day from three times a day. DON stated Resident 1 had a visit from psychiatry on 10/30/23, but no prior visits due to difficulty getting psychiatry follow up because [company contracted for psychiatry services] was short staffed. During an interview on 11/1/23 at 11:20 a.m. with the Activities Assistant (AA), the AA stated she heard yelling from Resident 2's room, went in and saw Resident 1 moving Resident 2's wheelchair back and forth aggressively. The AA stated Resident 2 stated, Help me. He's abusing me. I'm being abused. The AA stated she told Resident 1 to stop and ran out to get the nurse. During an interview on 11/1/23 at 11:25 a.m. with Licensed Nurse (LN) 1, LN 1 stated Resident had prior aggression to the staff. Resident 1 had pushed tray tables into staff. LN 1 stated, Resident 1 is territorial over his room. Seems to be aggressive with his room only and thinks he owns the room and the facility. During an interview on 11/1/23 at 11:35 a.m. with LN 2, LN 2 stated she heard yelling, the AA came to her and reported she saw Resident 1 pushing Resident 2's wheelchair. LN 2 stated she heard Resident 1 stating to the Certified Nursing Assistant (CNA) 1, This is my place. CNA 1 had moved Resident 1 to his room across the hall. LN 2 stated Resident 2 stated, Want to call the police. I have rights. He assaulted me. LN 2 stated Resident 1 was yelling, This is my place. He called me a bad word. LN 2 stated the side table had been moved and items were knocked on the floor. Resident 2 reported to LN 2 that Resident 1 had said he was going to kill him, and he did not want to sleep across the hall from him. LN 2 stated that Resident 2 reported Resident 1 had hit him with open palm on the right shoulder. During an interview on 11/1/23 at 11:50 a.m. with CNA 1, CNA 1 stated she had put Resident 2 in bed five to ten minutes prior to the incident with Resident 1. The AA was calling for help. CNA 1 went into Resident 2's room and Resident 2 stated that Resident 1 had thrown the water container at him. During a concurrent observation and interview on 11/1/23 at 1:30 p.m. with Resident 1, Resident 1 stated, Don't know resident across the hall. Never been in that room. Resident 1 then stated he had an incident with another resident a homeless jerk who came into his room. Resident 1 stated, I own the whole hospital. Observed Resident 1 ambulating in room without assistive device. During an interview on 11/1/23 at 1:35 p.m. with Resident 2, Resident 2 stated he was being pushed into his room and Resident 1 was screaming and yelling and he asked him to keep it down. Resident 2 stated Resident 1 came into the room yelling, Deputy sheriff, I own the building. Resident 2 stated, He was threatening, came up to my face, hit me on the shoulder with an open hand, and threw pitcher of water on me. Resident 2 stated, Didn't do anything to make him do that. During an interview on 11/1/23 at 1:55 p.m. with the DON, the DON stated that Resident 1's medications needed to be managed. Resident 1 did not have psychiatry follow up prior to 10/30/23 due to short staffing by [company contracted for psychiatry services]. The DON stated that a GDR was done because Resident 1 had come from acute hospital on 8/16/23 with Seroquel order increased to three times day and GDR should be attempted. The DON stated these altercations occurred after the Seroquel had been decreased to two times day on 10/12/23. The DON stated that an inpatient psychiatric referral had been made but have not had any luck with acceptance. The DON stated, Psyche [psychiatry] is on board now, has room at end of hallway, is isolated in room by himself. Not sure what else to do. 2. A review of Resident 1's Nurse Progress Note, dated 10/29/23 at 2:07 a.m., indicated .[Resident 1] came out to the nurse's station with complaint someone beat him up and tore his finger nails off, has bloody injury rt [right] hand index finger in the form of a broken nail possible just below quick, unsure, resident followed immediately to his room .to find another resident sitting on floor .with 2 small scratches on face. he pointed at another room when questioned about what happened .Unsure what has transpired but the man in room that the man on floor was pointing at said [Resident 1] was seen aggressing towards another resident . A review of Resident 1's Nurse Progress Note, dated 10/29/23 at 10:57 a.m., indicated .Resident with increased episodes of physical and verbal aggression towards staff and other residents. he had another altercation with residents last night. Due to increased safety concerns for residents and staff, resident was transferred to [name of acute hospital] for further evaluation .received written order for tx [treatment] to broken fingernails to right hand index finger and 3rd finger . A review of Resident 1's ED [Emergency Department] Provider Note, dated 10/29/23, indicated .to ED with increased aggression and right hand tenderness to palpation that began today .complaining of moderate .right wrist pain .and broken nail of left hand 3rd digit. Patient states he was hit and his fingernail was torn off .denies aggression or hitting other residents . A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in April 2022 with multiple diagnoses including cirrhosis of the liver (liver damage that causes scarring and liver failure), and Alzheimer's disease (progressive disease that destroys memory and other mental functions). A review of Resident 3's MDS, Cognitive Patterns, dated 7/21/23, indicated Resident 3 had a BIMS score of 0 out of 15 that indicated Resident 3 was severely cognitively impaired. A review of Resident 3's Nurse Progress Note, dated 10/29/23, indicated .resident found sitting on floor after another resident reported a white man came into his room and beat him up. I walked to the other resident's room to see what was up and [Resident 3] was sitting on floor with two small wounds to his mouth, first aide noted, are superficial noted .no other bruises or lumps . A review of Resident 3's Physician Visit Note, dated 10/29/23, indicated .Sitting up in w/c in hallway reported victim of an altercation with another resident, reporting done, monitor closely . A review of Resident 1's ED Provider Note, dated 10/29/23, indicated to ED with increased aggression and right hand tenderness to palpation that began today .complaining of moderate (6-7/10) right wrist pain .and broken nail of left hand 3rd digit. Patient states he was hit and his fingernail was torn off .denies aggression or hitting other residents . A review of Resident 3's Care Plan, initiated 10/30/23, indicated Focus .The resident was a victim of resident-to-resident altercation. Has scrapes to area surrounding the mouth and lips after being struck by peer. At risk for emotional distress .Interventions .Keep aggressor apart from victim resident .Social services to visit with resident daily x 3 days . A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in August 2023 with multiple diagnoses including metabolic encephalopathy (brain dysfunction due to chemical imbalance), peripheral neuropathy (weakness, pain, numbness from nerve damage in hands and feet) and diabetes (too much sugar in the blood). A review of Resident 4's MDS, Cognitive Patterns, dated 9/24/23, indicated Resident 4 had a BIMS score of 6 out of 15, that indicated Resident 4 was severely cognitively impaired. A review of the facility's five day follow up report for incident on 10/29/23. dated 11/3/23, indicated .It was reported that [Resident 1] hit [Resident 3] and pushed his wheelchair into [Resident 3]'s wheelchair while they were in the hallway .Statements .Charge Nurse .She said she found [Resident 3] siting on the ground in the hallway by [Resident 3's room]. [Resident 3] could not say what happened, but just pointed down the hallway towards the end of the hall . [Resident 4] .He said to the charge nurse that [Resident 1] pushed his wheelchair into [Resident 3] .Based on the investigation, the facility determined that the alleged physical abuse claim could have occurred .There were two small scratches on [Resident 3]'s face . During a concurrent observation and interview on 11/1/23 at 1:30 p.m. with Resident 1, Resident 1 stated, Don't know resident across the hall. Never been in that room. Resident 1 then stated he had an incident with another resident a homeless jerk who came into his room. Resident 1 stated, I own the whole hospital. Resident 1 stated the other resident, Broke my hand. I have 156 broken bones. Observed brace on Resident 1's right hand. Resident 1 removed the brace and observed slight redness and swelling to top of right hand. Observed Resident 1 ambulating in room without assistive device. During an observation on 11/1/23 at 1:32 p.m. of Resident 3, Resident 3 was asleep slumped in wheelchair and could not observe lower part of face. Did not observe scratches on upper part of Resident 3's face. Resident 3 did not arouse to voice. During a joint interview on 11/8/23 at 11:48 a.m. with the ADM and DON, reviewed altercation on 10/29/23 with Resident 1 and Resident 3. The DON stated Resident 3 was sitting on the ground in hallway near Resident 1's room. Resident 1 stated he owned the hospital. The DON stated that Resident 3 had small scratches by his mouth. DON stated Resident 4 stated Resident 1 pushed his wheelchair into Resident 3. During an observation on 11/8/23 at 1:10 p.m., Resident 3 was in bed asleep. Did not arouse to voice. Observed small scratch above right side of lip, approximately 1/4 inch long. During an interview on 11/8/23 at 1:20 p.m. with Resident 4, he stated he saw a guy in the doorway of Resident 1's room lying on the ground trying to get up. Resident 4 stated, The guy who lives in [Resident 1's room] was pushing a wheelchair into the other guy on the floor. The guy on the floor was trying to keep his back to the wheelchair. Resident 4 stated it happened at night. Resident 4 stated he went back into his room and did not see staff come to assist. During a telephone interview on 11/9/23 at 11:55 a.m. with LN 3, LN 3 stated Resident 1 came to the nurse's station and reported another resident had attacked him. LN 3 stated Resident 3 was on the floor in front of room at the end of the hall, his back against the door jamb of Resident 1's room and wheelchair was seven or eight feet from him. LN 3 stated Resident 3 had puncture wounds on his lip. Resident 1 had two broken fingernails. Resident 1 stated to LN 3, I own this facility and don't like this behavior. Resident 3 pointed at Resident 4's room and stated, Ask him. LN 3 spoke to Resident 4 who stated he thought Resident 1 had attacked Resident 3. A review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, indicated .Residents have the right to be free from abuse .This includes .freedom from .verbal .physical abuse .Protect residents from abuse .by anyone including .other residents .Protect residents from any further harm during investigations . A review of the facility's P&P titled Resident-to- Resident Altercations, revised 9/22, indicated .All altercation, including those that may represent resident-to-resident abuse, are investigated .Facility monitor residents for aggressive/inappropriate behavior towards other residents .or to the staff .Behaviors that may provoke a reaction by residents .wandering into others' rooms/space .If two residents involved in an altercation .identify what happened, including what might have led to aggressive conduct .consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management .

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

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Based on interview and record review, the facility failed to report to the Department a physical altercation between two residents (Resident 1 and Resident 3) that caused physical injury to both residents, within the regulatory time frame. This failure had the potential to cause harm to other residents without proper reporting. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility July 2023 with multiple diagnoses including schizophrenia (disorder characterized by thoughts or experiences out of touch with reality and affects ability to think and behave clearly) and Lewy body dementia (brain disorder that leads to problems with thinking and behavior). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 8/23/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 7 out of 15 that indicated he was severely cognitively impaired. A review of Resident 1's Nurse Progress Note, dated 10/29/23 at 2:07 a.m., indicated .[Resident 1] came out to the nurse's station with complaint someone beat him up and tore his finger nails off, has bloody injury rt [right] hand index finger in the form of a broken nail possible just below quick, unsure, resident followed immediately to his room .to find another resident sitting on floor .with 2 small scratches on face. he pointed at another room when questioned about what happened . don [Director of Nursing] called administrator notified, a call to [local police department] noted .and family notified noted. Unsure what has transpired but the man in room that the man on floor was pointing at said [Resident 1] was seen aggressing towards another resident . A review of Resident 1's Nurse Progress Note, dated 10/29/23 at 7:17 a.m., indicated .in addition to [local police department] notification via telephone fax sent to and messages left for [the Department] and ombudsman. total of 6 state and law enforcement notifications noted . A review of Resident 1's Nurse Progress Note, dated 10/29/23 at 10:57 a.m., indicated .Resident with increased episodes of physical and verbal aggression towards staff and other residents, he had another altercation with residents last night . A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in April 2022 with multiple diagnoses including cirrhosis of the liver (liver damage that causes scarring and liver failure), and Alzheimers disease (progressive disease that destroys memory and other mental functions). A review of Resident 3's MDS, Cognitive Patterns, dated 7/21/23, indicated Resident 3 had a BIMS score of 0 out of 15 that indicated Resident 3 was severely cognitively impaired. A review of Resident 3's Nurse Progress Note, dated 10/29/23 at 1:47 a.m., indicated .resident found sitting on floor after another resident reported a white man came into his room and beat him up. I walked to the other resident's room to see what was up and [Resident 3] was sitting on floor with two small wounds to his mouth, first aide noted, are superficial noted .no other bruises or lumps . A review of Resident 3's Nurse Progress Note, dated 10/29/23 at 7:19 a.m., indicated .In addition to calling [local police department], notification in fax noted, also notified ombudsman and [the Department] via fax and messages left noted, [Report of Suspected Dependent Adult/Elder Abuse], filled out and faxed via chain if comad [sic] . A review of Resident 3's Physician Visit Note, dated 10/29/23, indicated .Sitting up in w/c in hallway reported victim of an altercation with another resident, reporting done, monitor closely . A review of Resident 4's admission Record indicated Resident 4 was admitted to the facility in August 2023 with multiple diagnoses including metabolic encephalopathy (brain dysfunction due to chemical imbalance), peripheral neuropathy (weakness, pain, numbness from nerve damage in hands and feet) and diabetes (too much sugar in the blood). A review of Resident 4's MDS, Cognitive Patterns, dated 9/24/23, indicated Resident 4 had a BIMS score of 6 out of 15, that indicated Resident 4 was severely cognitively impaired. A review of the five day follow up report, dated 11/3/23, sent to the Department, indicated This report serves as the five day follow up for the alleged physical abuse incident that was reported on Sunday Oct. 29th, 2023, at around 2:00 am .The alleged abuse incident occurred between [Resident 3] and [Resident 1] .Physician, local ombudsman, police, resident's representative, and [the Department] were all notified .Based on the investigation, the facility determined that the alleged physical abuse claim could have occurred .The facility did follow its policy and procedures . A review of a facility fax report indicated that Fax Order or Information to the Physician regarding physical altercation of Resident 1 and Resident 3, was faxed successfully to the physician on 10/29/23 at 2:51 a.m. A review of a facility fax report indicated that the Report of Suspected Dependent Adult/Elder Abuse, faxed to the Department on 10/29/23 at 7:12 a.m., failed because the line was busy at the fax destination. A review of a facility fax report indicated the Report of Suspected Dependent Adult/Elder Abuse faxed to the Long Term Care Ombudsman (LTCO) office on 10/29/23 at 7:17 a.m., failed because the line was busy at the fax destination. During a telephone interview on 11/8/23 at 11:20 a.m. with the Long Term Care Ombudsman (LTCO), the LTCO stated she did not receive the Report for Suspected Adult/Elder Abuse, for physical altercation on 10/29/23 involving Resident 1 and Resident 3 and was not aware of the incident. During a joint interview on 11/8/23 at 11:48 a.m. with the Administrator (ADM) and the Director of Nursing (DON), reviewed the Department received the five day follow up report on 11/6/23, but had not received an initial report for incident between Resident 1 and Resident 3 on 10/29/23 within the regulatory time frame. The ADM acknowledged that the reports to the LTCO and the Department were not faxed successfully on 10/29/23. The ADM stated he was not able to find any further reports that they were sent again to the Department or the LTCO. Further reviewed with the ADM that the fax reports indicated the Report of Suspected Adult/Elder Abuse was faxed to the Department at 7:12 a.m. and the same report was faxed to the LTCO at 7:17 a.m. while the incident had occurred at approximately 2:00 a.m. The ADM acknowledged that reporting was attempted five hours after incident and should have been reported within two hours per regulation. The ADM stated, The staff has been inserviced on reporting within two hours of incident to the [Department], ombudsman, and police. During an interview on 11/8/23 at 1:30 p.m. with the DON, the DON acknowledged that Resident 3's Nurse Progress Note, dated 10/29/23 at 7:19 a.m., indicated the attempt to notify the Department via fax was at that time. The DON stated that the Department was not notified within two hours of the incident which took place at approximately 2:00 a.m. on 10/29/23. During a telephone interview on 11/9/23 at 11:55 a.m. with Licensed Nurse (LN) 3, LN 3 stated on 10/29/23 Resident 1 came to the nurse's station and reported that he had been attacked. Resident 1 stated to LN 3, I own this facility and don't like this behavior. LN 3 stated that Resident 3 was sitting in the doorway of Resident 1's room and had a puncture wound on his lip. Resident 3's wheelchair was 7 to 8 feet from him. LN 3 stated that Resident 1 had two broken fingernails. LN 3 stated that Resident 3 pointed at Resident 4's room. LN 3 stated that Resident 4 said he thought Resident 1 had attacked Resident 3 with his wheelchair. LN 3 stated the incident occurred after 1:00 a.m. and she charted at the time of the incident. LN 3 stated she notified the sheriff, the Department, the LTCO, and the physician by fax at 7:00 a.m. LN 3 stated the regulation is to report the incident within two hours to the Department, the LTCO, and the police. LN 3 stated she did not fax the reports until after 7:00 a.m. because she could not find the binder needed at night. LN 3 waited until the DON arrived in the morning to show her where the paperwork was. The binder was located on a shelf in the nursing station, but LN 3 stated she did not know where it was before the DON showed her. LN 3 stated she completed the Report of Suspected Dependent Adult/Elder Abuse at that time. LN 3 stated she received abuse training during orientation. A review of the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/21, indicated .Residents have the right to be free from abuse .This includes .freedom from verbal .or physical abuse .Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse .Investigate and report any allegations within timeframes required by federal requirements .Protect residents from any further harm during investigations . A review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, revised 9/22, 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 or the individual making the allegation immediately reports his or her suspicion the following agencies .The state licensing/certification agency responsible for surveying/licensing the facility .The local/state ombudsman .Immediately is defined as .within two hours of an allegation involving abuse .or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury .Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone . A review of the facility's P&P titled Resident-to-Resident Altercations, revised 9/22, .All altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator .The administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating .report incidents, findings, and corrective measures to appropriate agencies as outlined in Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide Social Services (SS) follow up for three days following abuse allegations for 3 of 5 sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for Resident 1, Resident 2, and Resident 3 to not receive competent and sufficient psychosocial support. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility July 2023 with multiple diagnoses including schizophrenia (disorder characterized by thoughts or experiences out of touch with reality and affects ability to think and behave clearly) and Lewy body dementia (brain disorder that leads to problems with thinking and behavior). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 8/23/23, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 7 out of 15 that indicated he was severely cognitively impaired. A review of Resident 1's Nurse Progress Note, dated 10/21/23, indicated .Resident to resident incident: resident is alert and responsive. said that resident from [Resident 2's room}, walked by and called him names. [Resident 1] got mad and went to [Resident 2's room] and assaulted him .he was irritated and angry and eventually got him to calm down. Nurse practitioner was notified verbally, recommends transporting out for further eval [evaluation] due to violence and agitation . A review of Resident 1's Nurse Progress Note, dated 10/29/23, indicated .[Resident 1] came out to the nurse's station with complaint someone beat him up and tore his finger nails off, has bloody injury rt [right] hand index finger in the form of a broken nail possible just below quick, unsure, resident followed immediately to his room .to find another resident sitting on floor .with 2 small scratches on face. he pointed at another room when questioned about what happened .Unsure what has transpired but the man in room that the man on floor was pointing at said [Resident 1] was seen aggressing towards another resident . A review of Resident 1's Social Services Note, dated 10/27/23, indicated .SS has been following up with resident since his altercation with another resident .SS will continue to visit and monitor any changes to resident's mood and behaviors . A review of Resident 1's Social Services Note, dated 10/30/23, indicated, .SS followed up with resident, noted to be in calm and good spirit resting in bed .SS will continue to visit as needed . A review of Resident 1's Social Services Note, dated 11/1/23, indicated .SS f/u [follow up] with resident on his overall well-being .SS will continue to follow up and monitor any changes to residents mood and behavior . A review of Resident 1's Care Plan, initiated 10/23/23, indicated Focus .Acute, combative, disruptive behavior R/T [related to] .Potential risk for other directed violence related to dementia, combative behaviors .Goal .Resident will not injure self or others daily .Interventions .Encourage resident to express feelings of anger, guilt, and frustration . A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility October 2023 with multiple diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow, makes it difficult to breathe), diabetes (too much sugar in the blood) and congestive heart failure (heart does not pump blood as well as it should). A review of Resident 2's MDS, Cognitive Patterns, dated 10/23/23, indicated Resident 2 had a BIMS score of 13 out of 15 that indicated he was cognitively intact. A review of Resident 2's Nurse Progress Note, dated 10/21/23, indicated .Resident to resident incident: resident is alert and responsive. said that resident from [Resident 1's] room, walked into his room and assaulted him. Activity staff saw some of the incident and reported it. we separated the two residents. resident stayed in the dining room. he was angry and wanted to make a police report. Assessed resident, said he was hit by [Resident 1]'s palm on the right shoulder but no pain and no injuries, water was thrown at him .PD [police department] arrived at 16:50 [4:50 p.m.], got a report from resident . A review of Resident 2's Social Services Note, dated 10/27/23, indicated .SS has been following up with this resident since his altercation with another resident .had daily visits with resident has not had any further conversations on the incident . A review of Resident 2's Social Services Note, dated 11/1/23, indicated .SS spoke with resident this morning .Has not talked about the altercation that happened with another resident .SS will continue to visit resident and monitor any changes to mood and behavior . A review of Resident 2's Care Plan, initiated 10/23/23, indicated Focus .The resident is at risk for depression r/t aggression from another resident .Interventions .Discuss with the resident any concerns, fears, issues regarding incident between resident .Provide time to talk and encourage the resident to express feelings . A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility in April 2022 with multiple diagnoses including cirrhosis of the liver (liver damage that causes scarring and liver failure), and Alzheimer's disease (progressive disease that destroys memory and other mental functions). A review of Resident 3's MDS, Cognitive Patterns, dated 7/21/23, indicated Resident 3 had a BIMS score of 0 out of 15 that indicated Resident 3 was severely cognitively impaired. A review of Resident 3's Nurse Progress Note, dated 10/29/23, indicated .resident found sitting on floor after another resident reported a white man came into his room and beat him up. I walked to the other resident's room to see what was up and [Resident 3] was sitting on floor with two small wounds to his mouth, first aid noted, are superficial noted .no other bruises or lumps . A review of Resident 3's Social Services Note, dated 10/30/23, indicated .SS followed up with resident on his overall wellbeing, resident did get into altercation with another resident .SS will continue to visit resident as needed . A review of Resident 3's Social Services Note, dated 11/1/23, indicated .Resident up and about his room .No distress noted .SS will continue to monitor any changes to residents mood and behavior . A review of Resident 3's Care Plan, initiated 10/30/23, indicated Focus .The resident was a victim of resident-to-resident altercation .at risk for emotional distress .Interventions .Social Services to visit with resident daily x 3 days . During an interview on 11/1/23 at 12:30 p.m. with the Social Services Director (SSD), the SSD stated she does three day follow up charting for abuse allegations to assess overall well-being, psychosocial needs, and see if they are back to normal. The SSD stated she works Monday through Friday. Reviewed with the SSD that SS charting for Resident 1 was on 10/27/23 and 10/30/23 and for Resident 2 on 10/27/23 for abuse allegation on 10/21/23. The SSD stated she summarized her visits on 10/27/23 for Resident 1 and Resident 2. The SSD acknowledged she did not chart daily for three day follow up with Resident 1 and Resident 2 for the incident on 10/21/23. When asked why she did not chart daily, the SSD stated, Probably didn't get to it. Doesn't mean I didn't see resident daily. I know if it it's not charted it's not done. The SSD stated that she was told by the administration just to summarize her visits on 10/27/23. During an interview on 11/1/23 at 2:15 p.m. with the Director of Nursing (DON), the DON stated the procedure is for SS to document follow up visits with residents involved in abuse allegations daily for three days. The DON acknowledged that SS follow up charting for Resident 1 and Resident 2 was not done daily for incident on 10/21/23. The DON stated, Should have been documented. Summarized notes are not the same. The DON stated that it has been the process for SS to follow up for three days. The DON stated it is the expectation that the follow up visits will be documented daily. During an interview on 11/8/23 at 11:48 a.m. with the DON, the DON acknowledged that SS charting was not done daily for three days for Resident 1 and Resident 3 for altercation on 10/29/23. The DON stated that SS visits should have been done and charted daily for three days after altercation on 10/29/23. Social Services Policy requested on 11/1/23. DON stated policy not available.

Oct 2023 26 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an informed consent was obtained when the dose of quetiapine (a medication used to balance hormones that help regulate mood, behaviors, and thoughts) was increased for one of 44 residents (Resident 32). This failure increased the potential for Resident 32's Responsible Party (RP) to not be informed of the risks and benefits of the medication. Findings: During a review of Resident 32's clinical record, the record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses which included depression, schizophrenia (a mental disorder in which people interpret reality abnormally), and dementia (a group of symptoms affecting memory, thinking and social abilities). During a review of Resident 32's clinical record, the record indicated that Resident 32 was discharged from the hospital and readmitted to the facility on [DATE]. During a review of Resident 32's hospital Discharge summary, dated [DATE], the summary indicated Resident 32 received quetiapine 75 milligrams (mg, a unit of measurement) twice daily in the hospital. During a review of Resident 32's physician's order, dated 8/16/23, the order indicated quetiapine 25 mg, give three tablets by mouth every eight hours for dementia with behavior disturbances manifested by physical and verbal aggression. During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 had severe memory impairment. During a concurrent interview and record review on 10/10/23 at 3:21 p.m., with the Director of Nursing (DON), the DON confirmed the quetiapine dose was changed from 75 mg twice daily to 75 mg every eight hours. The DON indicated there was no documented rationale to explain why the dose was increased. During a review of Resident 32's informed consent record, the record indicated that an informed consent was obtained for quetiapine 25 mg one tablet twice daily, and for the dose change of quetiapine 50 mg one tablet twice daily. The facility was not able to provide an informed consent for the dose increase of quetiapine 75 mg every eight hours, ordered on 8/16/23. During a telephone interview on 10/11/23 at 1:29 p.m., with the Pharmacy Consultant (PC), the PC stated, I didn't see anything in the document regarding informed consent. The PC stated, I was not aware that [Resident 32] received 75 mg BID [twice daily] in the hospital. During an interview on 10/11/23 at 1:58 p.m., with the DON, the DON stated the facility did not have a policy on obtaining informed consent.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of 21 sampled resident's (Resident 300) responsible party (RP, person in charge of making decisions) was notified of change in services. This failure had the potential to not allow the responsible party (RP) to appeal the decision in a timely manner. Findings: Resident 300 was admitted to the facility fall of 2023 with diagnoses of brain tumor and difficulty swallowing. Family Member 1 (FM 1) was listed as the RP. During a concurrent observation and interview on 10/11/23 at 10:47 a.m., with Resident 300, Resident 300 was observed lying in bed, wearing only an adult incontinence brief. Resident 300 was asked if he does any exercises, he stated, No. During an interview on 10/11/23 at 10:48 a.m., with the Director of Rehabilitation (DOR), the DOR was asked if Resident 300 was receiving physical therapy. The DOR stated, No, he is not on services [physical or occupational therapy]. His last covered day [last day he received therapy] was 10/8. During an interview on 10/11/23 at 10:57 a.m., with Occupational Therapy Assistant (OTA 1) 1, OTA 1 was asked why Resident 300 was no longer on services. OTA 1 stated the termination of services was, .based on [name of insurance plan]. He did not meet his goals . When asked the plan for Resident 300, OTA 1 stated, That is a good question. During an interview on 10/12/23 at 8:26 a.m., with the Social Service Director (SSD), the SSD was asked if the FM 1 was given the opportunity to appeal the decision to end services. The SSD stated, No, they did not. During an interview on 10/12/23 at 9:21 a.m., with the Business Office Manager (BOM), the BOM confirmed FM 1 for Resident 300 was not notified that the skilled services (physical and occupational therapy) had ended on 10/8/23. The BOM stated the facility sent a certified copy of the notice to FM 1 last night on 10/11/23. During an interview on 10/12/23 at 9:30 a.m., with Resident 300's FM 1, FM 1 stated, I did receive a call yesterday. We were not notified on the 8th of his end of service and was not given the information on the right to appeal. This has been a big deal. I am going to call [name of insurance plan] now to appeal . During a review of facility provided document titled, [Attestation Form] [attestation, evidence or proof of something] dated 10/11/23, the document indicated, Inform Rep [Representative] that acute/skilled services will no longer be covered beginning on date: 10/8/23 and financial responsibility starts on (date) 10/9/23 . The document indicated FM 1 was notified three days after Resident 300 stopped receiving physical and occupational therapy. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 5/17, the P&P indicated, Our facility shall promptly notify the resident .and representative .of changes in the resident's medical/mental condition and/or change of status [e.g., changes in level of care, billing/payments .] .A representative of the business office will notify the resident .and representative when: There is a change is the resident's billing .There is a change in the resident's level of care status .

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a transfer notice for one of 21 sampled residents (Resident 26) was sent to the Office of the State Long Term Care Ombudsman (resident advocate) as required when Resident 26 was transferred to the hospital. This failure had the potential to deny Resident 26 access to an advocate who could inform residents of their options and rights. Findings: Resident 26 was admitted to the facility in the fall of 2023 with diagnoses which included sepsis (life-threatening complication of an infection). During a review of Resident 26's Minimum Data Set (MDS, an assessment tool), the MDS indicated Resident 26 discharged from the facility on 9/3/23. During a review of Resident 26's Nursing Progress Notes (NPN), dated 9/3/23, the NPN indicated, The staff nurse called 911 .The resident left the building at 1900 [7 p.m.] via gurney . During an interview on 10/12/23 at 11:23 a.m., with the Medical Records Director (MRD), the MRD was asked to provide a copy of the Notice of Transfer (document which indicated the resident left the building) that was sent to the Ombudsman. The MRD stated, There is nothing to give. The MRD confirmed notification was not sent to the Ombudsman. When asked who was responsible for notifying the Ombudsman, the MRD stated, The nurse should do the Ombudsman notification. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated 10/22, the P&P indicated, .Notice of Transfer is provided .to the long-term care (LTC) ombudsman .

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive assessment was performed in accordance with regulatory time frames for three of 21 sampled residents (Resident 29, Resident 146 and Resident 300), when the admission MDS (Minimum Data Set, an assessment tool) assessments were not completed. This failure had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 29 was admitted in late 2023 with diagnoses which included altered mental status, weakness, repeated falls, depression, and diabetes (abnormal blood sugar levels). During a review of Resident 29's MDS, dated [DATE], the MDS indicated the assessment was incomplete, still in progress, and overdue. During a review of Resident 29's Nursing Care Plan (NCP), dated 8/11/23 and revised 10/6/23, the NCP indicated, [Resident 29] at risk for altered nutritional status R/T [related to] .feeling hungry between meals, requesting more food. During a concurrent observation and interview on 10/9/23 at 8:53 a.m., Resident 29 was in bed, awake, alert and verbally responsive, and stated, I have been here for two weeks .The food is not enough .They don't provide snacks in between meals especially in the evening after dinner. I am diabetic and they should offer snacks .I have lost 20 pounds and I am worried if they are not providing enough food. 2. Resident 146 was admitted in late 2023 with diagnoses which included stroke with memory impairment. During a review of Resident 146's MDS, dated [DATE], the MDS indicated the assessment was incomplete, still in progress, and overdue. During a review of Resident 146's NCP dated 9/13/23, the NCP indicated, [Resident 146] has impaired cognitive function/dementia or impaired thought processes. During a concurrent observation and interview on 10/9/23 at 10:17 a.m., Resident 146 was in bed, awake, alert and verbally responsive, and stated, I guess I'm doing okay .I think I am in an apartment building. I am just new here. When asked what time it was, Resident 146 stated, I think it is 6:30 in the morning. The clock time was at 6:30 and the hour and minute hands were not moving. When the resident was told it was around 10 in the morning, the resident stated, I guess the clock is not working. 3. Resident 300 was admitted to the facility in the fall of 2023 with diagnoses which included brain tumor and difficulty swallowing. During a review of Resident 300's MDS, dated [DATE], the MDS indicated the assessment was incomplete, still in progress, and overdue. During a concurrent observation and interview on 10/11/23 at 10:47 a.m., Resident 300 was in his bed wearing only an adult incontinence brief. Resident 300 was asked if he does any exercises, and he stated, No. During an interview on 10/11/23 at 2:45 p.m., with the MDS Coordinator (MDSC), the MDSC stated, I know that our transmissions are going late .At the entry and within seven days, we open them the day of or before the 48 hours, and complete on the 14th day, complete the five day on the 14th day, and should be the ARD [assessment reference date] between day five and day eight .We generally use day seven and completed by day 14 .So, beyond those time frames whenever there's day one or day two late, the MDS is late .I'm aware of who they are because I've seen us making copies of things and they are late .I can't exactly backdate any MDS. During a review of the facility's policy and procedure (P&P) titled Comprehensive Assessments, revised 3/22, the P&P indicated, Comprehensive assessments are conducted to assist in developing person-centered care plans .The admission assessment is a comprehensive assessment for a new resident, and under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. During a review of the undated Resident Assessment Instrument (RAI, the MDS process), the RAI indicated, The RAI process is a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life. The process helps nursing professional and staff assess a resident's strengths and needs to create an individualized care plan. This allows for a holistic approach to care for each resident. This assessment is completed initially and periodically and is comprehensive, accurate, and standardized. It is a reproducible assessment of each resident's functional capacity.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a baseline care plan (BCP, document that outlines care needs) for one of 21 sampled residents (Resident 300) within 48 hours of the resident's admission. This failure had the potential to place the resident at risk for unmet care needs. Findings: Resident 300 admitted to the facility in the fall of 2023 with diagnoses which included brain tumor and difficulty swallowing. Family Member 1 (FM 1) was listed as the responsible party. During a review of Resident 300's 48 HOUR BASELINE CARE PLAN, the BCP indicated, admission: [DATE]. The BCP was not completed. The notification of completion, and date reviewed with Responsible Party (person responsible for resident) were blank. During a concurrent interview and record review on 10/11/23 at 2:45 p.m., with the Minimum Data Set Coordinator, the MDSC stated, .The time frame to complete the BCP should be within 48 hours .for sure on [Resident 300] it looks like his baseline care plan was not done . Confirmed with MDSC the BCP was not completed or given to FM 1. During a review of the facility's policy and procedure (P&P) titled, Care Plans-Baseline, dated 3/22, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .The resident and/or representative are provided a written summary of the baseline care plan .Provision of the summary .is documented in the medical record.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to review and revise the comprehensive care plan for one of 21 sampled residents (Resident 13), when the care plan did not reflect the removal of the urinary catheter (a tube used to empty the bladder and collect urine). This failure had the potential to result in Resident 13's receiving outdated care and placing the resident at risk for not meeting her highest practicable well-being. Findings: Resident 13 was admitted to the facility in August 2023 with diagnoses which included retention of urine (difficulty emptying the bladder of urine) and urinary tract infection (UTI, infection of the bladder). During a review of Resident 13's Minimum Data Set (MDS, an assessment tool), dated 9/29/23, the MDS indicated Resident 13 had no memory impairment. During a review of Resident 13's Order Summary Report (OSR) dated 9/22/23, the OSR order indicated an antibiotic (a medication to treat infection) to be given with an end date of 9/27/23, and another order to remove Resident 13's urinary catheter. During a concurrent interview and record review on 10/11/23 at 3:04 p.m., with the Director of Nursing (DON), the DON verified Resident 13's Nursing Care Plan (NCP) use of a urinary catheter initiated on 8/15/23 had not been updated to reflect the removal of the urinary catheter. The DON stated, When orders are updated or discontinued, the care plan needs to be revised or discontinued. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 4/21, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The Interdisciplinary Team must review and update the care plan .when there has been a significant change in the resident's condition.

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

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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 orders were followed for three of 21 sampled residents (Resident 15, Resident 298, and Resident 300) when thin liquids were served instead of thickened liquids (beverage that is specifically designed for people who have difficulty swallowing; helps prevent choking by moving slower than thin liquids). These failures had the potential to increase the risk of choking. Findings: Resident 15 admitted to the facility late 2022 with diagnoses that included lung cancer, stroke and weakness. During a review of Resident 15's Minimum Data Set (MDS, an assessment tool), dated 3/26/23, the MDS indicated Resident 15 had a mechanically altered diet (diet that required a change in texture or liquids). During a review of Resident 15's Order Summary Report (OSR), order date 6/26/23, the OSR indicated, .Puree textures [food that is ground into smooth pudding texture], Nectar Thick Consistency [liquid comparable to heavy syrup consistency]. During a review of Resident 15's Care Plans (CP), initiated 9/24/23, the CP indicated, .mechanically altered diet texture with nectar thick fluids. During a concurrent observation and interview on 10/9/23 at 12:44 p.m., with the Speech Therapist (ST, specialist trained to assess swallowing skills) in Resident 15's room, Resident 15 was served thin consistency milk. The ST confirmed the diet order slip on the meal tray indicated, NECTAR THICK LIQUIDS, and verified the milk that was served was not nectar thick. Resident 298 was admitted to the facility in the fall of 2023 with diagnose that included stroke and dysphagia (difficulty swallowing). During a review of Resident 298's OSR, order date 9/13/23, the OSR indicated, .Nectar Thick consistency, Dysphagia. During a review of Resident 298's CP, initiated 9/13/23, the CP interventions indicated, .NT [nectar thick] fluids. During a review of Resident 298's MDS, dated [DATE], the MDS indicated Resident 298 had a mechanically altered diet. During a concurrent observation and interview on 10/9/23 at 12:27 p.m., with the Director of Clinical Operation (DOCO) in Resident 298's room, Resident 298 was served thin consistency milk. Observed signage on the wall indicated, RESIDENT MAY NOT HAVE THIN LIQUIDS. THICKEN ALL LIQUIDS TO NECTAR THICK /SLIGHLTY THICK CONSISTENCY. The DOCO confirmed the milk was not thickened. Resident 300 admitted to the facility in the fall of 2023 with diagnoses which included brain tumor and difficutly swallowing. During a review of Resident 300's CP, initiated 9/19/23, the CP interventions indicated, .NT fluids. During a review of Resident 300's OSR, order date 9/21/23, the OSR indicated, .Nectar Thick consistency. During a review of Resident 300's MDS, dated [DATE], the MDS indicated Resident 300 had a mechanically altered diet. During a concurrent observation and interview on 10/9/23 at 12:35p.m., with the ST in Resident 300's room, Resident 300 was served thin milk on his lunch tray. The ST confirmed the milk was not nectar thick and stated, It should be thickened. The ST pointed to signage posted on Resident 300's wall, there were two signs that indicated, Nectar Thick!!! and, PT [patient] IS ON NECTAR THICK LIQUIDS . A request for a policy and procedure for following physician orders was requested, but was not provided. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment . ordered by and within the scope of licensure of a physician .as defined by Section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. pp. 5)

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to properly apply bed rails for one of 21 sampled residents (Resident 300), when Resident 300 did not have a side rail assessment, risk for entrapment assessment or informed consent for the use of the two 1/2 bed rails. This failure had the potential to cause Resident 300 restricted exiting from the bed, increased risk of injury, increased depression, and entrapment. Findings: Resident 300 admitted to the facility in the fall of 2023 with diagnoses which included brain tumor. During a review of Resident 300's document titled, SIDE RAIL ASSESSMENT, effective date 9/20/23, the contents of the assessment had not been completed. The assessment was blank. During a concurrent observation and interview on 10/11/23 at 3:59 p.m., with the Physical Therapy Assistant (PTA 1) 1, in Resident 300's room, PTA 1 confirmed Resident 300 had two half side rails on his bed. During a concurrent interview and record review on 10/12/23 at 11:31 a.m., with the Director of Nursing (DON), the DON was asked about the process for placing side rails on a resident bed. The DON stated if someone had side rails, she would expect an assessment to be completed before the side rails were placed on the bed. The DON was shown the blank assessment for Resident 300 and confirmed the side rail assessment was not completed. When asked the importance of the consent, the DON stated, [The] consent itself, it's the patients' rights. During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, dated 8/22, the P&P indicated, .The use of bed rails .is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment and informed consent .The resident assessment also determines potential risks to the resident associated with the use of bed rails .

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacist identified an irregularity for an antipsychotic (medication used to treat hallucinations [seeing or hearing things that are not there] and delusions [fixed beliefs with no basis in reality] medication during the monthly drug regimen review for one of 21 sampled residents (Resident 32). This failure had the potential for Resident 32 to receive unnecessary medication, or inappropriate medication dosage, which had potential for increased risk and exposure to side effects such as sedation, memory loss, falls and abnormal involuntary movements. Findings: During a review of Resident 32's clinical record, the record indicated that Resident 32 was admitted to the facility on [DATE] with multiple diagnoses which included depression, schizophrenia (a mental disorder in which people interpret reality abnormally), and dementia (a group of symptoms affecting memory, thinking and social abilities). During a record review of Resident 32's Minimum Data Set (MDS, assessment tool) dated 8/23/23, the MDS indicated Resident 32 had no physical, verbal, or behavioral symptoms towards others and no behaviors of rejecting evaluation or care. A review of Resident 32's physician orders dated 8/16/23, indicated quetiapine (medication used to balance the hormones that help regulate mood, behaviors, and thoughts) 25 milligrams (mg, a unit of measurement), give three tablets by mouth every eight hours for dementia with behavior disturbances manifested by physical and verbal aggression. During a review of Resident 32's hospital Discharge summary dated [DATE], the summary indicated Resident 32 received quetiapine 25 mg, three tablets by mouth twice daily. During a concurrent interview and record review on 10/10/23 at 3:21 p.m. with the Director of Nursing (DON), the DON confirmed the medication list from the hospital discharge summary indicated quetiapine 75 mg twice daily and Resident 32's current dose of quetiapine was 75 mg every eight hours. The DON was not able to provide documented clinical rationale or justification as to why the dose increased to every eight hours. During a review of the Medication Regimen Review (MRR) dated July 2023 to September 2023, the MRRs did not indicate any irregularities were identified by the pharmacist when the dose for Resident 32's quetiapine was increased without documented clinical rationale. During an interview on 10/11/23 at 12:12 p.m. with the Pharmacy Consultant (PC), the PC stated Resident 32's drug regimen was reviewed twice, on 8/21/23 and 9/22/23. The PC stated, It did not look like an increase on my standpoint, I was not aware that he received [quetiapine] 75 mg twice daily in the hospital. A review of Lexi-comp, a nationally recognized drug information resource, indicated, Patients with dementia with Lewy bodies are at increased risk for severe adverse reactions; caution is required even with low doses .Dosing: Adult . Initial: 25 mg at bedtime; may increase dose gradually (eg, weekly) based on response and tolerability up to 75 mg twice daily. (www.lexicomp.com; accessed 10/16/23) During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 7/2022, the P&P indicated, 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use .14. All antipsychotic medications will be used within the clinically recommended dosage guidelines, or clinical justification will be documented for dosages that exceed guidelines for more than 48 hours.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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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 21 sampled residents (Resident 32) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 32's antipsychotic was increased without documented clinical rationale and was given in excess for the indication for use. This failure resulted in unnecessary medication for Resident 32, which had the potential for increased risk and exposure of side effects associated with psychotropic medications such as sedation, memory loss, falls and abnormal involuntary movements. Findings: During a review of Resident 32's clinical record, the record indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnoses which included depression, schizophrenia (a mental disorder in which people interpret reality abnormally), and dementia (a group of symptoms affecting memory, thinking and social abilities). During a record review of Resident 32's Minimum Data Set (MDS, assessment tool) dated 8/23/23, the MDS indicated Resident 32 had no physical, verbal, or behavioral symptoms towards others and no behaviors of rejecting evaluation or care. A review of Resident 32's physician orders indicated quetiapine (medication used to balance hormones that help regulate mood, behaviors, and thoughts) 25 mg (milligrams, a unit of measurement), give three tablets by mouth every eight hours for dementia with behavior disturbances manifested by physical and verbal aggression, dated 8/16/23. During a review of Resident 32's hospital Discharge summary, dated [DATE], the summary indicated Resident 32 was receiving quetiapine 25 mg, three tablets by mouth twice daily. During a concurrent interview and record review on 10/10/23 at 3:21 p.m. with the Director of Nursing (DON), the DON confirmed the medication list from the hospital indicated quetiapine 75 mg twice daily and Resident 32's current dose of quetiapine was 75 mg every 8 hours. The DON was not able to find documented clinical rationale in the resident's record to explain why the dose was increased from twice daily to every eight hours. During a review of the Medication Regimen Review (MRR), dated July 2023 to September 2023, the MRRs did not indicate any irregularities were identified by the pharmacist when the dose for Resident 32's quetiapine was increased without documented clinical rationale. During an interview on 10/11/23 at 12:12 p.m. with the Pharmacy Consultant (PC), the PC stated, It did not look like an increase on my standpoint, I was not aware that he received [quetiapine] 75 mg twice daily in the hospital. A review of Lexi-comp, a nationally recognized drug information resource indicated, Patients with dementia with Lewy bodies are at increased risk for severe adverse reactions; caution is required even with low doses .Dosing: Adult .Initial: 25 mg at bedtime; may increase dose gradually (eg, weekly) based on response and tolerability up to 75 mg twice daily. (www.lexicomp.com; accessed 10/16/23) During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 7/2022, the P&P indicated, 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use . c. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication. The P&P further indicated, 14. All antipsychotic medications will be used within the clinically recommended dosage guidelines, or clinical justification will be documented for dosages that exceed guidelines for more than 48 hours.

CONCERN (D)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

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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 food of appropriate nutritive content was provided for one of 21 sampled residents (Resident 29), when the resident did not receive and consume food as prescribed by the physician. This failure had the potential to result in the resident not attaining the treatment and plan of care in accordance with his goals and preferences. Findings: Resident 29 was admitted in late 2023 with diagnoses which included altered mental status, weakness, repeated falls, depression, and diabetes (abnormal blood sugar levels). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 had memory impairment and had no swallowing problems. During a review of Resident 29's Nursing Care Plan (NCP), dated 8/11/23 and revised 10/6/23, the NCP indicated, [Resident 29] at risk for altered nutritional status R/T [related to] .feeling hungry between meals, requesting more food .Diet as ordered-Double protein portions with meals. During a review of Resident 29's Weight Summary History which included the weights on 8/18/23 = 184 lbs (pounds, weight measure) and on 10/6/23 = 177 lbs, the summary indicated a 3.8% weight loss in one month. During a review of Resident 29's Food and Nutrition Review (FNR), dated 9/20/23, the FNR indicated, CCHO [Controlled Carbohydrate Diet] LARGE PORTION REGULAR w TIN (sic) LIQUIDS. During a review of Resident 29's Registered Dietitian Evaluation (RDE), dated 9/21/23, the RDE indicated, Likes double protein portions w/ [with] his meals. During a review of Resident 29's Order Summary Report (OSR), dated 9/25/23, the OSR indicated, CCHO-Controlled Carbohydrate Diet diet, Regular texture .Add double protein portions in all meals. During a concurrent observation and interview on 10/9/23 at 8:53 a.m., Resident 29 was in bed, awake, alert and verbally responsive, and stated, I have been here for two weeks .The food is not enough though. They don't provide snacks in between meals especially in the evening after dinner. I am diabetic and they should offer snacks .I have lost 20 pounds and I am worried if they are not providing enough food. During a concurrent observation and interview on 10/9/23 at 12:49 p.m., Resident 29 had finished his lunch. The meal tray was already completely consumed and there was nothing left on the tray. Resident 29 stated, I'm finished with it. It's not enough. I do need some more .I am still hungry. Of course, I want some more. During a concurrent observation and interview on 10/9/23 at 12:50 p.m., with the Director of Clinical Operations (DOCO), the DOCO entered Resident 29's room and asked the resident, [Resident 29], I heard you were asking for extra portions for lunch? Resident 29 answered, Yes. I wanted more food. I have a very small portion every day and I would like to have some more. The DOCO stated, Did you talk to the dietitian about your food preferences .to talk about your diet? Resident 29 stated, No. I have not talked to anybody about the food I want. The DOCO verified the meal card which indicated 'double portion', and stated, I think he needs double portion. During an interview on 10/10/23 at 10:33 a.m., with Licensed Nurse 3 (LN 3), LN 3 stated, Nurses would check the food and the diet if appropriate for the residents. During a concurrent interview and record review on 10/10/23 at 11:50 a.m., with the Dietary Supervisor (DS) and the Registered Dietitian (RD), the DS and the RD verified the menu spreadsheet. The DS indicated she was not aware there was no small portion or large portion in the menu spreadsheet. The RD confirmed the spreadsheet did not have portion specified for the small and large portions. During a concurrent interview and record review on 10/10/23 at 11:55 a.m., with [NAME] 1, [NAME] 1 verified and indicated there was no measurements on the spreadsheet for small portion or large portion. [NAME] 1 indicated she would give half portion of the meat, vegetables and starch on the plate, and for large portion, she would give one and half portion of the meats on the entree. During an interview on 10/10/23 at 12:20 p.m., with the RD, the RD indicated the small portion they provided to the residents was not with the correct serving since the spreadsheet did not provide the measured serving and would impact the residents' nutrition intake and may lead to weight loss. During an interview on 10/10/23 at 1:30 p.m., with the DS and the RD, both indicated they did not have the diet manual and could not compare the menu spreadsheet to the ordered diet for the small and large portions. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, revised 10/17, the P&P indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet .A 'therapeutic diet' is considered a diet ordered by a physician, practitioner or dietitian as part of the treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet .The dietitian, nursing staff and attending physician will regularly review the need for and resident acceptance of, prescribed therapeutic diets.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, and interview, the facility failed to ensure essential equipment was working for two of 21 sampled residents (Resident 10 and Resident 43), when the residents' call light button devices did not work. This failure had the potential to result in the residents not being able to ask staff for assistance. Findings: During a review of the facility's Work History Report (WHR) for 9/23, the WHR indicated, Nurse Call System Test: Conduct a test of the nurse call system .Marked done on-time .on 9/5/23. During a review of the facility's Maintenance Request Log (MRL) for 9/12/23 to 10/10/23, the MRL indicated a call light device repair request on 10/9/23. During a concurrent observation and interview on 10/9/23 at 8:57 a.m., Resident 10 and Resident 43 were both in bed having breakfast, both awake and alert and both verbally responsive. Resident 10 stated, These call lights, these things don't work .I turn it on and they don't respond. Resident 43 joined the conversation, and stated, [Resident 10] is right. I have turned on this call light, but I guess it is broken .I have turned on the call light about half an hour ago and nobody came in. When the call light system was checked, the call light turned on inside the room with no audible sound and the outside call light on top of the room door did not light on. Resident 43 stated, So, they probably don't know that we turned on the call light. During a concurrent observation and interview on 10/9/23 at 9 a.m. with LN 5, LN 5 checked Resident 10 and Resident 43's room, verified the call light was broken, and the light on top of the room door did not light on, and stated, I don't see any light outside the room. I wouldn't be able to know if call light was [turned] on. I think [the system] is not working. When it's not lighted and they turned it on, that means it does not work. The thing is broken. If they need help like an emergency and the call light is not working, that would not be safe. During a concurrent observation and interview on 10/9/23 at 10:21 a.m. with the Nurse Consultant (NC), the NC verified the call light device was not working and was not lighted outside the door for staff to monitor, and stated, For sure, the call light is not working. I think it comes on but just don't know if it is registered down there in the front desk or not, and the light outside is not on either. During an interview on 10/11/23 at 3:19 p.m. with the Director of Clinical Operations (DOCO), the DOCO stated, Call lights that are not working should be fixed for resident safety. During a review of the facility's P&P titled, Maintenance Service, dated 12/09, the P&P indicated, The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times .Maintaining the building in good repair and free from hazards. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, revised 9/22, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station .The resident call system remains functional at all times .The resident call system is routinely maintained and tested by the maintenance department.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, functional and comfortable homelike environment for three of 21 sample residents (Resident 32, Resident 10 and Resident 43), when: 1. Several items including loose pieces of metal panels, metal boxes and large framed paintings, and a meal tray not picked up for two days, were found in Resident 32's room; 2. The call light device was broken and not working in Resident 10 and Resident 43's room; These failures had the potential to result in the residents not attaining their highest practicable physical, mental and psychosocial well-being. Findings: 1. Resident 32 was admitted in the middle of 2023 with diagnoses which included memory impairment, infection, bone fracture, difficulty walking, and depression. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had severe memory impairment and needed moderate assistance with activities of daily living (ADLs). During a review of Resident 32's Nursing Care Plan (NCP), dated 8/16/23, the NCP indicated, [Resident 32] is at risk for falls; Resident at risk for altered ADLs. During an observation on Resident 32's room on 10/9/23 at 8:48 a.m., a long loose piece of metal panel leaning against the cabinet on the walkway at the foot of the bed, and on top of bed A were several items which included three large framed paintings, a box of cardboard items, a metal box, and another loose piece of metal panel and several small items. During an interview on 10/9/23 at 8:52 a.m. with Licensed Nurse (LN 5), LN 5 verified the loose piece of metal penal and the other items in the room, and stated, Definitely, [the loose piece of metal panel] shouldn't be here. That would be dangerous for the resident when they are walking or passing through. LN 5 verified the items on top of the bed, and stated, I think they are trying to fix this side of the bed. These things should not be here because the resident in here could be hurt. During a concurrent observation and interview on 10/9/23 at 8:55 a.m., Resident 32 sat at the side of the bed having breakfast meal, alert and verbally responsive, and on on top of the nightstand was another meal tray with the meal card date of 10/7/23, labeled with the name of Resident 32. Resident 32 stated, I am just finishing my breakfast .I have been here forever. When asked if he had two breakfast meal trays, Resident 32 stated, Oh no. That one was from the other day, like on Saturday. I don't why they have not picked it up. That has been there and it's dirty .They didn't pick up that tray .That does not feel right. During an interview on 10/9/23 at 8:49 a.m. with LN 6, LN 6 checked and verified the meal tray left in Resident 32's room and indicated the tray was not picked up or cleaned up, and stated, That's terrible. That has been there since Saturday, 10/7/23 and today is the 9th. 2. Resident 10 was admitted in late 2023 with diagnoses which included memory impairment, prostate cancer, repeated falls, difficulty walking and low back pain. During a review of Resident 10 MDS, dated [DATE], the MDS indicated Resident 10 had moderate memory impairment, had a urinary catheter, and needed extensive assistance with ADLs. During a review of Resident 10's NCP, dated 9/15/23, the NCP indicated, [Resident 10] is at risk for falls. Resident 43 was admitted in the middle of 2023 with diagnoses which included hip fracture. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had mild memory impairment and needed extensive assistance with ADLs. During a review of Resident 43's NCP, dated 9/1/23, the NCP indicated, Decreased functional mobility secondary to: L [left] hip femoral neck fx [fracture]. During a review of Resident 43's NCP dated 9/26/23, the NCP indicated, At risk for falls. During a concurrent observation and interview on 10/9/23 at 8:57 a.m., Resident 10 and Resident 43 were both in bed having breakfast, both awake and alert and both verbally responsive. Resident 10 stated, These call lights, these things don't work. The call light doesn't work. I turn it on and they don't respond. When it's working, they don't respond quite quick enough. If we need help to get up to go to the bathroom, they don't come. I wouldn't get up and I'd be on the floor before they get here, so I have to wet myself. Resident 43 joined the conversation, and stated, [Resident 10] is right. I have turned on this call light, but I guess it is broken. Nobody came here to check us and it has been an hour .Right now, I can't get nobody. You can't get nobody. I have turned on the call light about half an hour ago and nobody came in. When the call light was checked, the call light turned on inside the room. When the outside call light on top of the room door was checked, it did not light up. Resident 43 stated, So, they probably don't know that we turned on the call light. During a concurrent observation and interview on 10/9/23 at 9 a.m. with LN 5, LN 5 checked and verified the call light was broken and the light on top of the room door did not light on Resident 10 and Resident 43's room, and stated, I don't see any light outside the room. I wouldn't be able to know if call light was turned on. I think it is not working. When it's not lighted and they turned it on, that means it does not work. The thing is broken. If they need help like an emergency and the call light is not working, that would not be safe. During a concurrent observation and interview on 10/9/23 at 10:21 a.m. with the Nurse Consultant (NC), the NC verified the call light device was not working and was not lighting outside the door for staff to monitor, and stated, For sure, the call light is not working. I think it comes on but just don't know if it is registered down in there in the front desk or not and the light outside is not on either. During an interview on 10/10/23 at 9:10 a.m. with Resident 43, I am not sure if it's working now. Right now, I turned it on and it didn't light up here. I woke up in the middle of the night, I turned on the call light, and the nurse eventually came down here but it wasn't because of the light although she said that she knew the call light was on and saw the call light on. I don't know if it was working or not. During an interview on 10/11/23 at 3:19 p.m. with the Director of Clinical Operations (DOCO), the DOCO stated, Call lights that are not working should be fixed for resident safety. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, revised 3/21, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Be sure that the call light is plugged in and functioning at all times .Report all defective call lights to the nurse supervisor promptly. During a review of the facility's P&P titled, Maintenance Service, dated 12/09, the P&P indicated, The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times .Maintaining the building in good repair and free from hazards.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 10 was admitted in late 2023 with diagnoses which included memory impairment, prostate cancer, repeated falls, difficulty walking and low back pain. During a review of Resident 10's Nursing Care Plan (NCP), dated 8/11/23, the NCP indicated, [Resident 10] has indwelling Catheter r/t [related to] dx [diagnosis] of pyelonephritis [kidney infection] and BPH [benign prostatic hypertrophy - enlargement of the prostate]. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had moderate memory impairment and had a urinary catheter. During a concurrent observation and interview on 10/11/23 at 8:15 a.m., Resident 10 and the roommate, Resident 43, had breakfast with the privacy curtain open between the two beds. Resident 10 had a urinary catheter bag at the side of the bed. Resident 10 stated, I have had the catheter for a while. I don't know what's going on, but my roommate can see that I have one. He can see directly from the other bed. Resident 43 stated, Yes. I can see. He has that catheter for a while. During a concurrent observation and interview on 10/11/23 at 8:18 a.m., with CNA 1, CNA 1 verified the catheter bag was not covered with a privacy bag, and stated, There was a cover yesterday. I don't know what happened. There should be a cover for the urinary bag for privacy. During a concurrent observation and interview on 10/11/23 at 8:20 a.m., with LN 2, LN 2 verified the urinary catheter bag had no cover, and stated, There should be a blue bag to cover the urinary bag for privacy and dignity. During an interview on 10/11/23 at 3:19 p.m., with the Director of Clinical Operations (DOCO), the DOCO stated, For privacy and dignity on residents with urinary catheters, the catheter bags should have a cover. During a review of the facility's P&P titled, Quality of Care - Dignity, revised 1/22, the P&P indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example .helping the resident to keep urinary catheter bags covered. 3. Resident 29 was admitted in late 2023 with diagnoses which included altered mental status, weakness, repeated falls, and depression. During a concurrent observation and interview on 10/9/23 at 8:53 a.m., Resident 29 was in bed, awake, alert and verbally responsive, and noted the window blinds had a missing sheet. Resident 29 stated, I have been here for two weeks. A week ago, one of the blinds fell and they never replaced it. That bothers me because at night, the light comes in and there are high rise buildings over there in those hotels and they could look in here and that's bothering me. I am not scared but that's still in my mind that somebody is looking here in my room. During an interview on 10/9/23 at 10:23 a.m., with the Nurse Consultant (NC), the NC checked the room and verified the missing blind, and stated, The missing blind should have been replaced. It created no privacy for the resident. During an interview on 10/11/23 at 3:19 p.m., with the DOCO, the DOCO stated, For privacy and dignity on residents .window blinds that are missing or call lights that are not working should be fixed. During a review of the facility's P&P titled, Quality of Care - Dignity, revised 1/22, the P&P indicated, Residents are treated with dignity and respect at all times .Residents' private space and property are respected at all times .Staff promote, maintain and protect resident privacy. 4. Resident 32 was admitted in the middle of 2023 with diagnoses which included memory impairment, infection, bone fracture, difficulty walking, and depression. During a review of Resident 32's Nursing Care Plan (NCP), dated 8/16/23, the NCP indicated, [Resident 32] is at risk for falls; Resident at risk for altered ADLs. During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 had severe memory impairment and needed moderate assistance with ADLs. During an observation in Resident 32's room on 10/9/23 at 8:48 a.m., a long piece of metal panel leaning at the cabinet on the walkway at the foot of the bed and on top of bed A were several items including three large framed paintings, a boxed cardboard item, a metal box, another loose piece of metal and several small items. During an interview on 10/9/23 at 8:52 a.m., with LN 5, LN 5 verified the loose piece of metal and the other items in the room, and stated, Definitely, [the loose metal panel] shouldn't be here. That would be dangerous for the resident when they are walking or passing through. LN 5 verified the items on top of the bed, and stated, I think they are trying to fix this side of the bed. These things should not be here because the resident in here could be hurt. During a concurrent observation and interview on 10/9/23 at 8:55 a.m., Resident 32 sat at the side of the bed having breakfast, alert and verbally responsive, and on on top of the nightstand was another meal tray with the meal card dated 10/7/23 and labeled with the name of Resident 32. Resident 32 stated, I am just finishing my breakfast .I have been here forever. When asked if he had two breakfast meal trays, Resident 32 stated, Oh no. That one was from the other day, like on Saturday. I don't know why they have not picked it up. That has been there and it's dirty .They didn't pick up that tray .That does not feel right. During an interview on 10/9/23 at 8:59 a.m., with LN 6, LN 6 checked and verified the meal tray left in the Resident 32's room and indicated the tray was not picked up or cleaned up, and stated, That's terrible. That has been there since Saturday [10/7/23], and today is the 9th. 5. Resident 43 was admitted in the middle of 2023 with diagnoses which included hip fracture. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had mild memory impairment. During a concurrent observation and interview on 10/9/23 at 10:08 a.m., Resident 43 was in bed, awake and verbally responsive, and stated, I don't have any clock or television in this room. They said that if you want a TV you got to have it donated by your family. I'm okay with no TV, but no clock in here? They do have TV for everybody else in other rooms. The TV I understand, but no clock, I mean, I don't even know what time it is for the day right now. I have to call the CNA and ask for the time and they don't respond to that half of the time. But then again, the call light does not work. I feel neglected and don't have any dignity at all .I have nothing and have no Social Security and my income is very little to none, undignified existence right? During an interview on 10/9/23 at 12:53 p.m., with CNA 7, CNA 7 verified there was no wall clock or television in Resident 43's room, and stated, There are clocks and TVs in other rooms but this room has none. I don't know how the residents know what time of the day is. 6. Resident 146 was admitted in late 2023 with diagnoses which included stroke with memory impairment. During a review of Resident 146's incomplete MDS, dated [DATE], the MDS indicated Resident 146 had mild memory impairment and needed moderate assistance with ADLs. During a concurrent observation and interview on 10/9/23 at 10:17 a.m., Resident 146 was found in bed watching television, awake, alert and verbally responsive, and a non-working clock was observed on the wall with the time set at 6:30 with the hour and minute hands not moving. When asked what the time was, Resident 146 stated, I think it is 6:30 in the morning. When the resident was told it was around 10 in the morning, the resident stated, I guess the clock is not working. During an interview on 10/9/23 at 10:20 a.m., with the NC, the NC verified the wall clock in the room was not working, and stated, Okay. We have to get that fixed. The clock is not right. During a review of the facility's P&P titled, Resident Rights, revised 2/21, the P&P 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: a dignified existence; be treated with respect, kindness, and dignity .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .be supported by the facility in exercising his or her rights .privacy and confidentiality. During a review of the facility's P&P titled, Quality of Care - Dignity, revised 1/22, the P&P 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. Based on observation, interview, and record review, the facility failed to ensure the rights for dignity, privacy and homelike environment were promoted for six of 21 sampled residents (Resident 35, Resident 10, Resident 43, Resident 29, Resident 32, and Resident 146) to maintain and enhance the residents' self-esteem and self-worth and incorporate the residents' preferences, and choices, when: 1. Resident 35's finger nails were long with brownish discoloration under the nails with flaking nail polish; 2. The urinary catheter bag was not covered for Resident 10; 3. Window blind sheet was missing in the room of Resident 29; 4. Several items including loose pieces of metal panels, metal boxes and three large framed paintings, and a meal tray not picked up for two days, were found in Resident 32's room; 5. There was no wall clock or television for Resident 10 and Resident 43; and 6. A non-working wall clock was found in Resident 146's room. These failures had the potential to result in negatively impacting the residents physical, mental, emotional, and psychosocial well-being. Findings: 1. Resident 35 was admitted to the facility in the summer of 2023 with diagnoses which included intracerebral hemorrhage (brain bleed), hemiplegia (paralysis of one side), and diabetes (a disease that occurs when the blood sugar is too high). During a review of Resident 35's shower sheet (SS), dated 9/20/23, the SS indicated, Fingernails .Clean .Yes, but Need clipping was blank under Yes .No. During a review of Resident 35's Minimum Data Set (MDS, an assessment tool), dated 9/29/23, the MDS indicated Resident 35's memory was severely impaired and she was totally dependent on staff for all activities of daily living (ADLs). During a concurrent observation and interview on 10/9/23 at 9:11 a.m., with Resident 35, the Resident had long, unclean nails that were brown underneath and had flaking nail polish. The resident indicated she asked for them to be trimmed yesterday and is not sure who is responsible. During a review of Resident 35's care plan (CP) titled, The resident has potential impairment to skin integrity, initiated 10/4/23, the CP indicated, Avoid scratching . Keep fingernails short. During a review of Resident 35's SS, dated 10/11/23, Finger Nails .Clean .No but Need clipping was blank under Yes .No. During an interview on 10/10/2023 at 11:50 am., with Certified Nursing Assistant 3 (CNA 3), CNA 3 indicated, Resident 35 had been in the facility one month but she had not noticed that Resident 35's nails were long. CNA 3 said, CNAs don't cut nails. During an interview on 10/10/2023 at 11:56 am., with CNA 1, CNA 1 indicated, CNAs do cut nails but not diabetic nails. If the resident has diabetes, she will let the licensed nurse know. The CNAs are responsible for checking the nails on hands and feet of residents. During an interview on 10/10/23 at 12 p.m., Licensed Nurse (LN 4), LN 4 indicated she worked for a registry and no one had asked her to trim any resident's nails. She indicated usually a podiatrist clipped the nails but indicated CNAs could clip the nails during the resident's shower. During an interview on 10/10/23 at 12:12 p.m., with the Activities Assistant (AA 1), AA 1 said, The Activities department will paint nails or take the nail polish off one time a month for residents. With regards to [Resident 35], they have never done her nails .[Resident 35] is not able to ask to have her nails done so the family does them. During an interview on 10/11/23 at 10:24 a.m., with CNA 6, CNA 6 verified [Resident 35's] nails were long and need trimming. During an interview on 10/11/23 at 11:23 a.m., with the Director of Nurses (DON), the DON said, When CNAs give residents showers they check the resident's nails. If they are long, they will let the licensed nurse know. Only the licensed nurse can trim diabetic's nails. The licensed nurse usually trims them on the weekend when there's more time. We use a lot of Registry staff [coming for a day at a time] so it's hard to keep track of nails. I was unaware [Resident 35] had long nails. During an additional interview on 10/11/23 at 11:36 a.m., with Resident 35, Resident 35 was asked how it made her feel when her nails were long and untrimmed and she said, I can't wipe my cat [front] or back. I will scratch myself. Resident 35 reiterated that she asked someone to trim them. During an interview on 10/11/23 at 3:46 p.m., with the Director of Clinical Operations (DOCO), the DOCO said, The CNA will report the need for nail trimming to the RN [Registered Nurse] if the resident is a diabetic .If the resident does not have this [diagnosis], the CNA is trained to trim the nails. The CNAs should check the resident's nails with showers or bed baths. During a review of the facility policy and procedure (P&P) titled, Bath, Bed, revised 3/21, the P&P indicated Check the resident's fingernails .Provide nail care only when instructed . During a review of the facility P&P titled, Fingernails/Toenails, Care of, revised 2/18, the P&P indicated, Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .The following information should be recorded in the resident's medical record .If the resident refused the treatment .Notify the supervisor if resident refuses the care .

CONCERN (E)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 29 was admitted in late 2023 with diagnoses which included altered mental status, weakness, repeated falls, depression, and diabetes (abnormal blood sugar levels). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 had memory impairment and had no swallowing problems. During a review of Resident 29's FNR, dated 9/20/23, the FNR indicated, CCHO [Controlled Carbohydrate Diet] LARGE PORTION REGULAR w [with] TIN (sic) LIQUIDS. During a review of Resident 29's Registered Dietitian Evaluation (RDE), dated 9/21/23, the RDE indicated, Likes double protein portions w/ [with] his meals. During a review of Resident 29's Nursing Care Plan (NCP), dated 8/11/23, and revised 10/6/23, the NCP indicated, [Resident 29] at risk for altered nutritional status R/T [related to] .feeling hungry between meals, requesting more food. During a review of Resident 29's Order Summary Report (OSR), dated 9/25/23, the OSR indicated, CCHO-Controlled Carbohydrate Diet diet, Regular texture .Add double protein portions in all meals .Diet as ordered-Double protein portions with meals .Honor resident food preferences within diet parameters. During a concurrent observation and interview on 10/9/23 at 8:53 a.m., Resident 29 was in bed, awake, alert and verbally responsive, and stated, I have been here for two weeks .The food is not enough though. They don't provide snacks in between meals especially in the evening after dinner. I am diabetic and they should offer snacks .I have lost 20 pounds and I am worried if they are not providing enough food. During a concurrent observation and interview on 10/9/23 at 12:49 p.m., Resident 29 had finished his lunch. The meal tray was already completely consumed and nothing was left on the tray. Resident 29 stated, I'm finished with it. It's not enough. I do need some more .I am still hungry. Of course, I want some more. During a concurrent observation and interview on 10/9/23 at 12:50 p.m., with the Director of Clinical Operations (DOCO), the DOCO entered Resident 29's room and asked the resident, [Resident 29], I heard you were asking for extra portions for lunch? Resident 29 answered, Yes. I wanted more food. I have a very small portion every day and I would like to have some more. The DOCO stated, Did you talk to the dietitian about your food preferences .to talk about your diet? Resident 29 stated, No. I have not talked to anybody about the food I want. The DOCO verified the meal card which indicated 'double portion', and stated, I think he needs double portion. During a review of the facility's P&P titled, Therapeutic Diets, revised 10/17, the P&P indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .The dietitian, nursing staff and attending physician will regularly review the need for and resident acceptance of, prescribed therapeutic diets. 3. Resident 10 was admitted in late 2023 with diagnoses which included memory impairment, prostate cancer, repeated falls, difficulty walking and low back pain. During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 had moderate memory impairment, had a urinary catheter, and needed extensive assistance with ADLs. During a review of Resident 10's NCP, dated 9/15/23, the NCP indicated, [Resident 10] is at risk for falls. Resident 43 was admitted in the middle of 2023 with diagnoses which included hip fracture. During a review of Resident 43's NCP, dated 9/1/23, the NCP indicated, Decreased functional mobility secondary to: L [left] hip femoral neck fx [fracture]. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had mild memory impairment and needed extensive assistance with ADLs. During a review of Resident 43's NCP, dated 9/26/23, the NCP indicated, At risk for falls. During a concurrent observation and interview on 10/9/23 at 8:57 a.m., Resident 10 and Resident 43 were having breakfast in their own beds, both awake and alert and both verbally responsive. Resident 10 stated, I have issues with the people working here. I would turn on my call light and all they would say is, 'Sir, I'll come to you. I'll be there with you.' These call lights, these things don't work. The call light doesn't work. I turn it on and they don't respond .If we need help to get up to go to the bathroom, they don't come. I wouldn't get up and I'd be on the floor before they get here, so I have to wet myself. Resident 43 joined the conversation and stated, [Resident 10] is right. I have turned on this call light, but I guess it is broken. Nobody came here to check us and it has been an hour .Right now, I can't get nobody .I have turned on the call light about half an hour ago and nobody came in. When the call light was checked, the call light turned on inside the room with no audible sound. When the outside call light on top of the room door was checked, it did not turn on or light up. Resident 43 stated, So, they probably don't know that we turned on the call light. During a concurrent observation and interview on 10/9/23 at 9 a.m., with LN 5, LN 5 checked and verified Resident 10 and Resident 43's call lights were broken and the light on top of the room door did not turn on, and stated, I don't see any light outside the room. I wouldn't be able to know if the call light was on. I think it is not working. When it's not lighted and they turned it on, that means it does not work. The thing is broken. If they need help like in an emergency and the call light is not working, that would not be safe. During a concurrent observation and interview on 10/9/23 at 10:21 a.m., with the NC, the NC verified the call light device was not working and was not lighting up outside the door for staff to monitor, and stated, For sure, the call light is not working. I think it comes on but just don't know if it is registered down in there in the front desk or not and the light outside is not on either. During an interview on 10/11/23 at 3:19 p.m., with the DOCO, the DOCO stated, Call lights that are not working should be fixed for resident safety. During a review of the facility's P&P titled, Answering the Call Light, revised 3/21, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Be sure that the call light is plugged in and functioning at all times .Report all defective call lights to the nurse supervisor promptly. 4. During a concurrent observation and interview on 10/9/23 at 10:08 a.m., Resident 43 was in bed, awake and verbally responsive, and stated, I don't have any clock or television in this room. They said that if you want a TV you got to have it donated by your family. I'm okay with no TV but no clock in here? They do have TV for everybody else in other rooms. The TV I understand, but no clock, I mean, I don't even know what time it is for the day right now. I have to call the CNA and ask for the time and they don't respond to that half of the time. But then again, the call light does not work. I feel neglected and don't have any dignity at all .I have nothing and have no Social Security and my income is very little to none, undignified existence right? During an interview on 10/9/23 at 12:53 p.m. with CNA 7, CNA 7 verified there was no wall clock or television in Resident 43's room, and stated, There are clocks and TVs in other rooms but this room has none. I don't know how the residents know what time of the day is. During a review of the facility's P&P titled, Accommodation of Needs, revised 3/21, the P&P indicated, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being .The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis .In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs and preferences for four of 21 sampled residents (Resident 446, Resident 29, Resident 10, and Resident 43) when: 1. Water was not within reach for Resident 446; 2. Diet request for double protein portions was not provided to Resident 29; 3. The call light device was broken and not working in Resident 10 and Resident 43's room; and 4. There was no wall clock or television in Resident 10 and Resident 43's room. These failures had the potential to result in the residents' not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being. Findings: 1. Resident 446 was admitted to the facility in the fall of 2023 with multiple diagnoses which included aphasia (inability to speak), dysphagia (difficulty in swallowing), hemiplegia (paralysis of one side of the body), and pneumonitis (inflammation of the lungs). During a review of Resident 446's Nursing Care Plan (NCP), titled Resident is at risk for fluid volume deficit (dehydration) R/T [Related To] CVA [Cerebrovascular Accident, stroke] with weakness .impaired mobility, initiated 9/21/23, the NCP indicated, Offer fluids as tolerated or as indicated per diet order. During a review of Resident 446's Food and Nutrition Review (FNR), dated 9/21/23, the FNR indicated, Diet Order Puree Regular [with] Nectar Thick Liquids .Dysphagia. During a review of Resident 446's Minimum Data Set (MDS, an assessment tool), dated 9/28/23, the MDS indicated Resident 446 had severe memory impairment and required moderate assistance with activities of daily living (ADLs). During an observation on 10/9/2023 at 10:59 a.m., Resident 446 was lying in bed with no water pitcher at the bedside. During a concurrent observation and interview on 10/9/23 at 11:03 a.m., with Licensed Nurse 1 (LN 1), LN 1 verified that Resident 446 did not have a water container and said that there should be one at the bedside. During an interview on 10/9/23 at 11:05 a.m., with Activities Assistant 2 (AA 2) , the AA 2 stated, Residents should have water pitchers at the bedside. During an observation and attempted interview on 10/10/23 at 10:15 a.m., with Resident 446 there was no water pitcher observed at Resident 446's bedside. An attempt was made to interview the resident without success. During a concurrent observation and interview on 10/10/23 at 10:36 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 verified there was no water at the bedside and said, I get his water from the refrigerator. He's on a thickened liquid diet. During a subsequent observation on 10/10/23 at 12:50 p.m., there was no water pitcher at the bedside of Resident 446. Multiple observations were made throughout the survey and water was never observed at Resident 446's bedside over four days. During a review of the facility's policy and procedure (P&P) titled, Resident Hydration and Prevention of Dehydration, revised 10/17, the P&P indicated Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care .

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 32 was admitted to the facility in mid 2023 with multiple diagnoses which included depression, and dementia (memory impairment). During a review of Resident 32's MDS dated [DATE], the MDS indicated Resident 32 had severe memory impairment. During a review of Resident 32's OSR, the OSR indicated Resident 32 received medications which included sertraline (medication used to treat depression) 100 milligrams (mg, a unit of measurement), one tablet once a day for depression manifested by social isolation ordered on 8/24/23; and quetiapine (medication used to balance hormones that help regulate mood, behaviors, and thoughts) 25 mg, three tablets every eight hours for dementia with behavior disturbances manifested by physical and verbal aggression, ordered on 8/16/23. During a review of Resident 32's NCPs, the NCPs indicated monitoring of behavior side effects but were not specific for Resident 32's target behaviors, diagnoses of dementia, and the medications ordered. During an interview on 10/10/23 at 3:38 p.m., with the DON, the DON confirmed there was no specific care plans for dementia or depression. During a review of the facility's P&P titled, Resident Participation - Assessment/Care Plans, dated 2/21, the P&P indicated, A comprehensive care plan is developed within seven (7) days of completing the resident assessment. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/22, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident. 2. Resident 1 was admitted to the facility in the middle of 2017 with diagnoses which included difficulty in walking, chronic pain, and muscle weakness. During a review of Resident 1's Physician Progress Note (PPN), dated 8/5/23, the PPN indicated Resident 1 complained of dental issues. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had no memory impairment and had experienced mouth or facial pain, discomfort, and difficulty with chewing. During a review of Resident 1's Oral Evaluation/Treatment record, dated 9/15/23, the record indicated Resident 1 had two teeth extracted due to pain and infection and was fitted for dentures on 9/25/23. During a review of Resident 1's NCP, dated 9/1/23 and revised 10/11/23, the NCP indicated, [Resident 1] has oral/dental health problems r/t [related to] C/O [complaint of] MOUTH PAIN. The mouth pain was not specific to Resident 1's tooth extraction or dentures. During an interview on 10/11/23 at 11:04 a.m., with Licensed Nurse (LN) 3, LN 3 indicated she was aware Resident 1 had some teeth pulled last month, 9/23, and stated, Care plans are developed by the DON [Director of Nursing] and they should be initiated immediately when a new issue arises for a resident. During a concurrent interview and record review on 10/11/23 at 3:04 p.m., with the DON, the DON verified Resident 1's NCP was initiated on 9/1/23 and was not updated to reflect the tooth extraction and denture fitting. The DON stated, For a resident with a change of condition, the care plan should be initiated that same day. During a review of the facility's P&P titled, Care Plans, Comprehensive Person - Centered, revised 4/21, the P&P stipulated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.Findings: 1. Resident 300 was admitted to the facility in the fall of 2023 with diagnoses which included brain tumor, difficulty swallowing. During a review of Resident 300's Order Summary Report, (OSR), order start date 9/19/23, the OSR indicated, Triamcinolone Acetonide Cream 0.1% [medication used to treat skin conditions] Apply .every 12 hours as needed for rash . During a review of Resident 300's Nursing Care Plan, (NCP), initiated 10/10/23, the NCP indicated, The resident has a rash . During an interview on 10/11/23 at 2:45 p.m., with the Minimum Data Set Coordinator (MDSC, nurse who collects and assesses information), the MDSC was asked about the timing of care plans. The MDSC stated, .The care plan should be implemented immediately . I put some in today, they are late . Based on interview and record review, the facility failed to develop and implement comprehensive care plans for three out of 21 sampled residents (Resident 300, Resident 1, and Resident 32), when: 1. No care plan developed or implemented on medication for Resident 300's skin rash; 2. No care plan developed or implemented after teeth extraction for Resident 1; and 3. No care plan was developed or implemented for Resident 32's psychotropic medication. These failures had the potential to result in residents not attaining their highest practicable physical, mental and psychosocial well-being.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders in accordance with the professional standards of quality care for two of 21 sampled residents (Resident 1 and Resident 13), when: 1. Resident 1 was not weighed daily; and 2. Out of range blood sugar levels were not reported to the physician for Resident 13. These failures had the potential to result in the residents not obtaining their highest practicable well-being. Findings: 1. Resident 1 was admitted in the middle of 2017 with diagnoses which included difficulty in walking, edema (swelling caused by too much fluid trapped in the body's tissues) and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 8/29/23, the MDS indicated Resident 1 had no memory impairment. During a review of Resident 1's Order Summary Report (OSR) dated 10/9/23, the OSR indicated a physician's order for daily weights. During a review of Resident 1's Weight Summary History, the summary indicated the following: a. 7/24/23 198.0 lbs. (pounds, a unit of measurement) b. 8/25/23 192.0 lbs. c. 8/31/23 192.8 lbs. d. 10/6/23 190.6 lbs. During a concurrent interview and record review on 10/11/23 at 11:07 a.m., with Licensed Nurse 3 (LN 3), LN 3 checked and verified Resident 1's order for daily weights was ordered on 7/13/23. LN 3 confirmed there were no daily weights available for Resident 1 and stated, These are more like monthly weights, not daily weights. During a concurrent interview and record review on 10/11/23 at 3:07 p.m., with the Director of Nursing (DON), the DON checked and verified Resident 1's daily weights ordered, and indicated Resident 1 did not have daily weights taken as ordered. The DON stated, The licensed nurse should notify the Certified Nursing Assistant (CNA) which residents need daily weights and the expectation is the licensed nurse would follow the physician's order as written. 2. Resident 13 was admitted in late 2023 with diagnoses which included diabetes (abnormal blood sugar levels). During a review of Resident 13's MDS, dated [DATE], the MDS indicated Resident 13 had no memory impairment. During a review of Resident 13's OSR, dated 9/22/23, the OSR indicated to call the physician if the blood sugar was greater than 200mg/dL (milligram/deciliter, a unit of measurement). During a review of Resident 13's Medication Administration Record (MAR) from 10/23, the MAR indicated Resident 13's blood sugar levels fluctuated from 190mg/dL to 375mg/dL. During a concurrent interview and record review on 10/11/23 at 3:09 p.m., with the DON, the DON checked and verified Resident 13's physician's orders, and indicated there was no documentation to indicate the physician had been notified of the elevated blood sugars. The DON stated, The licensed should have contacted the physician regarding the elevated blood sugars and follow physician orders as written. A policy facility's policy and procedure for Physician's Orders was requested but not provided. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment . ordered by and within the scope of licensure of a physician .as defined by Section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. pp. 5)

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits of the Medication Administration Record (MAR) and Controlled Drug Record (CDR) for two out of three residents (Residents 2 and 31) did not reconcile to indicate they were given to the residents. 2. Implement a system to accurately document and secure emergency medications (E-Kit) for a census of 44. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions. Findings: 1. Resident 31 had a physician's order, dated 10/5/23, for hydromorphone (a medication to treat pain) 2 milligrams (mg, a unit of measurement), one tablet by mouth every four hours as needed for moderate pain. The MAR indicated one tablet was signed out on 9/1/23 at 9:47 p.m. The CDR did not indicate that hydromorphone was administered to Resident 31 on this date or time. Resident 2 had a physician's order, dated 7/28/23 for Tramadol (a medication to treat pain) 50 mg, one tablet by mouth every six hours as needed for moderate pain. The MAR indicated one tablet was signed out on 7/25/23, 7/26/23, and 7/27/23. The CDR did not indicate tramadol was administered to Resident 2 on these dates. The CDR also indicated one tablet of tramadol was signed out on 7/24/23 and 9/17/23 but the MAR did not indicate that tramadol was administered on these dates. During an interview on 10/10/23 at 9:57 a.m. with the Director of Nursing (DON), the DON confirmed the discrepancies with the count on the MAR and CDR for both Resident 31 and Resident 2. The DON stated medications should have been documented in both the MAR and the count sheets. The DON also stated there was a potential for overdose if not documented in the MAR because there was no documentation of when a dose was last administered. During a review of the facility's policy and procedure (P&P) titled, IIA-7 Controlled Medications, dated 3/2018, the P&P indicated, Procedures . D. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration 2) Amount administered 3) Signature of the nurse administering the dose, completed after the medication is actually administered. 2. During an inspection of the Medication Storage Room on 10/9/23 at 10:35 a.m. with the DON, the E-Kit containing first dose oral medications was observed with a red tag (indicating the E-Kit had been opened by the facility). The E-Kit logs inside indicated one capsule cefdinir (a medication to treat infection) 300 mg was removed on 9/22/23, two capsules cephalexin (a medication to treat infection) 250 mg were removed on 10/4/23, and one tablet sulfamethoxazole (a medication to treat infection) 800 mg/160 mg was removed on 10/6/23. During an inspection of the Medication Storage Room on 10/9/23 at 10:35 a.m. with the DON, the E-Kit containing oral antibiotics was observed with a red tag. The E-kit log inside indicated one single dose vial ceftriaxone (a medication to treat infection) 1 gram (g, a unit of measurement) was removed on 9/26/23. During an inspection of the Medication Storage Room on 10/9/23 at 10:35 a.m. with the DON, the narcotics (medications with a high potential for abuse or diversion) E-kit was observed with a red tag. The E-kit log inside indicated an unspecified amount of oxycodone 5 mg was removed on 9/9/23, and one tablet hydromorphone 2 mg was removed on 9/15/23. During an interview on 10/9/23 at 10:35 a.m. with the DON, the DON confirmed the quantity was not on the slip and stated staff should have documented how many tablets were removed. The DON also stated, I think three days nurses are supposed to call pharmacy once they remove medication. During an interview on 10/10/23 at 9:40 a.m. with the DON, the DON stated, The nurse who takes out the E-kit is the one responsible to call the pharmacy to have it replaced within 3 days. During a review of the facility's P&P titled, IC-3 Emergency Pharmacy Service and Emergency Kits, dated 3/2018, the P&P indicated, Procedures . G. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit by transmitting the entire order for the resident and indicating that the first dose was used from the kit. The nurse flags the kit with a red color-coded lock to indicate need for replacement of kit . K. If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. If replacing used medications, the replacement doses are added to the kit within 72 hours of opening.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility had a 10.53% error rate when four medication errors out of 38 opportunities were observed during a medication pass for two of six residents (Residents 31 and 299). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: During a medication pass observation on 10/9/23 at 8:21 a.m. with Licensed Nurse 1 (LN 1), LN 1 was observed preparing five medications for Resident 31 including one tablet docusate sodium (medication to treat constipation) 100 milligrams (mg, a unit of measurement), one capsule fluoxetine (medication to treat depression) 40 mg, one capsule gabapentin (medication to treat pain) 300 mg, two tablets allopurinol (medication used to treat gout, a form of inflammation in the joints) 100 mg, and miralax (medication used to treat constipation) 17 grams (g, a unit of measurement). A review of Resident 31's medical record indicated physician's orders for aspirin (medication used to prevent blood clots) enteric coated (EC, a coating formulation that allows aspirin to pass through the stomach to the small intestine before dissolving) 81 mg, one tablet by mouth once daily for deep vein thrombosis (DVT, a blood clot in a deep vein) prophylaxis, dated 8/5/2023, and albuterol (medication used to relax muscles in the airways) 0.083% solution, one vial three times daily, dated 8/5/23. These medications were omitted during the medication pass observation on 10/9/23 at 8:21 a.m. During a medication pass observation on 10/9/23 at 8:21 a.m. with LN 1, LN 1 was observed preparing five medications for Resident 299 including megestrol (medication used to treat loss of appetite and weight loss) 40 mg/mL, 10 milliliters (mL, a unit of measurement). The sticker on the bottle indicated an instruction to shake well. LN 1 withdrew the medication using a 10 mL syringe without shaking the bottle. During a medication pass observation on 10/10/2023 at 8:30 a.m. with LN 2, LN 2 was observed preparing seven medications for Resident 31 including one tablet docusate sodium 100 mg, one capsule fluoxetine 40 mg, one capsule gabapentin 300 mg, two tablets allopurinol 100 mg, one tablet benazepril 10 mg, one tablet aspirin EC 81 mg, and one vial albuterol 2.5 mg/mL solution. A review of Resident 31's medical record indicated a physician's orders for miralax 17 g one time a day for bowel care and 17 g as needed for constipation, dated 9/27/23. The medication was omitted during the medication pass observation on 10/10/23 at 8:30 a.m. During a concurrent interview and record review on 10/10/23 at 9:18 a.m. with LN 2, LN 2 confirmed the order for Miralax was scheduled for 8 a.m. LN 2 stated, Yeah, so she is due for Miralax. I don't know how I missed that, probably going back and forth to the med room. During an interview on 10/10/23 at 9:46 a.m. with the Director of Nursing (DON), the DON stated, If the nurse did not give the [scheduled] medication, that is a medication error. DON stated it was important to shake the megestrol before measuring a dose because the medication settled at the bottom of the bottle. A review of Lexi-comp, a nationally recognized drug information resource, indicated, Shake suspension well before use. (www.lexicomp.com; accessed 10/12/23) During a review of the facility's policy and procedure (P&P) titled, IIA-2 Medication Administration-General Guidelines, dated 3/2018, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing priniciples and practices .Procedure .B. Administration .2) Medications are administered in accordance with the written orders of the attending physician.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure: 1. Prepared medications were properly stored and labeled, and administered at the time of preparation; 2. Controlled medications were stored in accordance with facility policy and procedure; 3. Expired and discontinued medications were not available for resident use; and 4. Opened biologicals, eye drops, and inhalation solutions were dated once opened, to ensure they were not used beyond the discard date, and appropriately labeled with a pharmacy label or name to correctly identify which resident they were for. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage, and diversion or misuse of medications from not being securely stored. Findings: 1. During a medication administration observation on 10/9/23 at 9:07 a.m. with Licensed Nurse 1 (LN 1), two unlabeled medication cups containing white powder were observed on Resident 299's bedside. One of the medication cups indicated groin. LN 1 left the resident's room after administering medications and left the medication cups unattended on the resident's nightstand. During an interview on 10/10/23 at 9:22 a.m. with LN 2, when asked about the two medication cups left unattended at Resident 299's bedside, LN 2 stated, I would never do that, we're not supposed to leave medication at bedside. During an interview on 10/10/23 at 9:44 a.m. with the Director of Nursing (DON), the DON stated, It is not appropriate, there should be a nurse giving that, it is not okay to have it just there. The nurse is supposed to be administering it, not leaving it at bedside. During an interview on 10/10/23 at 10:35 a.m. with the Infection Preventionist (IP), the IP stated, No medications should be left at bedside. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 3/2018, the P&P indicated, Label and Storage of Drugs .13. The drugs of each patient shall be kept and stored in their originally received containers. No drug shall be transferred between containers. During a review of the facility's policy and procedure (P&P) titled, Medication Administration-General Guidelines, dated 3/2018, the P&P indicated, A. Preparation .4. Medications removed from prescription packaging .are not kept .for attempts of administering at a later time .B. Preparation .4. Medications are administered at the time they are prepared. 2. During a concurrent observation and interview on 10/9/23 at 10:15 a.m. with the DON, an inspection of the Medication Storage Room identified Narcotic (substance that affects mood or behavior) emergency kits (E-kits) were stored inside an unlocked cabinet. The DON confirmed the E-kits were stored unlocked in the cabinet. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 3/2018, the P&P indicated, Procedures .I. Schedule II through V controlled medications are stored separately from other medications in a separate area under double lock. During a review of the facility's P&P titled, IC-3 Emergency Pharmacy Service and Emergency Kits, dated 3/2018, the P&P indicated, Procedures .4. Emergency Schedule 2 controlled substances are kept at designated nursing stations or the medication room, as determined by the facility, under double-lock in a sealed, portable container. 3. During a concurrent observation and interview on 10/9/23 at 10:15 a.m. with the DON, an inspection of the Medication Storage Room identified the following expired and discontinued medications and medical supplies: - 3 MaxPlus Clear needleless connector, expired 4/2021 - 1 Medline 3 milliliters (mL, a unit of measurement) Safety Syringe, expired 9/8/21 - 7 bags discontinued 0.9% (percent, a unit of measurement) sodium chloride (a mixture of salt and water) injection solution - 3 boxes discontinued lokelma (a medication used to lower potassium levels) 5 grams (g, a unit of measure) - 3 boxes discontinued timolol (a medication used to treat increased pressure in the eye) 0.5% ophthalmic solution DON confirmed the items identified in the Medication Storage Room were expired and should have been removed from the facility's stock. The DON stated that any discontinued medications were to also be removed from stock. During a concurrent observation and interview on 10/9/23 at 10:48 a.m. with LN 1, an inspection of Medication Cart 2 (Med Cart 2) identified the following expired medications: - 1 bottle latanoprost (a medication used to treat increased pressure in the eye) 0.005%, expired 10/6/23 - 1 box prilosec (a medication that decreases the amount of acid produced in the stomach), expired 4/2023 - 1 aquapak (used to increase water vapor in the air), expired 7/31/23 LN 1 confirmed the identified medications were expired and should have been removed from the medication cart. During a concurrent observation and interview on 10/9/23 at 11:25 a.m. with the DON, the Medication Storage Room refrigerator was inspected and identified a bottle of compounded magic mouthwash (a compounded [customized] medication) expired on 6/9/23 and an opened vial of tubersol (a medication used as an aid in the detection of infection with tuberculosis, a bacterial disease that affects the lungs) opened 9/7/23. The DON confirmed the identified expired medications. When asked about the stability of tubersol once opened, the DON stated she did not know how long tubersol was stable for after first use. During an interview on 10/10/23 at 9:37 a.m. with the DON, the DON stated, Expired medications should be removed from stock and brought to the DON. During an interview on 10/10/23 at 10:34 a.m. with the IP, when asked about the stability of tubersol after first use, the IP stated, It [tubersol] is good for 30 days, then toss it. During a review of the facility's P&P titled, IIA-3 Dating of Containers When Opened, dated 3/2018, the P&P indicated, Procedures .C. Medication in Multi-dose (injection) vials: are to be dated when opened and discarded after 28 days unless the manufacturer recommends shorter expiration date. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 3/2018, the P&P indicated, Procedures .M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medical disposal .12. Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use. 4. During a concurrent observation and interview on 10/9/23 at 10:48 a.m. with LN 1, an inspection of Med Cart 2 identified two loose tabs in cart in a medication cup unlabeled. The following medications were observed without resident specific labeling: 1 carbamide peroxide (used to treat earwax buildup) 6.5% ear drops, 2 zaditor (medication to prevent and treat itching of the eyes) 0.035% eye drops, 1 Artificial Tears (used to lubricate dry eyes), and 1 vial albuterol sulfate (used to treat or prevent narrowing of the airways) 2.5 milligrams/3 milliliter (mg/ml, a unit of measurement). One fluticasone/salmeterol (used to reduce irritation and swelling of the airways) 250/50 micrograms (mcg, a unit of measurement) inhaler was also identified without an open date. LN 1 confirmed the identified medications and biologicals were not labeled appropriately and should have been labeled with information including the resident's name and date of birth . LN 1 stated it was not acceptable to label medications with just a room number because the residents could change rooms. During an interview on 10/10/23 at 9:41 a.m. with the DON, the DON stated nurses were expected to write the open date and the resident's name on the bottle itself when opening medications. The DON also stated that writing the resident's room number is not acceptable because the resident can be moved to a different room anytime. During a review of the facility's P&P titled, IC-6 Medication Storage, dated 3/2018, the P&P indicated, Procedures .A. Labels are permanently affixed to the outside of the prescription container .If a label does not fit directly onto the product, e.g., eye drops, the label may be affixed to an outside container or carton, but the resident's name, at least, must be maintained directly on the actual product container. During a review of the facility's P&P titled, IIA-3 Dating of Containers When Opened, dated 3/2018, the P&P indicated, Procedures .D. Eye Drops .2. Over the counter eye-drops .will need to have the date opened noted on the container .Over-the-counter eye drops need to also have the resident (last) name on the container, not just a room number .E. Inhalers .1. Inhalers dispensed by [supplier pharmacy] will either have a 'date opened' sticker in place on the inhaler container or a shortened expiration date placed on the prescription label .2. Inhalers dispensed by other pharmacy will need to have the date opened indicated on the inhaler and notation as to when to discard .

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician) during the lunch meals on 10/10/23 and 10/11/23 when: 1. Five residents (Resident 1, 6, 9, 14, and 19) with small portion diets who got the incorrect portion size with their meals, 2. Eight residents (Resident 1, 10,14, 21,23,28,31, and 32) with mechanical altered texture diets (a modified texture diet is soft and moist for people who has chewing or swallowing issues), and seven residents (Resident 4, 8, 15, 17, 19, 97, and 446) with puree texture diets (a modified texture diet in a consistency of pudding-like for people who has chewing and/or swallowing difficulties), who received ambrosia (a creamy fruit salad usually with pineapple, mandarin oranges, coconut and marshmallows) instead of mandarin orange as dessert, 3. [NAME] (CK) 1 prepared pureed meat and pureed vegetable without measurement of broth and not following the recipe. These failures had the potential to result in compromising the medical and nutritional status of 42 residents for a census of 44. Findings: 1. During an observation of lunch meal service on 10/10/23, beginning at 11:34 a.m., CK 1 used the regular serving scoop size to serve the five residents (Resident 1, 6, 9, 14, and 19) with small portions with their diets. A concurrent review of a facility menu, titled Fall/Winter 2023-Diet Spreadsheet (a display data sheet is indicated what food items, textures and portions to be served for each prescribed diet), indicated there were no small portions for each diet. A concurrent interview with the Registered Dietitian (RD), the RD confirmed that there was no small portion on the spreadsheet. She stated she was not aware there was no small portion and large portion on the spreadsheet and would need to call the menu company to add them on the spreadsheet. During an interview with the CK 1 on 10/10/23, at 11:55 a.m., during lunch meal service, she stated there was no measurement indicated small or large portions on the spreadsheet. She stated she would give half portion of regular portion for each food items for small portion. She stated for large portion, she would give one and a half portion of regular portion of meat on the entrée. During the follow-up interviews with the RD on 10/10/23, at 12:20 p.m. and 1:30 p.m., the RD stated and confirmed that the small portions that the kitchen provides to the residents were not with the correct servings and might affect residents' nutrition intake and might lead to weight loss. The RD added they did not have the diet manual for the facility which could have further information about small and large portions. A review of departmental policy and procedure, titled Portion Sizes, dated 2023, it stated, .the small and large portion servings will be served as printed on the cook's spreadsheets for every meal . A review of departmental policy and procedure, titled Menu Planning, dated 2023, it stated, .The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility . 2. During the observation of lunch meal service on 10/10/23, beginning at 11:34 a.m., found eight residents (Resident 1, 10, 14, 21, 23, 28, 31, and 32) with mechanical altered diets and seven residents (Resident 4, 8, 15, 17, 19, 97, and 446) with puree diets who received ambrosia instead of mandarin orange as dessert. A concurrent review of facility document, titled Fall/Winter 2023-Diet Spreadsheet, it indicated residents with mechanical altered and pureed diets should have orange mandarin. During an interview and concurrent review of Fall/Winter 2023-Diet Spreadsheet with the RD on 10/10/23, at 1:10 p.m., the RD was acknowledged and stated the residents with mechanical altered and pureed diets should have had mandarin orange as dessert instead of ambrosia. The RD stated the staff needed to follow the menu or spreadsheet to prepare the meals for the residents. A review of facility document, titled Job Description: Position: FNS (Food and Nutrition Services) Director, dated 2023, it indicated the FNS department should follow prepared menu. 3. During an observation of CK 1 preparing five servings of pureed meat (meatloaf) and vegetable (spinach with mushroom) for lunch meal on 10/11/23, at 11:42 a.m., observed CK 1 added vegetable broth to both pureed meat and vegetables without measurement and not using any recipes. A concurrent interview with CK 1, she stated she did not use recipes and never measure broth to make purees. She added there was no one teach her to measure the broth. A concurrent confirmation with the Dietary Supervisor (DS), she stated CK 1 needed to follow the recipe. She stated the way that CK 1 making puree was not correct. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated the [NAME] had to follow the recipe and follow the measurement to make the right pureed texture for the residents who have chewing or swallowing problems. A review of the pureed meat and vegetable recipes, titled Spinach with Mushrooms PU (Puree) and Meatloaf 3 oz. (ounces) PU, indicated that for pureed vegetables, they did not need to add broth, and for pureed meat, they should add half cup and two tablespoons of broth for making five servings. A review of facility document, titled Job Description: [NAME] A, dated 2023, it indicated the [NAME] should have ability to accurately measure food ingredients and portions. A review of facility document, titled Job Description: FNS Director, dated 2023, it indicated the FNS director should ensure the menus and accompanying recipes were followed.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a medication administration observation by the Health Facility Evaluator Nurse (HFEN) and the Pharmacy Consultant (PC) on 10/9/23 at 8:21 a.m. with LN 1, LN 1 prepared medications for Resident 299 which included megestrol (medication used to treat loss of appetite and weight loss) 40 milligrams/milliliter (mg/mL, unit of measurement), 10 milliliter (mL, unit of measurement). During preparation, LN 1 drew 10 mL from the bottle with a syringe. After measuring the medication, LN 1 placed the syringe directly on the medication cart. LN 1 then entered Resident 299's room and administered the medication directly into the resident's mouth with the syringe. During an interview on 10/10/23 at 9:53 a.m., with the Director of Nursing (DON), the DON indicated staff were expected to not place a syringe used to measure medication directly on top of the medication cart. The DON stated, The syringe should have only been used to measure the medication, which should have been poured into a medication cup for administration to the resident. The DON indicated the syringe should not have touched Resident 299. During an interview on 10/10/23 at 10:29 a.m., with the IP, the IP indicated oral syringes should have only been used for one person and should been discarded immediately after use. The IP stated, Oral syringes should have not been placed into the resident's mouth and nurses were expected to use a medication cup for administering liquid medications. The IP indicated the syringe on top of the medication cart should have been discarded because there was no barrier between the syringe and the medication cart. During a review of the facility's P&P titled, Medication Administration-General Guidelines, dated 3/18, the P&P indicated, Procedures .A. Preparation .2) .Disposable containers are never reused. During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/22, the P&P indicated, Single-use items are disposed of after a single use. 5. During a medication administration observation by the HFEN and the PC on 10/9/23 at 8:41 a.m. with LN 1, LN 1 checked Resident 25's blood pressure (BP) before administering a medication to treat high blood pressure. After obtaining the BP, LN 1 removed the BP cuff from Resident 25's left upper arm and placed the cuff without sanitizing or disinfecting back in a wire basket attached to the BP monitor cart. During an interview on 10/10/23 at 9:39 a.m., with the DON, the DON indicated BP pressure monitors were to be cleaned in-between residents. During an interview on 10/10/23 at 10:29 a.m., with the IP, the IP indicated devices used for multiple residents should have been cleaned and disinfected each time it was used, prior and after, and should have the proper dwell time (the amount of time a disinfectant must remain on a surface to effectively kill germs). During a review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/22, the P&P indicated, Non-critical items .(1) Non-critical resident-care items include bed pans, blood pressure cuffs, crutches and computers .(3) Non-critical items require cleaning followed by either low-or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA [Environment Protection Agency]-registered disinfectant labeled for use in healthcare settings .5. Reusable items are cleaned and disinfected or sterilized between residents . 6. During a medication administration observation on 10/10/23 at 11:31 a.m., with LN 4, LN 4 used a glucometer (device used to measure the blood sugar levels). After measuring the resident's blood sugar, LN 4 wore gloves and wiped only the port of glucometer using one alcohol swab. During an interview on 10/10/23 at 11:38 a.m. with LN 4, when asked about using an alcohol swab to clean the glucometer, LN 4 stated, Bleach would be more effective. LN 4 looked on the top and inside the medication cart and confirmed there were no appropriate disinfectant wipes available for use. During an interview on 10/10/23 at 12:59 p.m., with the IP, the IP indicated alcohol pads were not effective against all diseases that can spread through the blood. The IP stated, Staff should have used an EPA-registered disinfectant and staff were expected to clean the entire device, not just the port, after use. During a review the facility's P&P titled, Blood Sampling - Capillary (Finger Sticks), dated 9/14, the P&P indicated, Equipment and Supplies .6. Approved EPA registered disinfectant for cleaning of sampling device .Steps in the Procedure .8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. During a review of the facility's P&P titled, Policies and Practices - Infection Control, dated 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 .Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. 3. Resident 15 was admitted to the facility in late 2022 with diagnoses which included lung cancer and weakness. During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 had severe memory impairment and required total dependence for her personal hygiene (brushing teeth, washing hands). During a concurrent observation and interview on 10/9/23 at 11:06 a.m., in Resident 15's bathroom with the Infection Preventionist (IP, nurse responsible for infection control practices), an unlabeled and undated emesis basin (curved plastic bowl used to spit liquid in after brushing teeth) was found in the shared bathroom. The basin contained an uncovered toothbrush, nail file, nail clippers, tweezers, tooth paste, and mouth moisturizer stored together. The IP confirmed the findings and indicated that was not the correct way to store items, and stated, Hygiene items should be individually separated and have dates and identifiers. 2. Resident 9 was admitted in the middle of 2023 with diagnoses which included respiratory failure, heart failure, and muscle weakness. During a review of Resident 9's OSR, dated 7/17/23, the OSR indicated, Administer O2 (oxygen) via nasal cannula [tubing]/face mask 2-5 L [liter, a unit of measure] per minute as needed for shortness of breath. During a review of Resident 9's NCP, dated 8/31/23, the NCP indicated, The resident has altered respiratory status/difficulty breathing r/t [related to] Dx [diagnosis]. Acute Respiratory Failure .The resident has oxygen [O2] therapy prn [as needed]. During a review of Resident 9's MDS, dated [DATE], the MDS indicated Resident 9 had no memory impairment. During a concurrent observation and interview on 10/9/23 at 10:25 a.m., Resident 9 was in bed, awake, alert and oriented, and at the bedside was an O2 concentrator (a machine that takes oxygen from the air, purifies it, and delivers it to the patient) turned on with an O2 nasal tubing and a humidifier connected to the resident. Resident 9 stated, Usually, they change the [O2] tubing and my humidifier every week and there should be a date and time when they changed it. It is a piece of tape where they write the label. I don't know when they changed it. The O2 tubing and the humidifier were inspected and noted there were no labels found. During a concurrent observation and interview on 10/9/23 at 10:28 a.m., with LN 3, LN 3 checked and verified the O2 tubing and the humidifier, and stated, The tubing and humidifier are changed every week. I don't see any label right now. That is not safe because it could lead to respiratory infection. During a concurrent observation and interview on 10/10/23 at 9:11 a.m., the O2 tubing and the humidifier had no label. Resident 9 stated, They did change my humidifier yesterday .They brought a new humidifier bottle. I did not get a new cannula. They should have put a label and date on the bottle, and you even told them yesterday. That's not good. During a concurrent observation and interview on 10/10/23 at 9:15 a.m., CNA 1 checked and verified the O2 tubing and humidifier, and stated, There is no label on the humidifier and the oxygen tubing. There should be one. Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five out of 21 sampled residents (Resident 96, Resident 9, Resident 15, Resident 299, and Resident 25), when: 1. Oxygen equipment and personal items were not labeled for Resident 96; 2. Oxygen tubing and humidifier were not dated and labeled for Resident 9; 3. Personal hygiene items were not stored correctly for Resident 15; 4. An oral syringe used to measure medication was placed directly on the medication cart and used to orally administer medication to Resident 299; 5. A blood pressure cuff was not disinfected after use for Resident 25; and 6. A glucometer was not properly sanitized and disinfected after use. These failures had the potential to result in the transmission of infection in a vulnerable population. Findings: 1. Resident 96 was admitted to the facility in the fall of 2023 with multiple diagnoses which included COPD (Chronic Obstructive Pulmonary Disease, a lung disease) and shortness of breath (SOB). During a review of Resident 96's Minimum Data Set (MDS, an assessment tool), dated 10/2/23, the MDS indicated Resident 96's memory was severely impaired. During a review of Resident 96's Order Summary Report (OSR), dated 10/2/23, the OSR indicated Resident 96 was to receive Supplemental oxygen via NC [nasal cannula, 2 prongs used to deliver oxygen to the nose from an oxygen source] or oxy[oxygen]mask .for COPD and Ipratropium-Albuterol Solution [medication to open up the airways] .for SOB . During a review of Resident 96's Nursing Care Plan (NCP) titled, Risk for infections R/T [related to] inadequate primary defense, initiated 10/2/23, indicated, Administer O2 [oxygen] as ordered .administer breathing treatment as ordered . During an observation on 10/9/23 at 8:28 a.m., Resident 96's oxygen mask, nebulizer (delivers aerosolized medication) and incentive spirometer (IS, a tool to assist in lung inflation) were unlabeled and uncovered. During a concurrent observation and interview 10/9/23 at 8:29 a.m., with Licensed Nurse 5 (LN 5), LN 5 verified the oxygen mask, nebulizer tubing, and IS were unlabeled and uncovered and said the items should be labeled and covered. During an observation on 10/9/23 at 8:51 a.m., of Resident 23 and Resident 97's bathroom, one unlabeled bedpan was laying in the bathtub and one unlabeled toothbrush was laying on a shelf to the right of the mirror. During a concurrent observation and interview on 10/9/23 at 8:52 a.m., with Certified Nursing Assistant 5 (CNA 5), CNA 5 verified the observation and said, The bedpan should be labeled. Staff should get report and know the toothbrush was [Resident 23's]. During an observation on 10/9/23 at 9:11 a.m., a wash basin was found unlabeled inside the bathroom shared by Resident 4 and Resident 35. During a concurrent observation and interview on 10/9/23 at 9:12 a.m., with CNA 5, CNA 5 verified the observation and indicated [the wash basin] should be labeled. During an observation on 10/9/23 at 10:23 a.m., three Nurses hats (a specimen collector) and one bedpan were found in the bathroom shared by Resident 2 and Resident 30. During a concurrent observation and interview on 10/9/23 at 10:24 a.m., with CNA 5, CNA 5 verified the observation and said the items should be labeled. During a review of the facility's policy and procedure (P&P) titled, Accomodation of Needs, revised 3/21, the P&P indicated, In order to accomodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's .bathroom .Examples .labeling toiletry items with large print .

CONCERN (F)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to ensure one dietary personnel was competent to carry out the functions of the food and nutrition service when the Dietary Aide (DA) 1 was unable to practice correct hand hygiene practices during dishwashing with the dish machine performed by one person and unable to verbalize the process of manual (3-compartment sink) dishwashing (cross refer to F812, finding number 5). These failures had the potential to cause food borne illness in a potentially compromised population of 42 out of 44 residents who received food from the facility kitchen. Findings: During an initial kitchen tour on 10/9/23, a few observations conducted at 9:47 a.m., 9:51 a.m., and 9:56 a.m., observed the Dietary Aide (DA) 1 washing dishes with dish machine alone by himself. The DA 1 used his same bared hands touching the dirty dishes from the dirty side of dish machine, and then touching the clean dishes from the clean side without any handwashing in between. During a follow-up observation on 10/9/23, at 10:15 a.m., the DA 1 touched the dirty dishes from the dirty side, and he donned gloves without handwashing and touched the clean dishes from the clean side. During an interview with the Dietary Supervisor (DS) on 10/9/23, at 10:18 a.m., she stated DA 1 should perform handwashing and don gloves when doing dishwashing from dirty to clean sides to prevent cross contamination. During a follow-up interview with DA 1 on 10/9/23, at 10:20 a.m., he stated he was not aware that he needed to perform handwashing and don gloves when doing dishwashing between dirty and clean sides. During a concurrent observation and interview with DA 1 on 10/9/23, at 11:05 a.m., he explained the process of manual dishwashing with a 3-compartment sink. DA 1 stated he never performed and was not familiar with the process of manual dishwashing with a 3-compartment sink. He verbalized the process involved wash, rinse, and sanitize. He stated the washing water temperature should be 130 degrees Fahrenheit (F), the rinsing water temperature should be 120 degrees F. Then he stated after the dishes were washed and rinsed, the dishes would put in the sanitizer solution for two to three seconds. He added the sanitizer solution temperature should be 120 degrees F. He stated the last step was to air-dry. During an interview with the DS on 10/11/23, at 10:15 a.m., she stated she did not have any skill set competency and had no in-service done for DA 1. During an interview with the Registered Dietitian (RD) on 10/11/23, at 3:11 p.m., she stated if dishwashing with the dish machine performed by one person, the dishwasher or dietary aide should perform hand hygiene between dirty and clean sides to prevent cross contamination. The RD also stated the dishwasher should have knowledge of the process of manual dishwashing especially when the dish machine was not working. A review of facility employee file of DA 1, it indicated DA 1 was hired on 9/29/23 and there was no competency or performance evaluation in his file. A review of sample competency form provided by DS, titled Verification of Job Competency Demonstration-Dietary Aides dated 2023, it indicated Dietary Aide should have competency or knowledge of .Sanitation method used in dish machine .how to avoid cross contamination when working alone on the dish machine and its importance .emergency dish washing (manual dishwashing) procedure and when to use it .hand washing procedure .glove use in food preparation and service . A review of facility document, titled Job Description-FNS (Food and Nutrition Services) Director, dated 2023, it indicated, .the FNS Director (Dietary Supervisor) was responsible to schedule and supervise the FNS (dietary) staff providing in-service training and ensured the staff were oriented per policy form .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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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 food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. food items with missing or incorrect labeling and dating were found, 2. food items with opened packages were found not covered to prevent cross contamination (the unintentional transfer of bacteria and/or substances from one food to another), 3. food items that were expired were found and available for use, 4. ice machine was not clean located in the dining room, 5. Dietary Aide (DA) 1 was not able to verbalize the process of manual (3-compartment sink) dishwashing, and not practicing handwashing during dishwashing when perform by one person, 6. The food storage racks were not well maintained, and the condenser unit (a unit converts the refrigerant gas back into a liquid) with dripping water on the food in the walk-in refrigerator, 7. Juice dispenser machine was not clean, 8. Staff personal belongings were found in the food preparation area, 9. Various sizes of metal pans, insulate plate covers, insulated plate bases, and few food serving trays were stacked wet and stored in the clean and ready-to-use areas, 10. CK 2 was not able to verbalize ambient (room temperature) food cool down process, and 11. Residents' food was not stored at safe temperatures in the resident's food refrigerator located in the dining room. These failures had potential to cause food-borne illness in a highly susceptible population of 42 out of 44 residents who received food from the kitchen. Findings: 1. During an initial kitchen tour on 10/9/23, beginning at 9:12 a.m., there were following food items found opened and had no labels (stickers on the packages indicating opened date and expiration or used-by date) in the dry storage room: -a opened box of dry pasta (no opened and used-by date) -a opened bag of [NAME] powder (no opened and used-by date) In a concurrent interview with the Dietary Supervisor (DS), DS confirmed the opened package of food items and the staff needed to use labels to specify the opened and used-by date. During an interview with the Registered Dietitian (RD) on 10/11/23, at 3:11 p.m., she stated when the food items were opened, the staff should use the label and had the opened and used-by date written. A review of departmental policy and procedure, titled Labeling and Dating of Foods, dated 2023, it stated, .Newly opened food items will need to be .labeled with an open date and used by date . 2. During an initial kitchen tour on 10/9/23, beginning at 9:12 a.m., the following food items were found opened with a package or box not closed properly in the dry storage room: -one opened ten pounds (lbs, a unit of measurement) bag of dry pasta (the opening was not sealed) -one opened ten lbs. bag of dry pasta (the opening was taped but opened) -one opened box of dry pasta (the opening was not sealed) A concurrent interview with the DS, she stated when the food items were opened, and she expected kitchen staff to put opened packages of food in a closed container and sealed tightly. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated the opened food packages or boxes need to be sealed tightly. A review of departmental policy and procedure, titled Storage of Food Supplies, dated 2023, it stated, .Dry food items which have been opened, such as .noodles .will be tightly closed, labeled and dated . 3. During an initial kitchen tour on 10/9/23, at 9:12 a.m., 9:45 a.m., and 9:58 a.m., the following food items found passed the used-by date and were still available to use in the dry storage room, reach-in refrigerator, and walk-in refrigerator: -one bag of 10 lbs. of dry pasta (labeled with used-by date on 9/28/23) in the dry storage room -one bag of 10 lbs. of dry pasta (labeled with used-by date on 9/21/23) in the dry storage room -a pitcher of nectar thickened milk (labeled with used-by date on 10/8/23) in the reach-in refrigerator -a banana cream pie (labeled opened date of 9/7/23 and used-by date of 9/13/23) in the walk-in refrigerator During an interview with the DS on 10/9/23, at 9:12 a.m., she stated the pasta was past the used-by date and should be discarded. At 9:45 a.m., she stated the nectar thickened milk was past the use-by date and should be discarded. At 9:58 a.m., the DS stated the banana cream pie was past the used-by date and should be discarded. During an interview with the RD on 10/11/23, at 3:11 a.m., she stated the food items that were past the used-by date or expired and should be discarded. She also stated it was everybody's responsibility in the kitchen to monitor the food. A review of departmental policy and procedure, titled Storage of Food and Supplies, dated 2023, it stated, .No food will be kept longer than the expiration date on the product . 4. During an interview with the DS on 10/9/23, at 11:19 a.m., she stated the maintenance department was responsible for cleaning the ice machine in the dining room. During an interview with the Maintenance Supervisor (MS) on 10/9/23, at 3:12 p.m., MS stated he just started working in the facility for a month and had not cleaned the ice machine in the dining room yet. He stated he was not sure when the ice machine had been cleaned. A concurrent observation of ice machine revealed there was an orange and white slimy substance through the ice dispenser opening. The MS confirmed the substances and stated the ice machine should need service this week. A follow-up observation of the ice machine in the dining room and a concurrent interview with the outside vendor technician (OVT) and the Maintenance Supervisor (MS) on 10/10/23, at 3:03 p.m. was conducted. There was orange and white slimy substances accumulated at the ice dispenser opening, and white and brown substance on the drip tray. Confirmed with the OVT, and he stated the machine needed more frequent cleaning. The MS was not able to locate the cleaning log for the ice machine and was not able find the date of the last cleaning. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated she was not aware there was an ice machine in the dining room. She stated she never checked the ice machine and would start to check it on her monthly kitchen sanitation inspection. A review of facility document, titled Job Description: Food and Nutrition Service (FNS) Director, dated 2023, it stated, .Responsibilities .maintaining cleanliness of kitchen equipment, and follow all department of health regulations . A review of ice machine manufacturer's manual, dated 3/2015, on the maintenance and cleaning section, it stated, .it is important to keep the drip tray clean .Ice making and ice dispensing system cleaning instructions .frequency: Recommended minimum time between cleaning is 6 months . According to 2022 FDA (Food and Drug Administration) Food Code, on section 4-602.11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). 5. During an initial kitchen tour on 10/9/23, started at 9:47 a.m., observed the Dietary Aide (DA) 1 doing dishwashing with the dish machine performed by one person. The DA 1 used his same bared hands touching the dirty dishes from the dirty side and touching the clean dishes from the clean side without handwashing in between. Same actions were observed at 9:51 a.m. and 9:56 a.m. During another follow-up observation on 10/9/23, at 10:15 a.m., the DA 1 touched the dirty dishes from the dirty side, and he donned gloves without handwashing and touched the clean dishes from the clean side. During an interview with the DS on 10/9/23, at 10:18 a.m., the DS stated DA 1 should perform handwashing and don gloves when doing dishwashing from dirty to clean side to prevent cross contamination. During a follow-up interview with the DA 1 on 10/9/23, at 10:20 a.m., he stated he was not aware he needed to wash hands and don gloves when doing dishwashing between dirty and clean sides. During a concurrent observation and interview with the DA 1 on 10/9/23, at 11:05 a.m., he explained the process of manual dishwashing with a 3-compartment sink. DA 1 stated he never performed the manual dishwashing with 3-compartment sink and was not familiar with the process. He stated first step was to wash with water temperature of 130 degrees Fahrenheit (F), the second step was to rinse with water temperature of 120 degrees F, then put the dishes in the sanitizer in the sanitizing compartment for two to three seconds, and the water temperature should be 120 degrees F. Then the dishes needed to be air-dried. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated if dishwashing with dish machine performed by one person, the dishwashing or dietary aide should do hand hygiene between dirty and clean side to prevent cross contamination. The RD also stated the dishwasher should have knowledge for the process of manual dishwashing especially when the dishwashing machine was not working. A review of departmental policy and procedure, titled Hand Washing Procedure, dated 2023, it stated, Hand washing is important to prevent the spread of infection .When hands need to be washed .after handling soiled dishes and utensils .before and after handling food with the hands (cutting, peeling, mixing, etc.) . A review of department policy and procedure, titled 3-Compartment Procedure for Manual Dishwashing, dated 2023, it indicated the washing water temperature should be at 110-120 degrees F, the rinse water temperature should be at 110-120 degrees F. The sanitizer should be tested with test strip with concentration of 200 ppm (parts per million) and the dishes would immerse in the sanitizer solution for 60 seconds. The last step was to let the dishes air-dried. 6. During an observation in the walk-in refrigerator on 10/9/23, at 9:58 a.m., observed the food storage racks with brown substances and the paint was chipped. The condenser unit was dripping water on the food stored on the rack and the water puddled on the floor. In a concurrent interview with the DS, she confirmed the brown substance was rust on the food storage racks and verified the paint was chipped. She stated the storage racks needed to be replaced. The DS was aware the water was dripping from the condenser unit, and it needed to be fixed. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated the rusty and paint-chipped food storage racks should be replaced. She stated the chipped paint may cause physical contamination and the rusty areas may harbor bacteria. The RD stated the condenser unit in the walk-in refrigerator was not working properly and needed to be fixed and the food should be removed from the water drips. A review of departmental policy and procedure, titled Refrigerator and Freezer, dated 2023, it stated, Maintaining a clean refrigerator .can improve the safety and quality of your foods .Wipe up spill immediately .Clean the evaporator and condensing coil at least twice a year .inspect shelves and replace if coating is chipped away exposing metal shelves . A review of departmental policy and procedure, titled Storeroom, dated 2023, it stated, .The floor .shelves, and equipment must be kept clean by setting up, maintaining, and monitoring a regular cleaning schedule. Routine inspections must be made to ensure cleanliness and high standards of sanitation . 7. During an initial kitchen tour on 10/9/23, at 8:33 a.m., observation of the juice dispense machine was dirty with black crumbles and juice spilled at the interior when the door panel was opened, where the juice concentrate bottles could be replaced. A concurrent interview with the DA 2, she stated the juice machine and the nozzles (the opening where the juice dispensed) should be cleaned daily and did not know why it was not cleaned yesterday. A concurrent interview with the DS, she confirmed the juice machine was not cleaned. She stated the juice machine, and the nozzles should be cleaned and sanitized daily. A review of departmental policy and procedure, titled Dispenser Beverage Machine Cleaning, dated 2023, it indicated the maintenance and cleaning procedure of the juice machine was to follow the manufacturer's guidelines. The written instructions on the inside panel of the juice dispenser were reviewed and indicated the nozzles should be removed and cleaned daily. 8. During a concurrent observation and interview with the DS on 10/9/23, at 8:58 a.m., observation of a cart contained condiments, disposal cups, and snack bars. The DS stated that the cart was used for meal preparation during the meal services. A medicated nasal spray and a [company brand] insulated cup were found on the cart. The DS stated those items belonged to the staff. During a concurrent observation and interview with the DS on 10/9/23, at 9:00 a.m., observed there was a jacket hanging on the fire extinguisher. The DS stated the jacket belonged to the staff. The DS stated the staff's personal belongings should not be in the food preparation area. She added there was a designated area for the personal belongings outside the kitchen. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated the staff's personal belongings should be stored in a designated area but not in the kitchen especially the food preparation area. A review of departmental policy and procedure, titled Employee Personal Items, dated 2023, it stated, Personal items brought in by staff from the outside will not be kept in the kitchen . 9. During an initial kitchen tour on 10/9/23, at 8:50 a.m., 9:32 a.m. and 9:40 a.m., there were following food serving items/utensils found stacked wet and stored away at the clean and ready-to-use storage areas: -two of full sheet metal pans -four of half sheet metal pans -three of one-sixth (1/6, a unit of measurement) metal pans -eight of one-third (1/3) metal pans -11 of insulated plate covers -18 of insulated plate bases -two of full sheet meal serving trays During an interview with the DS on 10/9/23, at 9:40 a.m., she stated her expectation was all the dishes, pot, and pans should be dried completely before being stored away. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated the dishes and pans should be completely air-dried before storage because moisture would promote bacteria growth. According to 2022 FDA Food Code, under section 4-901.11 Equipment and Utensils, Air-Drying Required, it stated, .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 . 10. During a concurrent observation and interview with the [NAME] (CK) 2 on 10/9/23, at 2:24 p.m., observed a container of salad in the reach-in refrigerator and the temperature was taken with reading of 65.5 degrees F. CK 2 stated she just made the tuna salad for 10/9/23 dinner. She stated she did not monitor the temperature of the salad and was not aware that she needed to. She stated she never monitored and was never trained to put the temperature in the cool down log. During an interview with the DS on 10/9/23, at 3:07 p.m., she stated CK 2 only worked for a month and was not trained yet. DS stated she should put the temperature on the cool down log and monitor the temperature of the tuna salad. During an interview with the RD on 10/11/23, at 3:11 p.m., she stated the [NAME] should have knowledge of ambient (room temperature) food cool down process because that was food safety. A review of departmental policy and procedure, titled Cooling and Reheating of Potentially Hazardous or Time /Temperature Control for Safety Food, dated 2023, it stated, .Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food shall be cooled .in a method to ensure food safety .Ambient Temperature Food: PHF or TCS food shall be cooled within 4 hours to 41 degrees F or less, if prepared from ingredients at ambient temperature, such as .canned tuna .During the cooling process .thermometer to measure the internal temperature of the food .Note menu item, date, time, temperature, and cook's initials on the cool down log used . 11. During an observation of the resident's food refrigerator located in the dining room on 10/10/23, at 10:46 a.m., there were two issues identified: a. A review of facility document, titled Dining Room/Rec Room Refrigerator Log 2023, dated for the month of 10/2023, stated the refrigeration temperature should stay between 36 and 43 degrees F and the fridge (freezer) temperature should stay between 10 and 30 degrees F. b. A review of facility Dining Room/Rec Room Refrigerator log 2023, the month of 10/2023, it showed the fridge (freezer) temperatures were recorded 22-33 degrees F from 10/1/23 to 10/10/23. For the refrigerator temperatures, there were five times recorded at 42 degrees F. A concurrent interview with the Infection Preventionist (IP), he stated he was not aware temperature ranges for the refrigerator and freeze were not correct for food storage. A review of facility policy and procedure, titled Food Receiving and Storage, revised 11/2022, it indicated the food items should be stored in the refrigerator at or below 41 degrees F, and the frozen foods should be stored in the freezer at or below zero degrees F.

CONCERN (F)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to provide a clean environment for the residents and visitors when one garbage dumpster and one food waste bin, located outside the facility, were not secure with the dumpster lids closed. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During the kitchen initial tour observation on 10/9/23, at 11:14 a.m., one dumpster garbage bin and one food waste bin located outside nearby facility kitchen were not securely closed by the lids, and there were bags of trash inside both of bins. A concurrent interview with the Dietary Supervisor (DS), and she confirmed and stated both bins should have the lids completely close to prevent pest and rodents. During an interview with the Registered Dietitian (RD) on 10/11/23, at 3:11 p.m., the RD stated the trash bin and food waste bin should be covered with the lids closely to prevent the pest, rodents, and odor. A review of facility policy and procedure, titled Miscellaneous Areas: Garbage and Trash, dated 2023, it stated, .Garbage and trashcans must be inspected daily .that the lids are closed .The trash collection area is a potential feeding ground for vermin and rodents . A review of 2022 FDA (Food and Drug Administration) Food Code, dated 1/18/2023, indicated, .5-501.05 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers .

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to provide safety and supervision for one of three sampled residents (Resident 1), when the resident walked out of the building, seen and not prevented by staff, and was found unattended and unsupervised four blocks away from the facility. This failure had the potential to result in accidents, falls and injury. Findings: Resident 1 was admitted in the middle of 2023 with diagnoses which included stroke, altered mental status (change in mental functioning), dementia (cognitive/memory impairment), and difficulty walking. During a review of Resident 1's Order Summary Report (OSR), dated 7/17/23, the OSR indicated, [Resident 1] (DOES NOT) have the capacity to understand choices and make medical decisions. During a review of Resident 1's Nursing Care Plan (NCP), dated 8/16/23, the NCP indicated, Cognitive Loss R/T [related to] .Dementia Manifested by: Compromised short term memory .Compromised Long term memory Impaired capacity to make decisions .Keep environment free of hazards. During a review of Resident 1's NCP, dated 8/16/23, the NCP indicated, At risk for falls .Unaware of need for assistance .Impaired sense of balance .Needs assistance .with self-directed care. During a review of Resident 1's Nursing Progress Notes (NPN) dated 9/5/23, the NPN indicated, [Resident 1] hard to redirect, with lack of safety awareness. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/6/23, the MDS indicated Resident 1 had severe memory impairment, had wandered and placed the resident significant risk to a potentially dangerous place, and walked in room and corridors independently. During a review of the facility's follow up investigation document, dated 9/8/23, the document indicated, The receptionist notified the 6th floor nurses that [Resident 1] had gone out of the back door but didn't try to stop her. During an interview on 9/14/23 at 12:30 p.m. with the Receptionist (REC) at the facility building's first floor, the REC indicated the skilled nursing facility was on the 6th floor and was managed by a new company and downstairs was a different company, and stated, We do not monitor the skilled nursing residents when they come down but notify them upstairs. We don't stop them. During an interview on 9/14/23 at 12:42 p.m. with the Director of Nursing (DON), the DON stated, We were so busy that day when it happened .[Resident 1] is oriented by name and pleasantly confused .I don't know how she got to the elevator. The receptionist downstairs caught her while she was leaving out the door but did not stop her .The maintenance guy who does not know the resident saw her leave the facility but did not stop her too .They don't know exactly who the residents are .there should be a better way of preventing the residents to get in the elevators and out of the building .the infection control nurse went to look for her and she found the resident four blocks down . During an interview on 9/14/23 at I2:58 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, [Resident 1] is alert with confusion .I am aware of what happened .she went down to the elevator. I know someone should always be on the hallway to monitor the residents. I didn ' t see it because I was busy with my residents at that time .she could have hurt herself in the street. During an interview on 9/14/23 at 1:02 p.m. with CNA 2, CNA 2 stated, [Resident 1] is a wanderer .she needs a lot of redirection and monitoring .she got out one time. I did not see it. I was taking care of her that day .they told me that she was out. I have to keep an eye on her but I was busy with another patient .everybody's around to know to supervise her .She's just really confused. During a concurrent observation and interview on 9/14/23 at 1:08 p.m., Resident 1 sat in a wheelchair having her lunch eating independently, appeared confused, and stated, I don't know .I don't know what's going on. I have never been around here; I get myself together because I am always with myself. I've been eating lunch, but at this time, it's real funny. What kind of people are these? I don't know where I am. During a concurrent observation and interview on 9/14/23 at 1:12 p.m. with CNA 3, CNA 3 assisted another resident while supervising Resident 1 in the dining room, and stated, [Resident 1 is confused and she is oriented only with her name .She was wandering, took the elevator and went downstairs. I think that was that last week .I think they found her a couple of blocks away .If somebody's wandering downstairs or just anywhere we have to monitor them frequently. During an interview on 9/14/23 at 1:15 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated, [Resident 1] likes to walk around. She's very active .She does have confusion .She does need monitoring .She apparently went past everyone and people weren't aware of it and she was outside .she definitely needs supervision for her safety. During an interview on 9/14/23 at 1:24 p.m. with the Social Services Director (SSD), the SSD stated, [Resident 1] was found four blocks away from the facility .she is very confused .That was very shocking that she got in the elevator .probably a change of condition .she needs supervision. During an interview on 9/14/23 at 1:32 p.m. with the Activities Assistant (AA), the AA stated, [Resident 1] was out of the building and it shocked me that she got up and walked that far .when she gets that far, the streets are so busy with cars all over, and there's always the potential for accidents and falls and that could be fatal. During an interview on 9/26/23 at 2:50 p.m. with the Administrator (ADM), the ADM indicated the facility had no process in monitoring the residents at the skilled nursing facility for safety when they go downstair, and stated, The receptionist did not stop the resident from leaving the facility as reported .Somebody downstairs saw the resident leave but they did not stop the resident and the resident was found like a couple of blocks away. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 7/17, the P&P indicated, Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .the resident supervision may need to be increased .if there is a change in the resident ' s condition.

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to maintain equipment in safe operating condition when one of three sampled residents (Resident 1) had a call light (a device used to request assistance from facility staff) that did not light outside of the room indicating Resident 1 was calling for help. This failure had the potential for Resident 1's needs not being met and to negatively impact his physical and psychosocial well-being. Findings: Resident 1 was admitted to the facility in the summer of 2023 with diagnoses that included fracture of the neck (broken neck) and difficulty in walking. During a concurrent observation and interview on 8/21/23 at 2 p.m. with Resident 1, outside of his room, Resident 1 stated the light above the door did not go on when Resident 1 pushed the call light at the bedside. Resident 1 went on to say it has been like this for several days. The call light at the bedside was pushed and the light above the door outside Resident 1's room did not come on. During a concurrent observation and interview on 8/21/23 at 2:22 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 confirmed the light outside Resident 1's room was not working and should be working. CNA 1 stated it is important for the light to be working so she can tell when the resident needs help. During a concurrent observation and interview on 8/21/23 at 2:25 p.m. with the Maintenance Technician (MT), the MT confirmed that the light outside Resident 1's room was not working and should come on when the call light in the room is pushed. He stated he did not know how long it had not been working. During an interview on 8/21/23 at 2:30 p.m. with CNA 2, CNA 2 stated the light outside the resident's room is supposed to come on when the call light is pushed for help. CNA 2 stated, If the light doesn't come on, I would not know the resident needed help. During an interview on 8/21/23 at 2:50 p.m. with CNA 3, CNA 3 stated the light outside the resident's room should be working, it should go on when the resident pushes the call light. If the light isn't working, it should be noted in the maintenance log. CNA 3 was unable to locate the maintenance log. During an interview on 8/21/23 at 2:55 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated she was unaware that Resident 1's call light was not working. She confirmed the light outside of Resident 1's room should be in working order. The staff needs to be able to see the light outside of the room when a resident needs assistance and cannot if it is not working. During a record review of the facility's policy and procedure (P&P) titled, Call System, Residents, dated 2022, the P&P indicated, 3. The resident call system remains functional at all times.

Nov 2022 12 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

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Based on interview, and record review, the facility failed to ensure for one resident (Resident 6) in a census of 27, that the staff where informed of Resident 6's needs, when the care plan was not revised by the interdisciplinary team. This failure resulted in Resident 6 not having an updated care plan to communicate to staff her diagnosis of metastatic cancer (spread of cancer cells). Findings: Resident 6 was admitted to the facility in early 2017 with diagnoses which included irregular heart rate, acid reflux, heart failure, skin cancer, and metastatic cancer. During an interview on 11/08/22, at 8:12 a.m., with Resident 6, Resident 6 stated, I'm enjoying myself. I only like soup and easy to eat foods During a review of Resident 6's Minimum Data Set (MDS, an assessment tool), the MDS indicated the resident had a significate change dated 9/22/22. During an interview on 11/8/22, at 2:49 p.m., with the SSD (Social Service Designee), the SSD confirmed, Yes, Resident 6 has a new diagnosis of metastatic cancer, and there is no care plan in place with interventions for care. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, Timing and Revision, Dated 10/23/22, the P&P indicated, The care plan will identify priority problems and needs to be addressed by the interdisciplinary team .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure professional standards for medication administration were provided to one resident (Resident 15) in a census of 27, when the licensed nurse (LN) did not check resident's identity and did not explain the medications administered. This had the potential to result in medication errors, and in Resident 15 not meeting his highest practicable well-being. Findings: Resident 15 was admitted in early 2019 with diagnoses which included kidney disease, left knee pain, anxiety and major depression. During a review of Resident 15's Minimum Data Set (MDS, an assessment tool), dated 9/18/22, the MDS indicated Resident 15 had moderate memory impairment and needed limited to extensive assistance with activities of daily living. During an interview on 11/7/22, at 12:04 p.m., with Resident 15, Resident 15 stated, I have been here for two years. I don't really like it here. The people here don't tell me anything. During a concurrent observation and interview on 11/9/22, at 7:44 a.m., with Licensed Nurse (LN 2), LN 2 prepared medications for Resident 15 which included, bupropion (medication for depression) 300 mg (milligram, a unit of measure), Vitamin D3 25 mcg (microgram, a unit of measure), acetaminophen (medication for pain) 500 mg, and docusate sodium (stool softener). During an observation on 11/9/22, at 7:50 a.m., LN 2 administered the prepared medications to Resident 15. LN 2 gave the medication to the resident without checking the resident's identification and not explaining the medications. LN 2 stated, They [surveyors] just want to make sure you take the medicine. Here [nickname of Resident 15], take your medications. During an interview on 11/9/22, at 7:52 a.m., with LN 2, when asked how the medication pass procedure was, LN 2 stated, I did not check the resident's identify, and I did not explain the medications to the resident. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, revised 4/19, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed .The individual administering medications verifies the resident's identity before giving the resident his/her medications .checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (2) Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement treatment, disease prevention, or rehabilitative regiment .ordered by and within the scope of licensure of a physician .as defined by Section 1316.5 of the Health and Safety Code. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing 1997 State of California Department of Consumer Affairs. pp. 5).

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to provide effective care to one of 12 sampled residents (Resident 227), when there was no posted signage of oxygen in use outside Resident 227's room door. This failure had the potential to result in Resident 227's safety being compromised. Findings: Resident 227 was admitted in fall of 2022 with diagnoses that included, malignant neoplasm (abnormal growth of tissue), dementia (brain disease which interferes with learning, knowing, and understanding) and chronic (ongoing) pulmonary embolism (blood clot in the lung), and hospice. During a review of Resident 227's Minimum Data Set (MDS, an assessment tool), dated 10/13/22, the MDS indicated the resident had severe memory impairment. During a review of Resident 227's PHYSICIAN'S TELEPHONE ORDERS (PTO), dated 11/6/22, the PTO indicated, May administer O2 [oxygen] @ [at] 2LPM [liters per minute, amount of oxygen] via NC [nasal cannula, a tube in the nose] for SOB [shortness of breath] or comfort PRN [as needed]. During a review of Resident 227's Care Plan (CP), dated 11/10/22, the CP indicated, Require oxygen use for SOB .observe for any skin changes from cannula use. During a concurrent observation and interview on 11/7/22, at 8:30 a.m., Resident 227 was in bed, oxygen tubing on the floor and the oxygen concentrator (delivery system for oxygen) on at 2 LPM. Resident 227 did not respond to questions. Licensed Nurse 3 (LN 3) entered the room, changed the oxygen tubing and placed it on Resident 227. There was no Oxygen in Use signage posted in Resident 227's room door. During an observation, interview and record review on 11/10/22 at 8:30 a.m., with LN3, LN 3 confirmed there was no signage posted for oxygen in use outside Resident 227's room door, and stated, There should be signage when oxygen is in use. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated October 2010, the P&P indicated, The following equipment and supplies will be necessary .No Smoking/Oxygen in Use signs.

CONCERN (D)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected 1 resident

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Based on interview, and record review, the facility failed to ensure, for a census of 27, that the Quality Assessment and Assurance Committee (QAA) and Quality Assurance and Performance Improvement (QAPI) consisted of the minimum staff required to respond to deficiencies throughout the facility, when there was no Director of Nursing (DON) services available for these meeting. This failure resulted in not meeting the minimum requirements for the facilities quarterly QAA/QAPI meeting. Findings: During a review of the facility's QAA/QAPI sign in sheets for 8/11/22, 9/28/22 and 10/18/22, on 11/10/22, at 10:30 a.m., there was no DON signature. During a concurrent record review and interview on 11/10/22, at 10:31 a.m., with the Administrator (ADM), the ADM confirmed, Yes, there was no DON signature for the last three QAPI meeting notes. There should have been an RN (Registered Nurse) for these meetings. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement Committee, dated 7/2016, the P&P indicated, Committee Membership, the following individuals will serve on the committee: DON services .

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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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 resident care equipment in safe, operating condition for two of 12 sampled residents (Resident 14 and Resident 22), when a brake lever covering was missing and covered with painter's tape for Resident 22, and when Resident 14's wheelchair the arm rests were not secured and the upholstery was damaged. This failure increased the risk for accidents, injury and infection. Findings: Resident 22 was admitted to the facility in the spring of 2021 with diagnoses which included paralysis of the dominant side, weakness and dementia (memory loss). During a review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 10/7/22, the MDS indicated Resident 22's memory was severely impaired, and required extensive assistance for most of her activities of daily living (ADLs). During a review of Resident 22's PHYSICIAN TELEPHONE ORDERS [PTO], dated 10/4/22, the PTO indicated, POC [Plan of Care] wheelchair management to meet the LTG [Long Term Goal] . During a review of Resident 22's care plan (CP) titled, ADL Care Plan, updated 4/28/22, the CP indicated, Self care deficit related to .impaired mobility .Hx [history] of CVA [stroke] R [right] sided hemiplegia [paralysis] .W/C [wheelchair] bound .non ambulatory . Resident 14 was admitted in the summer of 2021 with multiple diagnoses which included Guillain-Barre Syndrome (transient paralysis) and dementia. During a review of Resident 14's CP titled ADL Care Plan, dated 3/1/22, the CP indicated, Self care deficit related to .Immobility .Dementia .forgetfulness .Transfer needs .W/C [wheelchair]. During a review of Resident 14's most recent MDS, dated [DATE], the MDS indicated Resident 14 had severe memory impairment but was able to make her needs known. During an observation on 11/7/22, at 8:35 a.m., Resident 22's hand grips for the wheelchair brakes had a thin white padding, covered with blue painter's tape that came off when gripped. During a concurrent observation and interview on 11/7/22, at 8:47 a.m., with the Maintenance Supervisor (MS), the MS verified the observation of Resident 22's wheelchair and indicated he did not know when it was last cleaned or repaired. During a concurrent observation and interview on 11/7/22, at 8:50 a.m., with Certified Nurses Assistant (CNA) 1, CNA 1 was asked about the condition of Resident 22's wheelchair, verified the observation and said, They used to clean them every week. Sometimes we forget to report or don't notice when it looks dirty [or needing repair]. During an observation on 11/8/22, at 8:15 a.m., Resident 14's wheelchair was positioned next to her bed with both arm rests missing pieces of upholstery and loose, freely moving back and forth when touched. [The arm rests] were not secure. During a concurrent observation and interview on 11/8/22, at 8:17 a.m., with CNA 2 , CNA 2 verified the observation, was asked what she would do if she saw resident equipment in disrepair, and said, We call Maintenance or put it in the Maintenance Log . I didn't notice the armrest or pad. During an interview on 11/9/22, at 7:09 a.m., with Housekeeper (HSKPR) 1, HSKPR 1 was asked about the cleaning and maintenance of resident wheelchairs and said, Maintenance is scheduled to clean the wheelchair. I don't know where the schedule is .If it's in the Maintenance Log, the Maintenance Supervisor should see it . During an interview on 11/9/22, at 7:18 a.m., with CNA 3, CNA 3 was asked what the process was for cleaning and repairing resident wheelchairs, and said, If I have a dirty wheelchair, you'd call maintenance or the housekeeper to come clean it right away. It's not put in the maintenance log. We just call them. During an interview on 11/9/22, at 7:29 a.m., with Licensed Nurse (LN) 1, LN 1 was asked what her expectations were for the cleaning and maintenance of resident wheelchairs, and said, Wheelchairs should be well maintained and kept clean at all times . During an interview on 11/9/2,2 at 7:57 a.m., with the Director of Housekeeping (DH), the DH was asked about the cleaning and maintenance of resident wheelchairs, and said, [Housekeeping] is in charge of cleaning in the .skilled nursing areas in the facility. We don't clean wheelchairs per contract. Maintenance should power wash the wheelchair on a schedule. I've never seen them do it. During a concurrent interview and record review on 11/09/22, at 8:23 a.m., with the Maintenance Supervisor (MS), the MS was shown copy of the wheelchair cleaning schedule provided, with no initials, dates, or repairs to be made indicated. He verified the record was not filled out and said, I'm making an inventory of the wheelchairs in the whole facility and then I can enact the cleaning schedule. There was about four months when there was no director of maintenance [MS]. Management failed to enforce required schedules of cleaning and maintenance of wheelchairs. We now have a verbalized agreement with the facility that both wheelchair cleaning and maintenance will be done by maintenance department. It wasn't clear before. During an interview on 11/9/22, at 8:53 a.m., with the Director of Rehab (DR), the DR was asked about the cleaning and maintenance of resident wheelchairs, and said, I understand the cleaning of the wheelchairs has been delegated to Housekeeping and Maintenance has a role in repairing them. If there's something that needs repair, it is put in the 'Tales System' and he can access it by phone. During a subsequent observation on 11/9/22, at 10:34 a.m., Resident 22 was observed in her wheelchair sitting across from nurses station, brake levers still wrapped in painters tape and not repaired. During a review of the facility document titled, Work Orders, dated 10/1/22 to 11/8/22, the document indicated there no documented request for the cleaning or repair of Resident 14 and Resident 22's wheelchairs. During a review of the undated document titled, [Name of facility] Job Description .Director of Maintenance, the document indicated, Make daily rounds to assure that maintenance personnel are performing required duties and that appropriate maintenance procedures are being rendered to meet the needs of the facility .Make periodic rounds to check equipment and to assure that necessary equipment is .working properly . During a review of the facility policy and procedure (P&P) titled, Maintenance Service, revised 2009, the P&P indicated, The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that .equipment [is] maintained in a safe and operable manner .

CONCERN (E)

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

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected multiple residents

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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 completed comprehensive and discharge assessments were encoded and transmitted to the (name of regulating organization) system within the required time frame for a census of 27, when: 1. The completed Minimum Data Set (MDS, an assessment tool) assessments for Resident 127, Resident 128 and Resident 227 were not transmitted to (name of regulating organization) and 2. The discharge MDS assessments for Resident 16, Resident 129, Resident 130 and Resident 131 were not transmitted to CMS. These failures had the potential to negatively affect the residents' care and care planning, and resulted in no records being found in the (name of regulating organization) system information. Findings: 1. Resident 127 was admitted in early 2021 with diagnoses which included stroke, muscle weakness, and hospice. During a review Resident 127's MDS, dated [DATE], the MDS was completed but not transmitted to (name of regulating organization). Resident 128 was admitted in late 2018 with diagnoses which included anxiety and muscle weakness. During a review Resident 128's MDS, dated [DATE], the MDS was completed but not transmitted to (name of regulating organization). Resident 227 was admitted in late 2022 with diagnoses which included malnutrition, cancer, and hospice. During a review Resident 227's MDS, dated [DATE], the MDS was completed but not transmitted to (name of regulating organization). During the initial pool observation on [DATE], at 8:03 a.m., Resident 127, Resident 128, and Resident 227 were included in the current facility census. There were no current or recent MDS assessments submitted in the (name of regulating organization) system. During an interview on [DATE], at 8:38 a.m., with Licensed Nurse 1 (LN 1), LN 1 indicated Resident 127 and Resident 128 had been in the facility for a while, and stated, The residents have been here and are not new admits. During an observation and interview on [DATE], at 8:51 a.m., with Certified Nursing Assistant 4 (CNA 4), CNA 4 was observed assisting Resident 127 with breakfast. CNA 4 stated, The resident has been here for a while. During an interview on [DATE], at 2:50 p.m., with the MDS Coordinator (MDSC), the MDSC indicated the MDS assessments for Resident 127, Resident 128 and Resident 227 were all completed. When asked if all of the MDSs were transmitted, the MDSC stated, The MDS of Resident 127 and Resident 227 were not transmitted because they are hospice residents. I don't know why [the MDS assessments] were not transmitted, and [hospice transmission] is not mentioned in the policy and procedure. I should have just transmitted the MDS assessments. 2. During a record review on [DATE], of the document titled, ADT [Admission-Discharge-Transfer] Report, the ADT report indicated the following: Resident 16 had an MDS assessment with a discharge reason as death on [DATE]; Resident 129 had an MDS discharge assessment with a discharge reason as discharged to home on [DATE]; Resident 130 had an MDS discharge assessment with a discharge reason as death on [DATE]; and Resident 131 had an MDS discharge assessment with a discharge reason as discharged to home on [DATE]. During a review on [DATE], the MDS assessments of Resident 16, Resident 129, Resident 130, and Resident 131 were not found in the (name of regulating organization) system information database. During an interview on [DATE], at 8:47 a.m., with the MDSC, the MDSC indicated Resident 16 had no discharge MDS transmitted to (name of regulating organization). The MDSC stated, I did not transmit due to the resident was on hospice. I will from now on .be sending all hospice MDS to (name of regulating organization) . During an interview on [DATE], at 12:58 p.m., with the MDSC, when asked if the discharge MDS for Resident 129, Resident 130, and Resident 131 were transmitted to (name of regulating organization), the MDSC stated, [MDS transmission] is inconsistent and it's not right. I should have submitted all the discharged residents. I've heard it from another facility that hospice residents are not submitted to the state, and I don't think it's right. During a review of the Resident Assessment Instrument (RAI) regulation and requirement, Encoding data: Within 7 days after a facility completes a resident's assessment .Transmitting data: Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the (name of regulating organization) system information for each resident.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a plan of care for two of 12 sampled residents (Resident 2 and Resident 12), when: 1. Resident 2 had no care plan developed for dry eyes and eye itchiness; and 2. Resident 12 had no care plan developed and implemented for chest pain. These failures had the potential to result in residents not attaining their highest practicable well-being. Findings: 1. Resident 2 was admitted in the middle of 2017 with diagnoses which included pain, falls, difficulty swallowing, muscle weakness, depression and anxiety. During a review of Resident 2's Minimum Data Set (MDS, an assessment tool), dated 9/15/22, the MDS indicated Resident 2 had no memory impairment and used eyeglasses. During a review of Resident 2's Physician's Order Sheet (POS), dated 4/2/19, the POS indicated, Artificial Tears .ONE Drop Into Each Eye Three Times Daily dry eyes. During a review of Resident 2's POS, dated 8/23/21, the POS indicated, [brand name, allergy eye drops] DROPS Both Eyes .Instill ONE gtt [drop] into each eye twice daily PRN [as needed] for itchy allergy eyes. During a concurrent observation and interview on 11/7/22, at 9:18 a.m., Resident 2 sat in a wheelchair at the bedside, awake, alert and verbally responsive, and stated, My eyes are itchy. I need medication right now, just my eye drops. It will make my eyes feel better. During an interview on 11/7/22, at 9:20 a.m., with Licensed Nurse 4 (LN 4), when asked what the Resident 2 had for her itchy eyes, LN 4 stated, She has artificial tears eye drops for her eyes. I'll give it to her right now. During an interview on 11/9/22, at 1:46 p.m., with LN 3, LN 3 stated, She has artificial tears eye drops. When asked the process when there was a problem with resident's care, LN 3 stated, We develop a care plan for the problem. LN 3 verified the chart for the eye drops care plan, and stated, I can't find a care plan for her eye problem. During an interview on 11/9/22, at 1:48 p.m., with LN 2, LN 2 stated, I can't remember if [Resident 2] had any care plan for eye irritation. Check with the medical records. During an interview on 11/9/22, at 1:50 p.m., with LN 3, LN 3 stated, Medical records has no documented care plan found for eye problem on [Resident 2]. 2. Resident 12 was admitted in the middle of 2020 with diagnoses which included lung failure, irregular heart rate, pain, falls, difficulty swallowing, muscle weakness and depression. During a review of Resident 12's POS, dated 7/15/20, the POS indicated, Nitroglycerine 0.4 mg [milligram, a unit of weight] .ONE tablet PO[by mouth]/SL[sublingual, below tongue] PRN for chest pain. During a review of Resident 12's POS, dated 7/16/20, the POS indicated, Monitor resident for pain every shift. During a review of Resident 12's NURSE'S NOTES, dated 7/22/22, the notes indicated, Observed [Resident 12] with some episodes of SOB [shortness of breath] and lethargy. During a review of Resident 12's Resident Transfer Form (RTF), dated 7/22/22, the RTF indicated, Resident 12 was transferred to the hospital for change in level of consciousness and decreased oxygen blood level. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had no memory impairment and had heart failure and a heart condition. During a concurrent observation and interview on 11/7/22, at 9:02 a.m., Resident 12 was in bed connected to an oxygen tubing to a concentrator, awake, alert and verbally responsive, and stated, My oxygen is set at two liters. I was sent to the hospital once for chest discomfort. During a concurrent observation on 11/10/22, at 8:11 a.m., Resident 12 was found in bed, alert and awake, with oxygen tubing connected, and stated, I had been to the hospital once .I had a chest pain and they sent me to be checked .Once in a while, I have shortness of breath when I don't have the oxygen. During an interview on 11/10/22, at 9:05 a.m., with LN 3, LN 3 stated, I've known [Resident 12] for six months .The resident has been going to the hospital for chest pain and last time she was lethargic .The resident has nitroglycerine for chest pain. LN 3 verified there was no documented evidence of a plan of care for the chest pain developed. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/16, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being.

CONCERN (E)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status for 2 residents (Resident 19 and Resident 21) out of a census of 27, as evidenced by severe weight loss. This failure had the potential to lead to malnutrition, decreased immunity, skin breakdown, and/or decreased ability to conduct activities of daily life. Findings: 1. Resident 19 was admitted spring of 2021 with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other mental functioning), generalized muscle weakness, and dysphagia (a condition affecting the ability to swallow). Weight log included the following entries: 6/14/21--103# (pounds), 8/2/21--106#, 2/10/22--102#, 5/16/22--86#, a loss of 16#/15.7% (a severe loss over 3 months of 15.7% of their body weight), 8/9/22--81#, a loss of 21#/20.6% (a severe loss over 6 months), 10/6/22--71#, a loss of 10#/12.3% (a severe loss over 2 months). Physician diet orders for November included the following: Diet of small portions, watered down, fortified, liquified, puree (started 5/25/22), Supplemental shake by mouth three times daily (started 7/6/22), and A protein supplement of 30 ml (milliliters, a unit of measurement) BID (twice a day) (started 9/6/22). The tray ticket for 11/8/22 listed the diet as small portions, puree, with extra thin liquified puree listed at bottom. Under Diet Intervention it included fortification (per AM supervisor this meant to add extra fat such as butter or gravy to one hot item per meal, for extra calories). Personal Menu Items included 8 oz Whole Milk, 8 oz Hot Tea, 6 oz Prune Juice, and 1 Vanilla Shake that were added to her meals. Do Not Serve included Juice and Cold Cereal. (No other preferences listed). Dietary Quarterly Progress Notes for 9/2/22 included a preference of hot foods. Under the summary of visit it stated: Significant weight loss (-9#/11.1% loss of body weight) for 1 month, plus 13# loss/15.3% over 3 months. Not beneficial given BMI (body mass index, a ratio of height to weight ) of 15 indicating underweight, likely related to declining by mouth intake of approximately 30% of meals and snacks. During an interview on 11/9/22, at 11:55 a.m. with the registered dietitian (RD), she was unsure of Resident 19's food preferences. During an interview on 11/10/22, at 8:26 a.m. with Licensed Nurse 6 (LN 6), he discussed interventions for when a resident has poor intake: We give them some snack or supplement . The supplement will be another shake and she's getting that in between meals. She already gets three shakes a day. 2. Based on chart review on 11/9/22, at 9:03 a.m., Resident 21 was admitted in the spring of 2022 with a decreased ability to use his right side after a stroke, acid reflux disease, dementia (a persistent disorder of mental processes), and type 2 diabetes mellitus (a disordered ability to use insulin to stabilize blood sugar levels) affecting his kidney function. Weight log entries included the following: 4/11/22--166# (pounds), 8/4/22--158# (-8#/4.8% of body weight), 9/6/22--148# (-10#/6.8% which is severe for 1 month), 10/16/22--142# (-6#/4.1% for 1 month, -24#/14.5% which is a severe loss over 6 months), 10/28/22--139# (-3#/2.1% in 2 weeks). Physician's orders for November included: Diet of CCHO (consistent carbohydrate, given to control carbohydrate levels), regular texture with thin liquids (started 9/6/2022). A sugar free, protein supplement of 30 mL (milliliters, a unit of measurement) given TID (three times per day, started on 11/2/22). ½ peanut butter and jelly sandwich with 8 oz of milk given at 1400 and 2000 for snack (started on 11/2/22). Resident 21 lunch tray ticket from 11/8/22 included his diet as CCHO (consistent carbohydrate). Personal Menu Items included: 8 oz 2% Milk, 4 oz Assorted Juice, and 4 oz of Diet Vanilla Ice Cream. Dislikes: Corn, Chips, Hard Taco Shells. (No other food preferences listed.) Nurses Weekly nursing summary: 10/11/22 indicated eating habits of 40-80% average meal for week, 10/18/22: 40-80%, 10/25/22: 25-50%, 11/01/22: 20-30%, 11/8/22: 20-20% Interdisciplinary Team (IDT) Progress Notes: 9/7/22- Review of weight loss of 10 pounds with intervention of discontinue no added salt diet. Responsible party aware and brings in food of choice from home. 11/3/22- Resident continues to refuse meal trays, does eat sweets. Responsible party brings him food she cooks at home. Met with wife who said she will start bringing him food twice daily, and that he eats better when she sits with him, which she has committed to do. Nutrition progress notes indicated the following: 8/17/22- Recommend discontinue consistent carbohydrate diet to liberalize diet. 10/10/22- Poor appetite, refuses supplement. Wife brings favorite snacks/meals. Intakes varies. 11/2/22- Weight loss likely due to meal refusals and by mouth intake average of 25% or less x 1 week. Eats anything with sugar . Nutrition At Risk Note 11/04/22 Rt (resident) continues meal refusals and PO (by mouth) intake average < (less than) 30% . RD (registered dietitian) recommends appetite stimulant to help increase po intake, therefore increase weight. During an interview on 11/9/22 at 11:55 a.m. with the registered dietitian (RD), she stated I recently recommend [an appetite] stimulant . His wife brings in food too, usually two times per day. This started last week so it is too soon to know if it is effective. He prefers sweets [over other foods]. RD was unaware of other food preferences. Facility provided Weight Assessment and Intervention policy (MED-PASS, Inc. 2001) includes the following under the analysis section: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made . 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Under the Interventions section it includes the following: 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences . The policy on resident food preferences was requested but not provided.

CONCERN (E)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, or designate an RN to serve as the Director of Nursing (DON) on a full time basis for a census of 27. This failure increased the potential for residents to have unmet care needs and services. Findings: During a review of the facility document on titled, OCTOBER, 2022 LICENSED NURSE SCHEDULE, there was no Registered Nurse scheduled for 8 hours per day on October 1, 6, 7, 8, 10, 14, 15, 17, 21 and 29, 2022. During a review of the facility document titled, PERSONNEL SIGN IN SHEET, there was no RN signed as on duty for eight hours in a 24 hour period for 10/16/22 and 10/28/22. There was no documented evidence of a sign-in sheet provided for October 1, 2, 6, 7, 8, 10, 14, 15, 17, 21, 29 and 31, 2022. During daily observations from 11/7/22 to 11/10/22, no DON was on duty in the facility. During an interview on 11/7/22, at 8:36 a.m., with LN 1, LN 1 stated, There is no DON [Director of Nursing] right now .We also don't have a Registered Nurse scheduled today. During an interview on 11/7/22, at 9:33 a.m., with the Administrator (ADM), the ADM was asked about the facility's DON and RN and said, There's no RN in house today .There's no RN from Registry. I think we have three to four RNs [on staff]. One is on [type of] leave .Residents are sent out if they need assessment . During an interview on 11/8/22, at 7:13 a.m., with the Social Services Designee (SSD), the SSD was asked about the presence of a DON and RNs in the facility and said, It's been close to a year since we had a DON. They've been putting an ad in .an online program for job openings .We've had three applicants who didn't accept the job because of the pay and lack of job security .The ADM is responsible for hiring. We're trying every day to get an RN through Registry. [For DON] we got an RN .A contract was signed for a month. After four days of orientation, she called and said she was returning to [country] for a family emergency in September. We have three on-call RNs who choose their days. I can't schedule them. Our full time RN is out on [type of] leave. We have a contract with two Registries for all staff. It takes four to six months to get a contract [with another Registry] signed because of the owner and due to transition. The SSD was asked who covered the DON's duties and said, The DON's duties are covered between the Infection Preventionist [IP], the Administrator [ADM], and the MDS [Minimum Data Set, an assessment tool] Coordinator. They have been sharing the duties of the DON until a new DON can be found .The Administrator has requested a pay increase which has not happened yet . If there's an emergency, we call 911 . During an interview on 11/8/22, at 10:17 a.m., with Licensed Nurse 2 (LN 2), LN 2 was asked about the availability of an RN, and said, Our regular RN is on [type of] leave. We have three RNs on call but they choose their times. We're really struggling to get replacements. We train them and they leave .We have a corporate nurse that comes over occasionally to check things. She doesn't work here .The former DON, comes in on call .once a week or once a month. I haven't seen her lately. During an interview on 11/9/22, at 9:15 a.m., with LN 1, when asked what the process for the disposition of discontinued and controlled medications was, LN 1 stated, The IP [Infection Preventionist] holds the key for the discontinued controlled medications. He is an LVN [Licensed Vocational Nurse]. He does the destruction of discontinued medications with the pharmacist. He has the key. He is on vacation. During an interview on 11/9/22 at 9:25 a.m., with LN 3, when asked what the process for the disposition of discontinued and controlled medications was, LN 3 stated, When we have discontinued narcotic medications, we wait for the RN or the Pharmacist, and we give the medications to them for destruction. Right now, we don't have a Director of Nursing [DON] or an RN. All narcotics are kept in the medication cart. During an interview on 11/10/22, at 11:52 a.m., with the ADM, the ADM was asked her expectations for having an RN and DON in the facility, and said, There should be an RN on duty eight hours per day, seven days per week. That would include the DON. During a review of the facility policy and procedure (P&P) titled, Departmental Supervision, revised 4/2006, the P&P indicated, A Registered Nurse (RN) is employed as Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday . During a review of the facility P&P titled, Director of Nursing Services, revised 8/2006, indicated, The Nursing Services department is under the direct supervision of a Registered Nurse .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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F812: Food Procurement, Store/Prepare/Serve-Sanitary Conditions (S&S: E) Based on observation, interview and record review the facility failed to provide food storage and preparation and maintain equipment and food contact surfaces in accordance with professional standards for food safety for a census of 27, when: 1. The hand washing sink was found next to the clean dishes' drying area. 2. Two out of two blenders were found stained. 3. Two out of two large pans were found rusty 4. One cutting board was found with scratches. 5. Three out of three soup bowls were found worn and discolored. 6. Two out of three cookie pans were found rusty. 7. One soup pan was found burned from outside and speckled with black markings from inside. 8 . One pot was found with black marking over the center of the bottom. 9. Two expired food products were found on the spices' shelf. 10.One used food product was opened and uncovered. 11.Two unlabeled/undated and three expired food products were stored in the reach-in refrigerator. 12.Two opened/cut food bags were stored in the walk-in refrigerator. 13. One opened food bag was stored in the basement's reach-in freezer. 14. One food product was heated using non-safe microwave bowl. These failures increased the potential for food-borne illnesses among the residents. Findings: 1. During an observation within the initial kitchen tour on 11/7/22 at 8:30 a.m., the hand washing sink was located next to the clean dishes' air-drying area with a six by ten inches (a unit of measure) small splash guard between them. During an interview with the Director of Dining Services (DDS) on 11/8/22 at 1:00 p.m., the DDS stated, Yes, water could splash [from the hand washing sink] onto the clean dishes [in the drying area], which could cause cross contamination. A review of the United States (US) Food and Drug Administration (FDA) Food Code 2017, section 4-903.11, titled Storing Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, indicated .Cleaned equipment and utensils .shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . 2. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:20 a.m., with the Sous-Chef (SC), two blenders were found stained. The SC stated, [Staff] can't get the stains off. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, I would replace them [the blenders], because bacteria grow in it. It wouldn't be safe . A review of the US FDA Food Code 2017, section 4-601.11, titled Cleaning Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, indicated Equipment food-contacting surfaces and utensils shall be clean to sight . 3. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:20 a.m., with the SC, two large pans were found rusty. The SC stated, Bacteria can grow [on the pans], so [it] should [be] replace[d]. A review of the facility's policy and procedure (P&P), titled Equipment, Utensils, and Linens 8.9, dated 2013, indicated .equipment and utensils .shall be: safe .corrosive resistant .smooth and easily cleanable .If equipment and utensils cannot maintain their original characteristics, they may become difficult to clean, allowing for harborage of pathogenic microorganisms and pests . 4. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:00 a.m., with the SC, one green cutting board was found scratched with worn surfaces. The SC confirmed the finding. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, I saw that too [cutting board with scratches]. We [facility] have to replace them because of bacteria growth . A review of the US FDA Food Code 2017, section 4-501.12, titled Cutting Surfaces, indicated Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 5. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:20 a.m., with the SC, three soup bowels were found worn and discolored. The SC stated, The bowls need to be replaced due to bacteria can grow in the gouges. A review of the facility's P&P, titled Equipment, Utensils, and Linens 8.9, dated 2013, indicated .equipment and utensils .shall be: safe .smooth and easily cleanable, resistant to .chipping, cracking/splitting, scratching .If equipment and utensils cannot maintain their original characteristics, they may become difficult to clean, allowing for harborage of pathogenic microorganisms and pests . 6. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:20 a.m., with the SC, two cookie pans were found rusty. The SC stated, The pan needs to be replaced due to bacteria, plus burnt food burnt or sugar may affect the flavor. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, That's probably sugar that got burned over and over. They [cookie pans] need to be replaced because of bacteria growth. A review of the facility's P&P, titled Equipment, Utensils, and Linens 8.9, dated 2013, indicated .equipment and utensils .shall be: safe .corrosive resistant .smooth and easily cleanable .If equipment and utensils cannot maintain their original characteristics, they may become difficult to clean, allowing for harborage of pathogenic microorganisms and pests . 7. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:20 a.m., with the SC, one soup pan was found burned from outside and speckled with black markings from inside. The SC stated, Bacteria growth can occur in the pan. The black markings are probably from burnt onions. It needs to be replaced. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, The burned soup pan is not good, because it's dented, and bacteria is growing in there. These are old pans. They need to be replaced. A review of the facility's P&P, titled Equipment, Utensils, and Linens 8.9, dated 2013, indicated .equipment and utensils .shall be: safe .corrosive resistant .smooth and easily cleanable, resistant to .chipping, cracking/splitting, scratching .If equipment and utensils cannot maintain their original characteristics, they may become difficult to clean, allowing for harborage of pathogenic microorganisms and pests . 8. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:40 a.m., with the SC, one pot was found with black marking over the center of the bottom. The SC stated, . [The pot] should be replaced. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, I don't think it's okay to use it [pot with black marking] .because we have people who are sick. A review of the facility's P&P, titled Equipment, Utensils, and Linens 8.9, dated 2013, indicated .equipment and utensils .shall be: safe .corrosive resistant .smooth and easily cleanable, resistant to .chipping, cracking/splitting, scratching .If equipment and utensils cannot maintain their original characteristics, they may become difficult to clean, allowing for harborage of pathogenic microorganisms and pests . 9. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:16 a.m., with the SC, two expired bottles of Mango Habanero wings seasoning mix and ground cumin were found on the spices' shelf. The Mango Habanero bottle was opened on 5/18/22 and the best by date was 2/26/22. The ground cumin bottle's best by date was 12/31/20. The SC confirmed the finding and stated, used by dates are important .expired products equal lower quality. [The spices] need to be thrown away. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, That [expired spices] is not acceptable, because it's . quality . A review of the US FDA Food Code 2017, section 3-501.17, titled Commercially Processed Food, indicated .Refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment .to indicate the date or day by which the food shall be consumed .or discarded .The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . 10. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:20 a.m., with the SC, one box of baking soda was opened and uncovered. The SC stated, Things can get into it [the baking soda box] and contaminate it. It should be covered. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, That's a problem [leaving the box of baking soda opened and uncovered], because things could get into it like air, bacteria, water, bugs. A review of the US FDA Food Code 2017, section 3-302.11, titled Packaged and Unpackaged Food -Separation, Packaging, and Segregation, indicated .Food shall be protected from cross contamination by . storing the food in packages, covered containers, or wrappings . 11. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:35 a.m., with the SC, two unlabeled/undated boxes of mayonnaise and cottage cheese and three expired boxes of ground sausage, broth, and tartar sauce were stored in the reach-in refrigerator. The ground sausage's use by date was 11/3/22, the broth's use by date was 10/20/22, and the tartar sauce's use by date was 11/4/22. The SC stated, Labels should include [the] date product came, opened, and use by d/t FIFO [first in, first out], and open dated needed to figure out how long to keep due to maintaining the quality. [The expired food] it should have been thrown out by morning supervisor . During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, It [food products] should be labeled the day it came, opened and when it going to be thrown. We [staff] need the label so if anybody else comes in here and .doesn't know .they're going [to] grab it and go .We need to do that because of quality. During an interview with the Registered Dietician (RD) on 11/9/22 at 11:55 a.m., Labels should include open and discard dates. That's what I tell them [staff] what to do . so that you are not serving old food, because it's unsanitary and [there is risk for] possible growth of bacteria, especially with our susceptible population here. A review of Unidine's undated P&P, titled Food Safety Labeling Procedures, indicated All food or beverage items that are either: stored, opened, prepared or leftover in .kitchens/storage areas .will be clearly identified as to the item name/product, the production or opened date and the use by date . A review of the US FDA Food Code 2017, section 3-501.17, titled Commercially Processed Food, indicated .Refrigerated, ready to eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment .to indicate the date or day by which the food shall be consumed .or discarded .The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety . 12. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:50 a.m., with the SC, two bags of ham and turkey slices were cut, opened to air, and stored in the walk-in refrigerator. The SC stated, [The opened bags] should be put into another bag to prevent contamination. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, They [staff] should use scissors and then put them [opened food bags] in another bag after opening it, because air can get into it .Bacteria can .grow and food can be contaminated with animals and people fingers. During an interview with the RD on 11/9/22 at 11:55 a.m., the RD stated, Bags should be sealed once open d/t potential for cross contamination. Definitely it needs to be sealed back, because it might get old faster, and something might drip or get inside of it. A review of the US FDA Food Code 2017, section 3-302.11, titled Packaged and Unpackaged Food -Separation, Packaging, and Segregation, indicated .Food shall be protected from cross contamination by . storing the food in packages, covered containers, or wrappings .protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened . A review of the US FDA Food Code 2017, section 3-303.12, titled Storage or Display of Food in Contact with Water or Ice, indicated .Packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water . 13. During a concurrent observation within the initial kitchen tour and interview on 11/7/22 at 9:57 a.m., with the SC, one bag of cinnamon rolls was opened and stored in the basement's reach-in freezer. The SC stated, [The bag] should be fastened securely. [I] expect the bag [to be] tied off and [the] box [to be] closed [to prevent] air and freezer burn, [and] decreased quality. During an interview with the DDS on 11/8/22 at 1:00 p.m., the DDS stated, When it's [bag of cinnamon rolls] opened, it needs to be closed in that bag, then the box [should] be closed, then labeled with opening date and used by date. A review of the US FDA Food Code 2017, section 3-302.11, titled Packaged and Unpackaged Food -Separation, Packaging, and Segregation, indicated .Food shall be protected from cross contamination by . storing the food in packages, covered containers, or wrappings .protecting food containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened . A review of the US FDA Food Code 2017, section 3-303.12, titled Storage or Display of Food in Contact with Water or Ice, indicated .Packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water . 14. During an observation on 11/8/22 at 12:09 p.m. in the 6th floor dining area, a charge nurse opened a soup can, poured it into a bowl, and heated it in the microwave. During an interview with the RD on 11/9/22 at 11:55 a.m., the RD stated, Cereal bowls are not appropriate for microwave per manufacturer. Will need to revise the process [for either] new microwave bowls or heating [food] in kitchen. A review of an article on Healthline, dated 6/4/20, titled Is it Safe to Microwave Plastic, indicated Microwaving plastic can release harmful chemicals .into your foods and drinks. Therefore, you should avoid microwaving plastic, unless it's labeled for this specific use.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent medication administration observation and interview on 11/8/22, at 8:15 a.m., with LN 4 , LN 4 put on gloves to take the Resident 10's blood pressure without performing hand hygiene. LN 4 then removed the gloves, did not perform hand hygiene and put on a new pair of gloves. When asked how the medication pass went, LN 4 stated I did not wash or sanitize my hands before I put gloves on or when I changed my gloves. During a concurrent medication observation and interview on 11/9/22 at 7:25 a.m., with LN 3, LN 3 prepared medication for Resident 20. LN 3 put on a pair of gloves without performing hand hygiene. LN 3 administered the medications to Resident 20 and removed his gloves. When asked how the medication pass went, LN 3 stated, I missed hand hygiene before preparing the medications. During an observation and interview on 11/9/22, at 7:44 a.m., LN 2 prepared the medications for the Resident 15 without performing hand hygiene. When asked how the medication pass went, LN 2 stated hand hygiene should be performed before preparing medications. During an interview and record review on 11/9/22, at 2:30 p.m., with LN 1, LN 1 stated that hand hygiene should be performed before and after giving medication. LN 1 stated hand hygiene should be performed before putting gloves on and after removing gloves. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 8/2015, the P&P indicated, Use an alcohol-based hand rub or soap and water .before preparing or handling medications .applying and removing gloves .perform hand hygiene before applying non-sterile gloves perform hand hygiene after removing gloves. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for a census of 27 when: 1. The wheelchairs of Resident 14 and Resident 22 were not clean; and 2. Hand hygiene was not performed by Licensed Nurses during medication administration. This failure had the potential for transmission of infection to vulnerable residents. Findings: 1. Resident 22 was admitted to the facility in the spring of 2021with diagnoses which included paralysis of the dominant side and weakness. During a review of Resident 22's Minimum Data Set (MDS, an assessment tool), dated 10/7/22, the MDS indicated Resident 22's memory was severely impaired and required extensive assistance for most of her activities of daily living (ADLs). During a review of Resident 22's PHYSICIAN TELEPHONE ORDERS [PTO], dated 10/4/22, the PTO indicated POC [Plan of Care] wheelchair management to meet the LTG [Long term Goal] . During a review of Resident 22's care plan (CP) titled, Self care deficit related to: impaired mobility. Hx [history] of CVA [stroke] R [right] sided hemiplegia [paralysis] . updated 4/8/22, the CP indicated, W/C [wheelchair] bound .non ambulatory . During an observation on 11/7/22, at 8:35 a.m., the horizontal frame underneath the seat of Resident 22's wheelchair was dirty with a thick layer of red, ketchup-looking grime on the horizontal bar running front to back under the seat. During a concurrent observation and interview on 11/7/22, at 8:47 a.m., with the Maintenance Supervisor (MS), the MS was asked how often the wheelchairs are cleaned, and said, I will find out how often the wheelchairs are cleaned. The MS indicated he did not know when it was last cleaned or repaired. During a concurrent observation and interview on 11/7/22, at 8:50 a.m., with Certified Nurses Assistant (CNA) 1, CNA 1 was asked about the condition of Resident 22's wheelchair. CNA 1 verified the red grimy substance on the horizontal bars under the seat of the wheelchair and said, They used to clean them every week. Sometimes we forget to report or don't notice when it looks dirty. During an interview on 11/7/22, at 9:24 a.m., with the Director of Housekeeping (DH), the DH was asked about the cleaning of facility wheelchairs, and said, Maintenance cleans the wheelchairs. If we notice a dirty bed, we wipe them down but not wheelchairs. It's not our duty per contract . Resident 14 was admitted in the summer of 2021 with multiple diagnoses which included Guillain-Barre Syndrome (transient paralysis) and dementia (memory loss). During a review of Resident 14's CP titled, Self care deficit related to: Immobility, dated 3/1/22, the CP indicated, Transfer needs .W/C [wheelchair] . During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had severe memory impairment. During an interview on 11/8/22, at 7:13 a.m., with the Social Services Designee (SSD), the SSD was asked about environmental services and said, We are contracted for environmental services with [company name] .We keep reminding them to clean them [the wheelchairs] but they don't clean them. During an observation on 11/8/22, at 8:15 a.m., Resident 14's wheelchair had an egg-crate type cushion uncovered with many short white particles that looked like hair. Both arm rests had cracked and missing upholstery with the padding showing through. During a concurrent observation and interview on 11/8/22, at 8:17 a.m., with CNA 2, CNA 2 verified the observation of Resident 14's wheelchair arm rests and pad and, when asked who she would report it to, CNA 2 said, We call Maintenance or put it in the Maintenance Log and they come up right away. CNA 2 said, I didn't notice the armrest [upholstery cracked and missing] or [egg crate cushion covered with hair like particles] pad . During an interview on 11/9/22, at 7:09 a.m., with Housekeeper (HSKPR) 1, HSKPR 1 was asked about the cleaning of wheelchairs and said, Maintenance is scheduled to clean the wheelchair. I don't know where the schedule is. We clean it if the CNA tells us. If it's in the Maintenance Log, the Maintenance Supervisor should see it. If they need it quick, CNA will tell us and we do it right then . During an interview on 11/9/22, at 7:18 a.m., with CNA 3, CNA 3 was asked what she would do if she noticed a dirty wheelchair and said, If I have a dirty wheelchair, you'd call maintenance or the housekeeper to come clean it right away. It's not put in the maintenance log . During an interview on 11/9/22, at 7:29 a.m., with Licensed Nurse 1 (LN 1) , LN 1 was asked what her expectations were for wheelchair maintenance and said, Wheelchairs should be well maintained and kept clean at all times. I don't know when they were last cleaned . During an interview on 11/9/22, at 7:57 a.m., with the Director of Housekeeping (DH), the DH was asked about wheelchair cleaning, indicated she was in charge of cleaning the skilled nursing areas in the facility and said, We don't clean wheelchairs per contract. Maintenance should power wash the wheelchairs on a schedule. I've never seen them do it . During a concurrent interview and record review on 11/9/22, at 8:23 a.m., with the MS, MS was shown a copy of the Wheelchair Cleaning Schedule provided which had no initials, dates, or repairs to be made indicated, and said, I'm making an inventory of the wheelchairs in the whole facility and then I can enact the cleaning schedule. There was about four months when there was no director of maintenance. Management failed to enforce required schedules of cleaning and maintenance of wheelchairs. We now have a verbalized agreement with the facility that both wheelchair cleaning and maintenance will be done by maintenance department. It wasn't clear before. During an interview on 11/9/22, at 8:53 a.m., with the Director of Rehab (DR), the DR was asked about the wheelchair of Resident 14, and said, Usually for infection control, a foam pad should be covered . During a review of the facility document titled, Work Orders, dated 10/1/22 to 11/8/22, the document indicated there was no work order for cleaning of Resident 14 or Resident 22's wheelchairs. During a review of the facility policy and procedure (P&P) titled, Wheelchair cleaning, dated 10/1/21, the P&P indicated It is the policy of the facility that resident wheelchairs will be cleaned on a monthly basis or sooner if needed.

CONCERN (F)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

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Based on observation, interview and record review, the facility failed to ensure safe and secure labeling and storage of medications and biologicals (vaccines and drugs) for a census of 27, when: 1. Expired medication was found in medication cart 1, expired medications and biologicals were found in the medication room, and an expired box of topical ointments was found in the house supply storage room; 2. An opened medication found in medication cart 1, and an opened medication and an opened vial of tuberculin skin test [TST] in the medication room refrigerator, had no open dates; 3. A medication supplement was inappropriately stored in the refrigerator; 4. The medication room ceiling above the stored medications and biologicals was leaking; and 5. There was no Registered Nurse (RN) to supervise the destruction and disposition of controlled medications. These failures had the potential to result in medications being administered which could cause negative effect on the health and well-being of the residents, and no accountability of discontinued and controlled medications. Findings: 1. During a concurrent medication pass observation and interview on 11/7/22, at 7:41 a.m., Licensed Nurse 4 (LN 4) pulled out a bottle of vitamin C tablets from medication cart 1. The bottle had an expiration date of 9/22, and LN 4 stated, The medication is expired. During a concurrent observation and interview on 11/8/22, at 9:37 a.m., five boxes of sensor blood sugar kits expired on 9/30/22 and boxes of COVID testing kits expired on 3/1/22 were found in the medication room. LN 3 verified the biologicals were expired, and stated, On expired medications, the meds should not be in the medication room and should be discarded. The RN and pharmacist should have wasted the medications and not stored [them] in the medication room. During a concurrent observation and interview on 11/8/22, at 11:36 a.m., a box of topical ointments, thera-calazinc body shield (skin protector), expired on 9/22, was found in the house supply storage room. LN 1 verified the skin protectors were expired, and stated, We have to monitor for side effects. [The ointments] would not be effective and would have an adverse effect on the resident. During an interview on 11/9/22, at 10:34 a.m., with the Pharmacy Consultant (PC), the PC stated, If I see expired medications .I take [medications] out of circulation, and then I set it aside for them [to be destroyed] .expired medications have to be removed [from the medication room] .so that there's no potential for them to use [the expired medications]. 2. During a concurrent medication pass observation and interview on 11/7/22, at 7:43 a.m., LN 4 pulled out a [brand name, breath inhaler] with no open date. LN 4 verified the inhaler medication had no open date, and stated, I don't see [the open date] .I would not know when it was opened. [The medication] would not be effective to the resident. During a concurrent observation and interview on 11/8/22, at 9:37 a.m., a bottle of acidophilus pectin [probiotic and protein supplement], and an opened vial of TST were found in the medication room refrigerator with no open dates. LN 3 verified the supplements and the vial had no open dates, and stated, Medications that are opened should have an open date, per policy. During an interview on 11/9/22, at 10:34 a.m., with the PC, the PC stated, All medications should have the date when opened. There are some [medications and biologicals] that are not effective after a certain amount of time and should be discarded. 3. During a concurrent observation and interview on 11/8/22, at 9:37 a.m., with LN 3, bottles of cranberry extract were found stored in the medication room refrigerator. The bottle indicated the supplement needed to be stored at room temperature. LN 3 stated, I'm not sure why these bottles are in the refrigerator. I don't know who put them there. The supplements .are not supposed to be here in the medication room. During an interview on 11/9/22, at 10:34 a.m., with the PC, the PC stated, I don't think [cranberry extract] should be refrigerated .If [the medication container] indicates the medication should not be refrigerated, then it should not be. 4. During a concurrent observation and interview on 11/8/22, at 9:37 a.m., with LN 3, the ceiling of the medication room was found leaking above the bags of COVID testing kits. LN 3 verified the leaking ceiling and stated, I have not noticed the leak. I have not reported the leak to the maintenance supervisor. During an interview on 11/9/22, at 8:53 a.m., with the Maintenance Supervisor (MS), the MS stated, Recently, we had the roof checked because of leaking .I am not aware of the medication room leaking then, but I am aware now. I have not inspected it. I just received an email yesterday about the problem. We don't have a maintenance log. We don't generally inspect the medication room, but I need to know if it needs attention. I have only been here for three months and we are picking up the pieces .There are many things that need to be fixed. If the roof was leaking and it is affecting a lot of things, it needs attention. During a review of the facility's policy and procedure (P&P) titled Storage of Medications, revised 4/19, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the pharmacy or destroyed .Medications requiring refrigeration are stored in a refrigerator. 5. During an interview on 11/7/22, at 8:36 a.m., with LN 1, LN 1 stated, There is no DON [Director of Nursing] right now .We also don't have a Registered Nurse scheduled today. During an interview on 11/7/22, at 9:33 a.m., with the Administrator (ADM), the ADM was asked about the facility's DON and RN and said, There's no RN in house today .There's no RN from Registry. During an interview on 11/8/22, at 7:13 a.m. with the Social Services Designee (SSD), the SSD was asked about the presence of a DON and RNs in the facility and said, It's been close to a year since we had a DON. During an interview on 11/9/22, at 9:15 a.m., with LN 1, when asked what the process for the disposition of discontinued and controlled medications was, LN 1 stated, The IP [Infection Preventionist] holds the key for the discontinued controlled medications. He is an LVN [Licensed Vocational Nurse]. He does the destruction of discontinued medications with the pharmacist. He has the key. He is on vacation. During an interview on 11/9/22 at 9:25 a.m., with LN 3, when asked what the process for the disposition of discontinued and controlled medications was, LN 3 stated, When we have discontinued narcotic medications, we wait for the RN or the Pharmacist, and we give the medications to them for destruction. Right now, we don't have a Director of Nursing [DON] or an RN. All narcotics are kept in the medication cart. During an interview on 11/9/22, at 10:34 a.m., with the PC, when asked what the process for disposition of discontinued and controlled medications was, the PC stated, I last destroyed [discontinued and controlled medications] with, I think, the IP. They made arrangements for me to come in to get those done so I got those done .Technically [destruction and disposition of discontinued and controlled medications] have to do that with the director of nurses, but they did not have a director of nurses, and when the account was taken on, you know, I was asked to to make sure that everything is in order .I don't know if [the IP] has all the documentation and all that. During an interview on 11/10/22, at 11:52 a.m., with the ADM, the ADM was asked her expectations for having an RN and DON in the facility, and said, There should be an RN on duty eight hours per day, seven days per week. That would include the DON. During a review of the facility's P&P titled Pharmacy Services Overview, revised 4/19, the P&P indicated, Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice .Specific procedures governing pharmacy services are developed by the consultant pharmacist in collaboration with the medical director and the director of nursing services.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most California facilities.

Concerns

• Multiple safety concerns identified: Federal abuse finding. Review inspection reports carefully.
• 59 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade F (35/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Pioneer House's CMS Rating?

CMS assigns PIONEER HOUSE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Pioneer House Staffed?

CMS rates PIONEER HOUSE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 47%, compared to the California average of 46%. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Pioneer House?

State health inspectors documented 59 deficiencies at PIONEER HOUSE during 2022 to 2025. These included: 59 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Pioneer House?

PIONEER HOUSE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CYPRESS HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 50 certified beds and approximately 45 residents (about 90% occupancy), it is a smaller facility located in SACRAMENTO, California.

How Does Pioneer House Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, PIONEER HOUSE's overall rating (2 stars) is below the state average of 3.1, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Pioneer House?

Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.

Is Pioneer House Safe?

Based on CMS inspection data, PIONEER HOUSE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Pioneer House Stick Around?

PIONEER HOUSE has a staff turnover rate of 47%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Pioneer House Ever Fined?

PIONEER HOUSE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Pioneer House on Any Federal Watch List?

PIONEER HOUSE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 50
Avg. Residents: 45
Occupancy: 90.2%
Ownership: For profit - Limited Liability company
Chain: CYPRESS HEALTHCARE GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
59 Deficiencies: -10
Abuse Finding: -15
Final Score: 35/100

Nearby Alternatives

FOLSOM CARE CENTER 5-star SHERWOOD HEALTHCARE CENTER 5-star SACRAMENTO POST-ACUTE 5-star

View all in SACRAMENTO →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555542