BAYSHIRE TORREY PINES POST-ACUTE
For profit - Limited Liability company
45 Beds
BAYSHIRE SENIOR COMMUNITIES
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
43/100
#292 of 1155 in CA
Photo by Bayshire Torrey Pines
Photo by Bayshire Torrey Pines
Photo by Bayshire Torrey Pines
1 / 10 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bayshire Torrey Pines Post-Acute has received a Trust Grade of D, indicating below-average quality with some concerns about care. In California, it ranks #292 out of 1,155 facilities, placing it in the top half, and #37 out of 81 in San Diego County, meaning only a few local options rank higher. The facility is improving, as it reduced issues from 13 in 2024 to 2 in 2025, which is a positive trend. However, staffing is a weakness with a rating of 2 out of 5 stars and a 50% turnover rate, significantly higher than the state average. There are serious concerns regarding food service, as the facility lacked proper oversight from a qualified dietitian, leading to residents receiving meals that did not align with their dietary needs, potentially risking their health.
- Trust Score
- D
- In California
- #292/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 50% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $150,597 in fines. Higher than 88% of California facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Top 25%
Review needed
13 → 2 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 2 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
Staff Turnover: 50%
Near California avg (46%)
Higher turnover may affect care consistency
Federal Fines: $150,597
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: BAYSHIRE SENIOR COMMUNITIES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 52 deficiencies on record
1 life-threatening
Feb 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a baseline care plan for two of 43 sampled r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a baseline care plan for two of 43 sampled residents (Resident 1 and Resident 3) with actual pressure ulcers.
This deficient practice had the potential to delay the necessary person-centered care needed to prevent negative outcomes.
Cross reference F686
Findings:
1. A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked).
A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits.
On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1.5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care.
A clinical chart review for Resident 1 was conducted, which indicated:
- The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25.
- admission ordered on 2/1/25 indicated, .Treatment: Sacralcoccyxgeal [tailbone and the triangular shaped bone to the lower spine] open wound. Apply Barrier Cream To Area To Protect Skin For Maint [maintenance] Tx [treatment] x14 Days BID [twice daily] &PRN [as needed] every day and evening shift for (Skin Integrity Prevention) for 14 Days .
- Skin & Wound Evaluation: 2/4/25 In-house Stage III Sacrum Present on admission. Measurements area: 0.6cm length 1.2 cm width 0.6 cm.
- Medical Doctor (MD) ordered on 2/4/25 indicated, .Treatment- Cleanse stage 3 pressure injury to coccyx with wound cleanser, pat dry and apply santyl [ointment that removes dead tissue] f/b [followed by] DSD [Director of staff Development]. Monitor for s/s [signs and symptoms] of infection, notify MD of any changes. every day shift for wound care .
On 2/7/25 at 2:21 P.M., an interview and record review was conducted with the Minimum data set (MDS) nurse. The MDS nurse stated the admission assessment states open area to coccyx with measurements. I believe that ' s a pressure ulcer. The reason why is because they [admission nurses] are told to not stage it until the RN wound nurse is able to stage it if there is really a pressure ulcer. The MDS nurse stated that the pressure ulcer care plan as not in place within the 48-hour time frame and should be in place to indicate an actual pressure ulcer to help determine if the pressure ulcer got worse and to provide the proper treatment to promote healing.
On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON). The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer. The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed. The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments.
A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals .
2. A review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included a history of malnutrition (lack of proper nutrition).
A record review of Resident 3's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/29/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 3 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits.
A clinical chart review for Resident 3 was conducted, which indicated:
- The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN, LPN, LVN] on 1/23/25.
- admission ordered on 1/23/25 indicated, no treatment orders to the pressure ulcer on the coccyx.
- Medical Doctor (MD) ordered on 1/29/25 indicated, - Treatment- Cleanse chronic stage 3 pressure injury to coccyx with wound cleanser, pat dry and apply santyl f/b calcium alginate and DSD. Monitor for s/s of infection, notify MD of any changes. every day shift for wound care .
- Skin & Wound Evaluation 2/4/25: Coccyx Present on admission. Measurements area: 1.2 cm length 1.9 cm width 0.9 cm.stage 3 pressure injury to sacrococcyx [tailbone and the triangular shaped bone to the lower spine] .
2/7/25 at 2:10 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 3 ' s admission skin assessment dated [DATE] indicated, .Coccyx [tailbone] with small skin opening and quarter sized redness but was checked marked as a pressure ulcer. LN 1 stated the pressure ulcer care plan was initiated on 1/26/25 and should have been initiated within 48 hours (three days after admission). LN 1 stated it was important that the pressure ulcer care plan was in place within 48 hours to prevent delayed care and treatment for the pressure ulcer. LN 1 further stated delayed care can contribute to the worsening of pressure ulcers and infections if not cared for timely.
On 2/7/25 at 2:38 P.M., an interview and record review was conducted with the Minimum Data Set (MDS) nurse. The MDS nurse stated Resident 3 ' s admission skin assessment dated [DATE] indicated Resident 3 had a pressure ulcer to the coccyx. The MDS nurse stated it was important that the pressure ulcer care plan was completed within 48 hours to provide a baseline description for the monitoring the pressure ulcer ' s status with interventions and/or worsening of the pressure ulcer and infection.
On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON). The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer. The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed. The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments.
A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess an actual pressure ulcer on admissi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess an actual pressure ulcer on admission, provide appropriate treatment and preventative measures according to standards of practice to prevent further progression of a pressure ulcer for one of 43 sampled residents (Resident 1) at risk for pressure ulcers.
This failure resulted in a delay of Resident 1's stage III pressure ulcer to be appropriately staged during an initial admission assessment and proper treatment for continous care necessary to prevent the worsening of the pressure ulcer.
Cross reference F655
Findings:
1. A review of Resident 1's admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (a stroke that occurs when blood flow to the brain is blocked).
A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 1/14/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits.
On 2/7/25 at 1:52 P.M., an interview and record review was conducted with LN 1. LN 1 stated Resident 1 ' s admission skin assessment on 2/1/25 indicated there was an open area to coccyx [tailbone] measures 1.5x1.5. LN 1 stated that admission nurses do not stage pressure ulcers and wait until the wound Medical Doctor (MD) stages for them but are not always available during admissions to stage pressure ulcers. LN 1 stated Resident 1 ' s pressure ulcer risk assessment indicated a score of 17 (0-18) that indicated moderate risk (below 9 indicated high risk). LN 1 stated there was no actual pressure ulcer care plan until 2/4/25 (three days after admission) that was initiated by the wound RN. LN 1 stated this should have been included in Resident 1 ' s 48-hour baseline care plan if Resident 1 did have an actual pressure ulcer to prevent any worsening or delay in pressure ulcer care.
A clinical chart review for Resident 1 was conducted, which indicated:
- The admission assessment titled, Skilled Nursing Initial Eval was conducted by a Registered Nurse [RN] on 2/1/25.
- admission Medical Doctor (MD) ordered on 2/1/25 indicated, .Treatment: Sacralcoccyxgeal [tailbone and the triangular shaped bone to the lower spine] open wound. Apply Barrier Cream To Area To Protect Skin For Maint [maintenance] Tx [treatment] x14 Days BID [twice daily] &PRN [as needed] every day and evening shift for (Skin Integrity Prevention) for 14 Days .
- Skin & Wound Evaluation: 2/4/25 In-house Stage III Sacrum Present on admission. Measurements area: 0.6cm length 1.2 cm width 0.6 cm.
- MD ordered on 2/4/25 indicated, .Treatment- Cleanse stage 3 pressure injury to coccyx with wound cleanser, pat dry and apply santyl [ointment that removes dead tissue] f/b [followed by] DSD [Director of staff Development]. Monitor for s/s [signs and symptoms] of infection, notify MD of any changes. every day shift for wound care .
On 2/7/25 at 2:21 P.M., an interview and record review was conducted with the Minimum data set (MDS) nurse. The MDS nurse stated the admission assessment states open area to coccyx with measurements. I believe that ' s a pressure ulcer. The reason why is because they [admission nurses] are told to not stage it until the RN wound nurse is able to stage it if there is really a pressure ulcer. The MDS nurse stated that the pressure ulcer care plan as not in place within the 48-hour time frame and should be in place to indicate an actual pressure ulcer to help determine if the pressure ulcer got worse and to provide the proper treatment to promote healing.
On 2/7/25 2:57 PM an interview was conducted with the Director of Nursing (DON). The DON stated, It was important to include an actual pressure ulcer on the admission assessment and the baseline care plan to prevent the pressure ulcer from worsening and delaying treatment to the pressure ulcer. The DON stated her expectations were for the initial admission assessments to be clear and note an actual pressure ulcer that indicated at the minimum if the skin was red or reddened as blanching [when skin appears paler or white after pressure is applied] or non-blanching [stays red] if they were unsure or stage the pressure ulcer according to what they [Registered Nurse] assessed. The DON further stated that the admission RNs should not wait for the wound RN to stage the pressure ulcer or wait until the wound RN initiated the actual pressure ulcer care plan within 48 hours to prevent worsening complications and delaying treatments.
A review of the facility's policy and procedure titled PREVENTION OF PRESSURE ULCERS dated 2001, indicated .Assess the resident on admission (within eight hours) for existing pressure injury risk factors .Use facility-approved protective dressings for at risk individuals .
Dec 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure it followed professional standards of practice ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure it followed professional standards of practice when a gastrostomy tube (GT-tube inserted through the belly to bring nutrition and medications directly to the stomach) placement and residual (the amount of liquid drained from a stomach following administration of nutrition) was not checked before medication administration for one resident (20).
This failure had the potential for causing complications related to GT health.
Findings:
Per the facility face sheet, Resident 20 was admitted to the facility on [DATE] with diagnoses that included gastrostomy status (presence of an artificial opening into the stomach).
On 12/11/24 at 8:22 A.M., licensed nurse (LN) 1 was observed and interviewed during a medication administration for Resident 20.
On 12/11/24 at 8:31 A.M., LN 1 entered Resident 20's room. LN 1 explained the procedure to Resident 20 and detached Resident 20's GT from the nutrition feeding tube. LN 20 attached a syringe to the GT and flushed the GT with water. LN 20 then proceeded to administer medications.
On 12/11/24 at 8:45 A.M., LN 1 stated she was done with administering Resident 20's medication. LN 1 stated, I forgot to check the GT placement and residual prior to giving the medications.
On 12/12/24 at 2:00 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was her expectation that all nurses check GT placement and residual prior to administering medications and that it is important in order to help prevent complications such as aspiration pneumonia.
A review of the facility policy titled, Administering Medications through an Enteral Tube dated November 2018, .6. Verify placement of feeding tube .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nail care to one of two residents (Resident 9...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide nail care to one of two residents (Resident 96), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents.
As a result, Resident 96 was at risk for skin injury and infection.
Findings:
Resident 96 was admitted to the facility on [DATE], with diagnoses which included generalized muscle weakness and needed assistance for personal care, per the facility's admission Record.
On 12/9/24 at 4:03 P.M., an observation and interview were conducted for Resident 96 as she laid in bed. Resident 96's arms and hands were exposed, and fingernails appeared long, split and with brown materials underneath the nails. Resident 96 stated, No one asked if I want my nails cut short, I want it trimmed but no one asked me. They (facility staff) see it.
On 12/10/24, Resident 96's clinical record was reviewed.
A review of Resident 96's History and Physical (H&P) dated 11/30/24, indicated Resident 96 had fluctuating capacity to make her own medical decisions.
A review of Resident 96's minimum data set (MDS - a federally mandated resident assessment tool), dated 12/3/24, Resident 96 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 11/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). The functional status indicated Resident 96 required one to two-person (staff member) assistance for hygiene and grooming.
A review of Resident 96's care plan (directs the plan of care for the residents that included the goal and interventions), dated 11/28/24, indicated one of the goals for Resident 96's ADLs included provide grooming and hygiene daily .
On 12/10/24 at 4:24 P.M., a follow up observation and an interview were conducted for Resident 96 as she laid in bed. Resident 96 pointed her right thumb fingernail, stated the facility staff did not trim her fingernails, and there was a split between her fingernails. Resident 96 stated she was not comfortable about the split in her fingernail. Resident 96 stated There is something underneath it and they have to trim so that it will not split.
On 12/10/24 at 4:33 P.M., a joint observation of Resident 96's fingernails and an interview with Certified Nursing Assistant (CNA) 11 were conducted. CNA 11 stated the CNAs spent the most time with the residents when providing care, and should have checked Resident 96's fingernails. CNA 11 stated Resident 96's fingernails were long and needed to be trimmed. CNA 11 stated Resident 96 might scratch herself with long fingernails.
On 12/10/24 at 4:50 P.M., a joint observation of Resident 96's fingernails and an interview with Licensed Nurse (LN) 11 were conducted. LN 11 stated LNs did the assessment to newly admitted residents and one of their responsibilities was to check the residents' fingernails. LN 11 stated Resident 96's fingernails were long, curling and with brown materials underneath the fingernails. LN 11 stated Resident 96's fingernails needed to be trimmed. LN 11 stated the brown materials underneath Resident 96's fingernails could have been a food debris. LN 11 stated it was important to trim the residents' fingernails because they might scratch themselves and if something was in the fingernails, it might cause an infection to the residents.
On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectations was for the facility staff to ensure the residents' fingernails were cleaned and trimmed as part of the hygiene provided to the residents.
A review of the facility's undated policy titled, Activities of Daily Living (ADL), Supporting, indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal .hygiene .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a dressing for a peripherally inserted central ca...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a dressing for a peripherally inserted central catheter (PICC- a long, thin, flexible tube inserted into a vein that allows delivery of medications) was changed in a timely manner for one resident (151).
This failure had the potential to increase the risk of infection to Resident 151.
Findings:
Per the facility face sheet, Resident 151 was admitted to the facility on [DATE] with diagnoses that included pelvic osteomylitis (infection of the bone).
On 12/9/24 at 3:56 P.M., an observation and interview was conducted with Resident 151 in the resident's room. Resident 151 was sitting in the wheelchair watching TV. An observation of a PICC line on the resident's left upper arm covered with a dressing dated 12/1/24. Resident 151 stated that the dressing had not been changed since the nurse at the hospital did.
On 12/12/24 at 2:15 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 151's PICC line dressing should have been changed on 12/8/24 and that it was her expectation that all dressings be changed according to standards of practice and facility policy.
A review of the facility policy titled, Peripheral and Midline IV Dressing Changes dated March 2023, indicated that IV dressings need to be changed .a. at least every 7 days .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to indicate the appropriate indication for the use of anticoagulant (b...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to indicate the appropriate indication for the use of anticoagulant (blood thinner) medication for one of two residents (Resident 22), reviewed for unnecessary medications.
This had the potential for unnecessary medication use and had the potential to negatively impact the resident's well-being.
Findings:
A review of Resident 22's admission Record indicated Resident 22 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) and atrial fibrillation (A-fib, irregular and rapid heartbeat).
A review of Resident 22's physician order dated 11/9/22 indicated the following order:
- Apixaban (blood thinner medication) for anticoagulant.
On 12/10/24 at 4:33 P.M., a concurrent review of Resident 22's clinical record and an interview with Licensed Nurse (LN) 12 was conducted. LN 12 stated Resident 22 had been in the facility since 11/9/22. LN 12 stated there was a physician's order of apixaban for Resident 22 on 11/9/22 and the indication for its use was for anticoagulant. LN 12 stated the LN who transcribed the order no longer worked in the facility. LN 12 stated there should be a clear indication for the use of apixaban whether it's for A-fib or PVD for Resident 22. LN 12 stated the LNs should have verified with the attending physician what was the apixaban intended for.
On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to verify the order from the physician and clarify the indication for the medication and the intended use of it.
A review of the facility's policy titled, Medication Orders, revised 10/2018, indicated, .B. Completeness of Orders .1 .Orders must include the drug .It is also recommended that the indication/diagnosis for use be included on each order .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to indicate the appropriate use of anti-anxiety (medication used for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to indicate the appropriate use of anti-anxiety (medication used for worry and fear) medications and communicated the target behavioral monitoring for the use of anti-anxiety medication among staff members, for one of five residents reviewed for unnecessary psychotropic (mind-altering) medications (Resident 96).
This failure had the potential for unnecessary psychotropic medication use, its side effects, and a decline for residents psychological and mental well-being.
Findings:
A review of Resident 96's admission Record indicated Resident 96 was admitted to the facility on [DATE].
A review of Resident 96's physician order dated 11/28/24 indicated the following order:
- Clorazepate (an anti-anxiety medication) for psychosis.
- Monitor episodes of ( .psychosis .AEB [sic, as evidenced by]: hallucinations, agitation) .for drug use of clorazepate.
On 12/10/24 at 4:33 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 11, outside Resident 96's room. CNA 11 stated she was familiar with Resident 96. CNA 11 stated Resident 96 had no behaviors, and no behavior monitoring was reported for them (the staff) to observe.
On 12/11/24 at 10:02 A.M., an interview was conducted with CNA 12, outside Resident 96's room. CNA 12 stated Resident 96 was a nice resident and there was no behavioral monitoring conducted for Resident 96. CNA 12 stated the nurses will tell us if they (residents) need to have any behavioral monitoring.
On 12/11/24 at 12:12 P.M., a concurrent review of Resident 96's clinical record and an interview was conducted with Licensed Nurse (LN) 12. LN 12 stated she admitted Resident 96 to the facility on [DATE]. LN 12 stated Resident 96 had a physician's order of clorazepate and was indicated for psychosis. LN 12 stated Resident 96 had no diagnosis of psychosis. LN 12 stated clorazepate was an anti-anxiety medication. LN 12 stated the indication of the clorazepate is not the right diagnosis, it is important to know the right indication because with this one, it is not the right behavior that we are targeting. LN 12 stated it was important to specify the indication to prevent confusion and unnecessary drug use. LN 12 stated she put the order, Wrong. In addition, LN 12 stated she did not know where to find the documentation for the behavioral monitoring related to the use of clorazepate for Resident 96.
On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation was for the LNs to clarify the indication of psychotropic medication. The DON stated it was important to know why the residents were taking the medications and what disease process the residents were treated for.
A review of the facility's undated policy, titled Psychotropic Medication Use, indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition .2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: .c. Anti-anxiety medications .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe infection control practices when a urinar...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe infection control practices when a urinary catheter (a tube inserted into the bladder to aid in urine flow) bag and dignity bag (a bag used to cover and conceal contents inside) was lying on the floor for one of two residents reviewed for urinary catheter care (Resident 95).
This failure had the potential for cross contamination (spread of germs and bacteria) and infection.
Findings:
A review of Resident 95's admission Record indicated Resident 95 was admitted to the facility on [DATE], with diagnoses which included benign prostatic hyperplasia (BPH, a condition in which the prostate gland is larger than normal and may block the bladder and the urethra) with urinary tract symptoms.
A review of Resident 95's history and physical (H&P) dated 11/29/24, indicated he had the capacity to make his own medical decisions. The H&P indicated Resident 95 had chronic urinary retention due to BPH with chronic urinary catheter.
A review of Resident 95's minimum data set (MDS - a federally mandated resident assessment tool), dated 12/5/24, Resident 95 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 15/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). The MDS section for bowel and bladder indicated Resident 95 had a urinary catheter upon admission.
On 12/9/24 at 3:14 P.M., an observation and an interview with Resident 95 was conducted in his room. Resident 95 laid in bed with a urinary catheter visible next to the bed. Resident 95's catheter bag and privacy bag were on the floor. Resident 95 stated he was, Not comfortable.
On 12/9/24 at 3:18 P.M., an observation with Licensed Nurse (LN) 14 was conducted. LN 14 administered medication to Resident 96. After giving Resident 96 his medications, LN 14 jumped over the catheter bag and the privacy bag which were on the floor.
On 12/9/24 at 3:22 P.M., an interview was conducted with LN 14. LN 14 stated the catheter bag should have been hung and not laid on the floor to prevent from accidentally pulling the catheter which may cause trauma, and prevent bacteria to enter the catheter bag which may cause an infection to Resident 95.
On 12/10/24 at 2:22 P.M., an interview was conducted with the Infection Preventionist (IP). The IP stated the urinary catheter, and the privacy bag should be always off the floor to prevent infection to the residents.
On 12/12/24 at 1:59 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated there should be no catheter bag on the floor for infection control purposes. The DON stated, That should not happen.
A review of the facility's policy titled Catheter Care, Urinary, dated 2001, indicated, .Infection Control .2. Be sure the catheter tubing and drainage bag are kept off the floor .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when:
1...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when:
1. Opened food items had no use by date.
2. Food items with mold in it.
3. Employees' personal belongings were stored inappropriately in a food preparation area.
4. Boxes on top of the ice machine.
These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.
Findings:
1. On 12/9/24 at 8:40 A.M., an observation was conducted with the Certified Dietary Manager (CDM) in the walk-in refrigerator. These observations included:
- sweet and sour basting sauce with no use by date
- grated carrots with no use by date
- salsa with no use by date
- noodle soup with no use by date
- tomato soup with no use by date
On 12/12/24 at 11:09 A.M., an interview was conducted with the CDM. The CDM stated it was important to label and indicate the use by date on the food items to ensure residents were not served with expired foods for safety, and protocols were taken to ensure susceptible residents were free from harm related to food consumption.
On 12/12/24 at 1:45 P.M., an interview was conducted with the Registered Dietician (RD) with the presence of the Administrator (ADM) and the Director of Nursing (DON). The RD stated the expectation was for the dietary staff to conduct quick inspection, label, and indicate the use by date to ensure residents were not served expired foods.
According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 3-501.17 (A) (B) (C) (D), .required food labeling and dating .the day the original container is opened .The date marked shall not exceed a manufacturer's use by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises.
A review of the facility's policy, titled Food Storage, revised 7/11/24, indicated, .All products should be .dated upon receipt, when open and when prepared. Use Use-By dates on all food stored in refrigerators .
2. On 12/9/24 at 8:40 A.M., an observation was conducted with the CDM in the walk-in refrigerator. There were two packs of strawberries with mold in it. The CDM stated, I don't know what to say.
On 12/12/24 at 11:09 A.M., an interview was conducted with the CDM. The CDM stated it was important to inspect the food items in the refrigerator to ensure the residents were served fresh fruits and free from harm related to food consumption.
On 12/12/24 at 1:45 P.M., an interview was conducted with the RD with the presence of the ADM and the DON. The RD stated the expectation was for the dietary staff to check the fruits to ensure they were fresh because it was a health risk to the residents.
A review of the facility's policy, titled Food Storage, revised 7/11/24, indicated, .All products should be inspected for safety and quality .Fresh Fruits, 1. Fresh fruit should be checked .
3. On 12/9/24 at 8:40 A.M., an observation was conducted with the CDM in the food preparation area. There was a cellphone, keys, and speaker by the food tray. Next to these items was a gallon of corn syrup. On the other side, was a tray of bread.
On 12/12/24 at 11:09 A.M., an interview was conducted with the CDM. The CDM stated the employees' personal belongings should be kept in the lockers and should not be in the food preparation area to prevent food contamination.
On 12/12/24 at 1:45 P.M., an interview was conducted with the RD with the presence of the ADM and the DON. The RD stated the expectation was for the dietary staff to keep their personal belongings in the designated location to prevent food contamination, which may cause illness to the residents.
According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 6-305.11(B), .Storage of personal items: Lockers or other suitable facilities are to be provided for the storage of employee personal possessions, 6-403.11 (b) - lockers or suitable facilities are to be located in a designated area where contamination of food, equipment, utensils cannot occur .
A review of the facility's policy, titled Personal Hygiene/Safety/Food Handling/Infection Control, revised 5/18/23, indicated, .5. Designated Area for Employee Personal Belongings .b. Personal belongings .may be stored in the designated area .
4. On 12/9/24 at 8:40 A.M., an observation and an interview was conducted with the CDM in the food preparation area. There were two boxes of Styrofoam products on top of the ice machine. The CDM stated, The boxes should not be there.
On 12/12/24 at 11:09 A.M., an interview was conducted with the CDM. The CDM stated the boxes were removed on top of the ice machine. The CDM stated, The kitchen should be clutter free as a best practice.
On 12/12/24 at 1:45 P.M., an interview was conducted with the RD with the presence of the ADM and the DON. The RD stated, The expectation was the ice machine should be completely clear to keep the ice machine sanitized because there might be a debris that may fall in the ice machine which could create mold because mold builds up very quickly.
According to the 2017 Federal Food and Drug Administration (FDA) Food Code, Section 4-601.11, Equipment .Food-Contact Surfaces .indicate, .(A) Equipment Food-Contact Surfaces .shall be clean .
Nov 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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures when the facility failed to condu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement policies and procedures when the facility failed to conduct a comprehensive investigation of allegations of inappropriate comments that involved one resident (Resident 1).
This failure had the potential for allegations of inappropriate behavior to not be fully investigated.
Findings:
According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included visual loss and need for assistance with personal care.
According to the Minimum Data Set (MDS, an assessment tool), Resident 1 was cognitively intact with a BIMS (Brief Interview of Mental Status, a cognition tool) score of 12.
On 10/22/24 at 10:59 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated on 9/16/24 Certified Nursing Assistant (CNA) 1 reported while assisting Resident 1 with a shower, Resident 1 made inappropriate comments to her. The DSD stated the comments were of a sexual nature.
On 10/22/24 at 2:04 P.M., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON acknowledged CNA 1 had accused Resident 1 of making inappropriate sexual comments to her. The DON stated she did not document the investigation per facility policy. The DON further stated .no, it wasn ' t done . The DON stated it was important to follow the facility ' s abuse policy .so that no harm comes to them [residents and staff] .so they stay safe in the facility .
On 11/8/24 at 2:22 P.M., an interview was conducted with the Administrator (ADM). The ADM stated his expectation was for the facility to follow their abuse policy. The ADM stated, .the tricky thing for this is we didn ' t classify it as abuse .we didn ' t have the stuff [documentation] in the chart .
A review of the facility ' s policy titled Abuse, Neglect, Exploitation or Misappropriation—Reporting and Investigating revised September 2022 indicated, All reports of .are thoroughly investigated by facility management .The individual conducting the investigation as a minimum .reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly .
Jan 2024
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat a resident with dignity when a Certified Nursing...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to treat a resident with dignity when a Certified Nursing Assistant (CNA 1) stood while assisting with breakfast (Resident 108).
This failure had the potential to cause Resident 108 a loss of self-esteem and/or self-worth.
Findings:
Resident 108 was admitted to the facility on [DATE] with diagnoses to include generalized muscle weakness and dysphagia (difficulty swallowing), per the admission Record.
On 12/29/23, Resident 108 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment.
On the same date, Resident 108 was assessed to require partial to moderate assistance with eating.
On 1/9/24 at 8:30 A.M., an observation was conducted in the dining room. Six residents were seated, five were feeding themselves. Resident 108 was seated at a table, with his hands in his lap. CNA 1 was standing on Resident 108's right side, feeding him the plated food.
On 1/9/24 at 8:35 A.M., an interview was conducted with CNA 1. CNA 1 stated she should have been seated while feeding Resident 108, as well as all residents who require feeding assistance. CNA 1 stated being seated would make it easier to see how the resident was chewing and swallowing, and would give the resident dignity while dining.
On 1/9/24 at 8:40 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the CNA should have been seated in order to provide dignity to the resident.
Per a facility policy, revised July 2017 and titled Assistance with Meals, .Residents Requiring Full Assistance: .2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. Not standing over residents while assisting them with meals .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and transmit Discharge Minimum Data Set (MDS, a comprehensive assessment and care screening tool) assessments for two of two reside...
Read full inspector narrative →
Based on interview and record review, the facility failed to develop and transmit Discharge Minimum Data Set (MDS, a comprehensive assessment and care screening tool) assessments for two of two residents reviewed for Resident Assessment (Residents 5, 8).
This failure resulted in Resident 5 and 8's discharge status not being communicated to the Centers for Medicare and Medicaid (CMS) as required, and had the potential to result in delayed quality measurements from the data.
Findings:
On 1/11/24, a record review was conducted.
Per the MDS 3.0 Resident Assessments list:
Resident 5 was due for a Discharge MDS assessment on 9/19/23. Resident 5's MDS status was indicated as, In progress.
Resident 8 was due for a Discharge MDS assessment on 8/28/23. Resident 8's MDS status was indicated as, In progress.
On 1/11/24 at 2:35 P.M., a concurrent interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated it was important to complete a Discharge MDS when a resident left the facility. The MDSC reviewed Resident 5 and Resident 8's MDS summaries and stated, I missed these. I take ownership of it, it was a mistake.
On 1/11/24 at 3:19 P.M. an interview was conducted with the Director of Nursing (DON). The DON stated it was important for the MDS to be completed and transmitted in order for CMS to track the resident, and to see that payment was correct and not fraudulent.
Per a facility policy, dated 2001, titled, Resident Assessment, .Required Assessments-are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes .1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a required assessments conducted for all residents in the facility: .(7) Discharge Assessment .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to utilize urine collection containers (UCC) in a safe, c...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to utilize urine collection containers (UCC) in a safe, clean manner for two of two residents reviewed for Environment of Care.
This failure had the potential to cause urinary tract infections (UTIs).
Findings:
1. Resident 156 was admitted to the facility on [DATE] with diagnosis to include a fractured bone in the spine and UTI, per the admission Record.
On 1/8/24, at 9:30 A.M., Resident 156 was observed in bed. A plastic device with long tubing was observed set on towels on the floor. The coiled tubing went from the device on the floor up under the blankets and between Resident 156's legs. A liquid which appeared to be urine was in the tubing, and in the UCC. Resident 156 stated she did not know what the tubing or device were for.
On 1/11/24, a record review was conducted.
On 12/29/23, Resident 156 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition.
Per a nursing admission Evaluation, dated 12/23/23, Resident 156 was on an antibiotic (a medication to treat infections) for a current UTI.
2. Resident 107 was admitted to the facility on [DATE] with diagnosis to include paralysis to one side of the body, per the admission Record.
On 1/11/24 at 9:10 A.M., an observation of Resident 107 was conducted in her room. Resident 107 was in bed, sitting up. Resident 107 had a UCC sitting on the floor, on towels. The UCC tubing was coiled on the towel. Resident 107 stated her family brought the device for her to use at night, so she would not have to get up and walk to the bathroom. Resident 107 stated the UCC would remove urine from her body through the tube. Per Resident 107, the device was always left on the floor.
On 1/11/24, a record review was conducted.
On 12/23/23, Resident 107 had a BIMS score of 13, indicating intact cognition.
On 1/11/24 at 9:30 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated the UCC for both residents was brought in by family members. LN 1 stated the UCC needed to be kept below bladder level to work properly, so it was placed on towels on the floor. LN 1 stated leaving the UCC and tubing on the floor could cause UTI's. LN 1 stated a low table or container should be used rather than placing the UCC on the floor but this had not been done.
On 1/11/24 at 9:40 A.M., an interview was conducted with Infection Preventionist 1 (IP 1). IP 1 stated, The device shouldn't be on the floor, it could put the resident at risk for infections. UTIs could easily be a result of poor practice. IP 1 stated since the UCC was not commonly used in the facility, staff had to be trained on its proper use to prevent infections. IP 1 stated the training had not been provided for the UCC.
On 1/11/24 at 10:09 A.M., an interview was conducted with the Director of Nursing (DON). Per the DON, the UCC cannot sit on the floor. The DON stated the towel was intended as a way to keep the UCC off of the floor, but may not be best practice for infection prevention.
Per a facility policy, revised September 2014 and titled Catheter Care, Urinary, .Infection Control .2B. Be sure the catheter tubing and drainage bag are kept off the floor .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure residents received foods in measured amounts when standardized recipes were not followed for residents receiving puree...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure residents received foods in measured amounts when standardized recipes were not followed for residents receiving pureed diets.
This failure had the potential for residents to have decreased nutrition and possible weight loss.
Findings:
An observation of the pureed food production for lunch was conducted on 1/10/24 at 10:30 A.M. The Culinary Director (CD) cut seven portions of the ravioli bake casserole and placed them in the blender. The CD did not measure or weigh the portions. In addition, seven portions of cauliflower were pureed with no measurement or weighing of the portions. The CD poured chicken stock into the blender without measuring the amount. There was no recipe/recipe book available for the CD to use.
An interview was conducted with the CD on 1/10/24 at 10:45 A.M. The CD stated, I did not use a recipe, I know them. There is a recipe binder here in the department. It is important to follow the recipes to keep nutritional value.
An interview was conducted with the Dietary Services Manager (DSM) on 1/10/24 at 10:50 A.M. The DSM stated, It is important to use the recipes so that the correct texture is obtained; if it is too runny or too thick, residents might not eat it.
An interview was conducted with the Director of Nursing (DON) on 1/ 11/24 at 9:43 A.M. The DON stated, Following the recipe is important for nutritional value and for consistency.
An interview was conducted with the Registered Dietitian (RD) on 1/11/24 at 11:46 A.M. The RD stated, Following recipes for puree food is very important because the recipe has specific amounts of servings and liquid to preserve the nutrition, and we don't want to dilute or add to the diet.
A review of the facility policy titled, Standardized Recipes, dated 4/2017, indicated, Policy statement: Standardized recipes shall be developed and used in the preparation of foods.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure food safety was maintained in the kitchen according to facility policy when multiple food items were not dated or were...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure food safety was maintained in the kitchen according to facility policy when multiple food items were not dated or were dated in the future; and no received on or use by date was noted.
These deficient practices had the potential to cause foodborne illness.
Findings:
An observation of the facility's kitchen was conducted on 1/8/24 at 8:30 A.M.
Seven containers had no received or expire dates: parsley flakes, black pepper, granulated garlic, oregano, paprika, thyme leaves, and basil.
Multiple items were marked with received dates which were in the future (2/5/24): a one-pound package of ground beef, a one-pound package of ground pork, boxes of [NAME] Krispy Treats, quick oats, boxed pancake mix, boxed cake mix, cans of tomato soup, cans of cranberry sauce, cans of corned beef hash and a box of quinoa.
There were multiple items with dates but not identified as whether the date was received by, or use-by dates: pecan pieces, sugar, pancake syrup, coffee creamer, brown sugar, salt, pound cake, and frozen mixed berries.
Several items had no dates: bags of shredded cabbage and bags of shredded carrots, whole cabbage (stored in boxes) and cantaloupes (stored in boxes.)
An interview was conducted with the Dietary Services Manager (DSM) on 1/8/24 at 8:40 A.M. The DSM stated, There are many things mislabeled, staff should be more careful, we don't want to serve expired food to residents.
An interview was conducted with the facility administrator (Admn) on 1/11/24 at 9:43 A.M. The Admn stated, Non-labeled food can be expired and that can cause food borne illness.
An interview was conducted with the Director of Nursing (DON) on 1/11/24 at 9:43 A.M. The DON stated, Food that is expired can cause illness.
An interview was conducted the the Registered Dietitian (RD) on 1/11/24 at 10:46 A.M. The RD stated, It is important to label and date items so that we know what we are serving to residents and that it is safe.
The facility was unable to provide a policy regarding labeling and dating of foods.
Dec 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the acceptable standard of care for the blood pressure medic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the acceptable standard of care for the blood pressure medication was followed for one of two sampled residents. This failure had the potential to affect Client 1 ' s quality of life, health and well- being.
Findings:
Resident 1 was admitted to the facility on [DATE], per the facility ' s Face Sheet.
On 11/15/23 a record review was conducted. Resident 1 had diagnoses which included subarachnoid bleed (bleeding in the space that surrounds the brain), per the physician ' s admission history and physical visit, dated 10/6/23. Per the MDS, dated [DATE], Resident 1 had a BIMS of 11 (BIM score of 8-12 indicated a resident was moderately cognitively impaired).
On 11/15/23 at 3:07 P.M., an interview and record review were conducted with Licensed Nurse (LN) 2. The LN 2 stated Client 1 had an order of blood pressure medicine since she was admitted to the facility on [DATE]. The blood pressure medication was ordered one time a day and scheduled at 9 A.M. There was no written parameter order until 10/13/23. The LN 2 stated the standard of practice for blood pressure medication was to check the blood pressure of the resident before giving the medication and follow the physician ' s parameter order. If no written parameter, follow the facility standard of practice which to hold the medicine if the systolic blood pressure is below 110 millimeter of mercury (mmHg) and if pulse was less than 60 beats per minute.
On 11/15/23 at 3:27 P.M., an interview was conducted with LN 4. The LN 4 stated that he always checked the blood pressure of residents before administering the blood pressure medicine. The LN 4 stated the normal practice was to hold the blood pressure medicine if the systolic pressure was below 110 mmHg and if pulse below 60 and notify attending physician. LN 4 further stated, if there were no parameters written, verify with the attending MD.
On 11/15/23 a record review of Client 1 ' s Medication Administration Record (MAR) and Vitals Summary log was conducted. Per the MAR, dated 10/11/23, the blood pressure medicine was administered to Client 1 at 9 A.M. There was no documentation of Client 1 ' s blood pressure (BP) reading in the MAR. Per the Vitals Summary Log, dated 10/11/23 at 7:04 A.M., the BP reading was 104/61 and at 19:31 P.M., Client 1 ' s BP reading was 90/60. Per the MAR, on 10 /12/23, the blood pressure medicine was administered at 9 A.M. There was no documentation of BP reading in the MAR. Per the Vitals Summary Log, dated 10/12/23 at 9:48 A.M., Client 1 ' s BP reading was 103/58 mmHg.
Per the Physician ' s order dated 10/12/23 indicated Irbesartan Oral Tablet 150 MG (Irbesartan) Give 150 mg by mouth one time a day for HTN Hold for SBP less than 110.
On 11/15/23 at 3:45 P.M., a joint record review and interview with the Director of Nursing (DON) was conducted. The DON stated, staff should have held the medicine when the blood pressure reading was low even with no parameter was written. The standard of practice of the facility was to hold medicine when BP reading is below 110 mmHg and pulse below 60 beats per minute.
On 12/19/23 at 4:37 P.M., an interview with LN 3 was conducted. The LN 3 stated BP reading should be checked before giving the blood pressure medicine. Hold medicine when BP reading is below 110 mmHg and pulse less than 60 beats per minute. The LN 3 stated that they have a policy & procedure on the administration of the blood pressure medicine and parameter when to hold the medicine.
On 12/19/23 at 4:45 P.M., an interview with LN 4 was conducted. The LN 4 stated the standard of practice was to check resident BP before administered the medicine. If systolic blood pressure is below 110 mmHg and pulse was less than 60 beats per minute was to hold the medicine and notify the attending physician.
Policy and procedure were not provided upon request.
Nov 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide regular showers to two of two sampled residents (1, 2).
As ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide regular showers to two of two sampled residents (1, 2).
As a result, Resident 1 and Resident 2 were placed at an increased risk of skin infections.
Findings:
1. Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include paraplegia (difficulty moving the lower half of the body) and muscle weakness.
Per the facility's Shower Schedule, each resident had showers scheduled on two days of the week based on what room they were in.
Per the facility's Body Check Sheets, there was documentation of the facility providing 7 of the 11 scheduled showers to Resident 1. There was no documentation of the facility offering a shower to Resident 1 on 8/3, 8/10, 8/14, or 9/1.
On 10/27/23 at 11:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, she was not able to find documentation to explain the missing shower notes for Resident 2. The DON further stated, the staff should have documented whether a shower was given or refused on each scheduled shower day.
2. Per the facility's admission Record, Resident 2 was admitted to the facility on [DATE] with diagnoses to include hemiplegia (difficulty moving one side of the body), need for assistance with personal care, and weakness.
Per the facility's Shower Schedule, each resident had showers scheduled on two days of the week based on what room they were in.
Per the facility's Body Check Sheets, there was documentation of the facility providing 4 of the 12 scheduled showers to Resident 2. There was no documentation of the facility offering a shower to Resident 2 on 7/28, 8/4, 8/8, 8/11, 8/18, 8/22, 8/29, or 9/1.
On 10/27/23 at 11:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, she was not able to find documentation to explain the missing shower notes for Resident 2. The DON further stated, the staff should have documented whether a shower was given or refused on each scheduled shower day.
Per the facility's policy, titled Bath, Shower/Tub, revised February 2018, .Documentation . The date and time the shower/tub bath was performed . If the resident refused the shower/tub bath .
Mar 2023
32 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0801
(Tag F0801)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility document reviews, the facility failed to ensure the management and oversig...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility document reviews, the facility failed to ensure the management and oversight of food and nutrition service operations was maintained with a qualified full-time dietitian or nutrition professional who met the requirements as specified in established state (California Code, Health and Safety Code - HSC § 1265.4) standards and federal standards, which include an onsite, qualified, full-time dietetic services supervisor (DSS) or food service manager (FSM); and a Dietitian employed full or part-time. The lack of oversight of dietetic and food services by a full-time DSS or FSM, resulted in the kitchen staff not having adequate oversight, tools, and training to develop the skills to carry out the Food and Nutrition Services in a competent, safe, and sanitary manner, particularly when the dietitian was part-time. In addition, because the facility did not employ a Dietitian from December 22, 2022 - January 23, 2023, regular frequently scheduled consultations between the Dietitian and the DSS or FSM, did not occur.
The lack of competent, full-time, dietetic services management oversight of the food and nutrition services staff placed 38 residents who received food from the licensed kitchen at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutrition needs of the residents, which both have the potential to result in death.
An Immediate Jeopardy situation (IJ, a situation in which facility noncompliance has placed the health and safety of a resident at risk for serious harm, injury, serious impairment or death) was declared on February 28, 2023, at 5:31 P.M., in the presence of the Administrator (ADM) for not having a full-time qualified professional, onsite for day-to-day oversight in the Food and Nutrition Services Department which left kitchen staff unable to carry out necessary functions to safely feed the Skilled Nursing facility residents.
The facility submitted a removal plan of action, which included:
1) a signed contract between the facility and a consulting company for employment of a full-time Registered Dietitian (RD) to serve as Manager of Food and Nutrition Services (also referred to as a dietary services supervisor- DSS) until a Certified Dietary Manager (CDM) was employed and trained at the facility;
2) The RD manager initiated one-to-one (1:1) education with each kitchen staff member including Cooks and Diet Aides who provide meals to residents in the licensed skilled nursing unit, which included staff return demonstration to RD;
3)
The Director of Staff Development (DSD)/Nurse Consultant initiated 1:1 education for Certified Nursing Assistants and licensed nursing staff to ensure resident are served meals with meal tray tickets that match the physician ordered diet using a facility physician ordered diet list. Education will be validated with verbal return demonstration.
4)
The therapeutic menu spreadsheet was signed and approved by the RD Manager on 3/1/23, and the signed therapeutic menus were provided to the Cooks and Diet Aides who prepare and serve meals to residents in the facility's licensed unit. And the signed therapeutic menu spreadsheet was posted on a clip board near the trayline station in the licensed satellite kitchen. The RD will monitor meal service 3 times weekly alternating mealtimes to ensure dietary staff are following the menu spreadsheet. On the spot reeducation will be given to staff if any issues are identified.
5)
All resident meal diet tickets were updated to match the physician ordered diets as of 2/28/23 at 8 pm. This was validated on 3/1/23 by the facility's corporate culinary consultant. The RD manager will enter and update all diet orders going forward until a full-time CDM is hired and trained to ensure accuracy and they match the physician's order.
6)
In the event the full-time RD Manager is unavailable to provide oversight of the facility's dietetic services, another RD consultant group signed an agreement to provide coverage at the facility until a CDM is hired.
When evidence of an onsite full-time DSS/RD Manager was employed by the facility, and the facility's kitchen and clinical staff were in-serviced on how to perform essential food and nutrition services tasks such as safe food preparation, storage, and service; and safe meal tray delivery accuracy, an acceptable removal plan of action provided by the ADM was approved on March 2, 2023, at 1:07 P.M., and the immediate jeopardy was removed.
Findings:
A.
The facility did not have an onsite, full-time, qualified DSS, FSM or RD to provide oversight of Food and Nutrition Services operations in the Skilled Nursing Facility (SNF) satellite kitchen.
During multiple observations of the main and SNF satellite kitchens, staff interviews, and document reviews from 2/27/23 at 8:24 A.M. and 2/28/23 at 5:00 P.M., the facility did not have a qualified, full-time, nutrition professional onsite to provide management and oversight for the dietetic, food, and nutrition service systems for the SNF residents.
During the initial tour of the main kitchen on 2/27/23 at 8:26 A.M., an observation and concurrent interview was conducted with [NAME] (CK) 1 and Diet Aide (DA) 1. The main kitchen was cluttered and with multiple empty cardboard boxes, empty food containers, chemical bottles scattered on the floor, along with wrappers, trash, and other debris on the floor along the walkway from the kitchen entrance to the food equipment area. CK 1 was in the middle of plating breakfast meals service. CK 1 was asked if the manager in charge was available and he stated Yes, he's in the office. CK 1 also stated, He's new, but I was told he is the new kitchen manager. I haven't seen the old manager in a while.
On 2/27/23 8:33 A.M., an interview was conducted with the Executive Chef (EC) in the main kitchen office. The EC stated he was recently hired and, started working at the facility a week ago. The EC stated he did not know where many things in the kitchen were. EC stated he was hired to manage the facility's the entire kitchen department, which included both the main and satellite kitchens. The EC was asked if he was a Certified Dietary Manager (CDM) and he stated No, but I have my ServSafe Certificate. The EC further stated he had not seen or met with the former kitchen manager or the facility's Registered Dietitian (RD).
On 2/27/23 at 12:35 P.M., an interview was conducted with the ADM about the kitchen manager for the SNF unit and the facility's RD. The ADM stated the kitchen manager was out sick with covid and she did not know when he would return. The ADM stated the kitchen manager was a CDM, and a new consultant RD was hired sometime in January 2023, who would be at the facility this afternoon. The ADM stated the facility ended the last RD Consultant contract in December 2022. The ADM stated the last time the kitchen manager/certified dietary manager (CDM) was onsite at the facility was a couple of weeks ago, but she had to double check the exact date.
On 2/27/23 at 1:01 PM, an interview was conducted with the consultant RD. The RD stated she was hired to work part-time for the SNF residents, and the ADM told her the facility would be hiring a new person to replace the kitchen manager. The consultant RD stated she worked at the facility 16 hours a week starting late January 2023. The consultant RD stated she had not seen or worked with the kitchen manager.
On 2/27/23 at 1:36 PM, a review of the EC's personnel file indicated no documentation of a CDM credential or other evidence of education or training to meet the requirements of a DSS/FSS to oversee and manage the daily operations of the SNF satellite kitchen, per state and federal regulations.
On 2/27/23 at 03:36 PM, an interview of the PM [NAME] (CK) 2 was conducted. CK 2 stated she was the head evening cook on Sundays and Mondays. CK 2 stated the kitchen manager left the facility three weeks ago, and it's been a while since she saw him.
On 2/27/23 at 4:15 PM, an interview was conducted with the consultant RD. The consultant RD stated she primarily performed clinical nutrition services like monitoring residents on tube feedings and other tasks, but she had not completed any kitchen sanitation audits or staff in-services.
During an observation and interview on 2/28/23 at 7:43 AM with CK 3 in the main kitchen, CK 3 stated neither manager, the old kitchen manager, or the new kitchen manager (EC) was there.
On 2/28/23 at 8:03AM, a joint observation and interview was conducted with DA 1 and DA 3 in the SNF satellite kitchen. DA 1 stated she was told the EC was the new manager and in charge of both kitchens, but he was not at work yet, today. DA 1 also stated she was also told when the EC was not there, the Lead Diet Aide (LDA) was in charge. DA 1 further stated when neither the EC or LDA is here, the MSD (minimum dataset) Nurse will help out if we need assistance or guidance in the kitchen.
On 2/28/23 at 11:59 AM, an interview was conducted with the ADM. The ADM stated the manager/supervisor over the assisted living restaurant is the same person as the executive chef (EC) from the facility's executive chef job description. The ADM stated the facility recently hired a person who started a week ago in the EC position.
During an interview with the ADM on 2/28/23 at 3:05 PM, the ADM stated the facility had an FSM who asked to work evenings and weekends as of January 16, 2023. The ADM stated the FSM called out sick on February 17th, 2023 but she could not confirm when or if he worked in the facility in January or February 2023. The ADM restated the FSM was the manager of both the SNF satellite kitchen and main kitchen for the assisted living section. The ADM further stated she did not know if he would return to work and the facility did not have an RD from December 2022 - January 2023, until a consultant RD was hired part-time. The ADM stated the consultant RD did not have a set schedule.
Review of the RD consultant services from October-December 2022 indicated there were no kitchen sanitation audits for food safety conducted.
According to the state of California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian.
According to the 2022 Federal FDA Food Code, the person in charge (PIC) of a food establishment is accountable for developing, carrying out, and enforcing procedures aimed at preventing food-borne illness. Section 2-102.11 states how a person in charge may demonstrate required knowledge of food safety is through certification .by passing an examination that is part of an accredited program.
Review of the undated document titled SNF Dietary Manager Job Description, indicated .Minimum Qualifications .must have successful completion of a course approved by the Dietary Manager's Association (or possess a minimum of individual state regulation requirements for Dietary Services Director position); Certified Dietary Manager (CDM) .Essential functions and responsibilities included but not limited to: .1. plans, develops, organizes, implements, evaluates, and directs Dietary Department programs and activities in accordance with departmental policies and current federal, state, and local regulations .2. Supervise dietary department employees . responsibility for training competent personnel, evaluate employee performance; ensure that quality food service and nutritional care is always provided for each resident; .6. Participates in long term care survey process, always maintains a presence while surveyors are onsite and directs timely collection of information required by the survey team .
Review of the facility undated document titled Registered Clinical Dietitian indicated, .Essential Duties and Responsibilities .completes clinical duties which include comprehensive and accurate, timely nutritional documentation as indicated. This includes annual assessments, quarterly progress notes as well as residents deemed as high risk .conducts sanitation audits of dietary dept. in conjunction with Dietary Service Director to ensure dept. is maintained in safe, clean, sanitary manner .Routinely audits food service areas and practices for compliance with current regulations and policies (includes sanitation reviews, meal service, nutritional documentation) .
Review of the undated document titled Registered Clinical Dietitian Job Description indicated, Overall function: Responsible for nutritional care of the residents in accordance with current federal, state, and local regulations; Essential duties and responsibilities included but not limited to: completes comprehensive and accurate, timely nutrition documentation including annual assessment and quarterly notes for residents at high risk; provides nutrition education to dietary dept. as well as other departments; routinely audits food service areas and practices for compliance with current policies (includes sanitation reviews, meal service) .
Review of the Consulting Agreement between the Consultant Registered Dietitian and the skilled nursing facility signed on 1/2/23 by the ADM, showed the Consultant RD was to perform consultative duties within the realm of her profession. The services performed may include, but not limited to, the following: 1) review nutritional documentation on all new resident admissions, residents with significant weight loss/gains, or require tube feeding nutritional support; 2) review all yearly or quarterly basis for changes in nutritional status; 3) evaluate sanitation and safety practices in food service department; 4) survey readiness; 5) provide in-service education and training as needed for dietary staff; 6) review and approve all regular and therapeutic diet menus for facility's residents. The contract showed the number of hours is as needed per the administrator and shall be determined by the needs of the facility.
B.
The facility did not have a qualified, full-time DSS, FSM, or RD to oversee or monitor safe sanitizer solution levels for the SNF satellite kitchen dish machine.
On 2/27/23 at 10:06 AM, a concurrent observation and interview was conducted with DA 1 in the satellite kitchen. DA 1 failed to correctly demonstrate the process to test the chlorine chemical sanitizer solution level of the low temperature dish machine with the manufacturer's test strips. DA 1 tried three different sets of test strips, and each test strip color was white and did not change colors. The white color on the test strip container indicated zero (0) ppm (parts per million) of chlorine chemical in the solution. DA 1 stated the strips do not work. DA 1 stated she may be using the wrong test strips, but she didn't know where any other test strips were in the kitchen. DA 1 was asked when the last time the sanitizer in the dish machine was checked and she said yesterday, I believe. DA 1 further stated she was not trained on how to test the dish machine sanitizer level correctly.
On 2/27/23 at 10:30 A.M., a joint observation and interview was conducted with DA 1 and EC in the satellite kitchen. EC brought a small ring of test strips down to the satellite for DA 1 to test the chemical sanitizer of the dishwasher. DA 1 tore of an inch of the orange strip from the ring and dipped it into the dish machine solution. The test strip did not turn a different color, so both DA 1 and EC stated, the chemicals must not be working or it's the wrong test strip. DA 1 stated there are usually other types of test strips in the satellite kitchen but she did not know where any of those strips were. EC stated he could not confirm when the dish machine sanitizer level was checked or if it was at a safe level since he started working at the facility a week ago.
According to the 2022 Federal FDA Food Code, section -2-103.11, the person in charge (PIC) is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of chemical concentration and temperature for chemical sanitizing. In addition, a warewashing machine and its auxiliary components are to be operated in accordance with the machine's data plate and other manufacturer's instructions. A test kit or other device that accurately measures the concentration of sanitizing solution is to be provided. The Food Code Annex indicate, the PIC is to ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. The effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. In addition, the Food Code Annex explains epidemiological outbreak data repeatedly identify contaminated equipment as a major risk factor related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness.
According to the 2022 Federal FDA Food Code, section 4-302.14, titled Sanitizing Solutions, Testing Devices, testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic.
According to the 2022 Federal FDA Food Code, section 4-501.11 Good Repair and Proper Adjustment, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk . Adequate cleaning and sanitization of dishes and utensils using a warewashing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize . A chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization.
According to the 2022 Federal FDA Food Code, section 4-501.15, titled Warewashing Machines, Manufacturers' Operating Instructions, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly .
Review of the undated document titled SNF Dietary Manager Job Description, indicated .Essential functions and responsibilities include but not limited to: .1. plans, develops, organizes, implements, evaluates, and directs Dietary Department programs and activities in accordance with departmental policies and current federal, state, and local regulations .2. Supervise dietary department employees . responsibility for training competent personnel, evaluate employee performance .3. Completes management duties including schedules .conducts routine in-services for department personnel in conjunction with the registered dietitian; Routinely audits dietary areas and practices for compliance with current regulations and policies (i.e. meal service, sanitation .food temperatures .); reports all hazardous conditions/equipment to the Administrator immediately .
Review of facility policy dated October 2008, titled Sanitization, indicated The food service area shall be maintained in a clean and sanitary manner .8. Dishwashing machines must be operated using the following specifications: .Low-temperature dishwasher chemical sanitization .final rinse with 50 parts per million (ppm) hypochlorite chlorine for at least 10 seconds .
C.
The facility did not have a qualified, full-time DSS, FSM, or RD onsite to provide oversight of safe food storage in the facility kitchens that served residents in the SNF; including oversight and monitoring staff competency of thermometer calibration for temperature monitoring.
During the facility's initial tour on 2/27/23 at 8:34 A.M. of the main kitchen, an observation of the cook's food production area, the walk-in refrigerator and walk-in freezer was conducted. In the cook's food prep area, there was a large clear plastic storage container uncovered, unlabeled, and undated filled with white powder on top of the counter above the food prep sink. The walk-in refrigerator had multiple uncovered, unlabeled, and/or undated potentially hazardous and Time/Temperature Control for Food Safety (TCS) foods (i.e. meat, dairy, etc.) stored unsafely including: a medium sized plastic storage container with black olives half full without a lid, a medium sized plastic container ¾ full of pickles in juice uncovered dated 1-12-23 without a lid, a medium sized metal pan with chopped pulled barbecue chicken unlabeled and undated with plastic wrap, a large sheet pan of a brown soup or liquid dish with plastic wrap on the top shelf unlabeled and updated, five limes with black gray spots resembling mold in a case of brownish green colored limes, and a metal pan with green leaf lettuce in it covered with plastic wrap with no label or date. The walk-in freezer had four large 1/3 gallon ice cream tubs- strawberry, vanilla, chocolate and mint chocolate chip flavors on the shelf uncovered with bent lids falling off the sides. The ice cream was semi-soft, partially melted and not rock solid.
During an observation of the dry storage in the main kitchen on 2/27/23 at 9:39 AM, a large open 10-pound bag of sugar wrapped in plastic and a large opened bag of Panko, were both undated.
On 2/27/23 at 9:42 A.M., an interview was conducted in the main kitchen with the EC. The EC acknowledged the undated and unlabeled food items in the in the cook's prep area, the walk-in refrigerator, walk-in freezer, and dry storage and stated, all foods should be labeled and dated with at least an opened date.
During an observation in the SNF satellite kitchen of the reach-in refrigerator and freezer and interview on 2/27/23 at 9:50 AM with DA 1, the following foods were found undated and unlabeled: a medium sized plastic container of chopped melon chunks, a plastic container of chopped pineapple, and a plastic container of cream-colored pudding. A dirty rag with brown stains was on a tray with ten glasses of 8 oz. glasses of juice and milk. DA 1 stated she forgot to remove the rag from the tray after wiping the inside of the refrigerator. The reach-in refrigerator's internal thermometer temperature was 50 degrees Fahrenheit (F). The Surveyor took the temperature of a glass of milk, and it was 44.8 degrees F. The DA 1 stated sometimes the refrigerator gets warmer than 40 degrees. There was also an unlabeled and undated large pastry desert in the reach-in freezer.
During the observation of the reach-in refrigerator in the SNF satellite kitchen on 2/27/23 at 10:00 AM and interview with DA 1, the Surveyor asked DA 1 if the thermometer she used to take food temperatures in the SNF kitchen had been calibrated. DA 1 stated she did not know the last time it was calibrated.
During an interview and record review on 2/28/23 at 10:30 A.M. in the main kitchen, the January 2023 and February 2023 walk-in refrigerator and freezer temperature logs were reviewed. The temperature logs were missing AM and PM temperatures by kitchen staff, during the week of February 22nd -26th. The EC acknowledged the missing temperatures and staff initials.
According to the 2022 Federal Food Code, section 2-103.11, an important duty of the Person in Charge (PIC) is to make sure that any required temperatures are achieved or maintained when foods are cooked, cooled, thawed, or held in a food establishment. By making it a duty of the Person in Charge to ensure that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced. This includes oversight of temperature monitoring to ensure: 1) that animal foods are being cooked to the required minimum temperatures to prevent the survival of pathogens that may be present (2-103.11(G)); 2) that cooked foods are being cooled rapidly to ensure that the growth of bacterial pathogens and toxin production is prevented (2-103.11(H)); and 3) that temperatures for time/temperature control for safety (TCS) foods (i.e. meat, dairy, foods) are routinely monitored during thawing to ensure that the growth of bacterial pathogens and toxin production is prevented (2-103.11(J) and 4) that foods that require temperature control for safety are being held at temperatures that adequately prevent pathogen growth and toxin production (new 2-103.11(I)).
According to the 2022 Federal Food Code, section 3-302.12 Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food.
According to the 2022 Federal Food Code, section 2-103.11, the person in charge (PIC) shall ensure that employees are using properly calibrated thermometers to routinely monitor cooking temperatures. In addition, food temperature measuring devices that are scaled in Fahrenheit shall be accurate within a range of degrees in the intended range of use. According to the Food Code Annex, thermometers provide a means for assessing active managerial control of time temperature control for food safety (TCS) food temperatures. Food thermometers must be calibrated at a frequency to ensure accuracy. If a food temperature measuring device is not maintained in good repair, the accuracy of the reading is questionable. Consequently, a temperature problem may not be detected.
According to the 2022 Federal Food Code, section 4-302.12, titled Food Temperature Measuring Devices; the presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded.
Review of facility policy dated October 2017, titled Food Receiving and Storage, indicated .7. Dry foods stored in bins will be .labeled and dated (use by date) .8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .10. Refrigerated foods must be stored below 41 degrees F .12. The freezer must keep frozen foods solid .
On 2/27/23 at 11:54 AM, a review of the trayline food temperature logs from the SNF satellite kitchen was conducted. The temperature log binder had logs from January 2022- December 2022, but the logs for January 2023 were missing. There were 3 temperature log dates completed for February 2023, the 7th, 25th, and 27th. DA 1 confirmed those were the only trayline food temperature logs in the SNF satellite kitchen.
On 2/27/23 at 12:06 PM, an observation and interview with DA 1 was conducted of the lunch meal service in the SNF satellite kitchen. DA 1 pushed a food warmer with the lunch meal in separate sheet pans down to the satellite kitchen from the main kitchen. DA 1 entered the satellite kitchen, put on gloves, and started to assemble the pans on the trayline station. DA 1 did not wash her hands before she put on gloves. DA 1 then took temperatures of the trayline food. The trayline temperatures were rice pilaf- 149 degrees F, pork chops -138 degrees F, Chicken breast - 145 degrees F, DA 1 stated the chicken temperature should be 165 F. The surveyor took temperatures of both the puree brussel sprouts, which was 129 F and regular brussel sprouts -133F. DA 1 took the regular brussel sprouts temperature, which was 132.6 F, and the mashed potatoes was 143 F. DA 1 stated the food could be warmer, but it was okay to serve it because the temperatures were higher than 120 degrees F.
According to the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 3-501.16, titled Time/Temperature Control for Safety Food, Hot and Cold Holding, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) .135oF or above .or .may be held at a temperature of .130oF or above; or (2) At .41ºF or less.
During an observation and interview on 2/28/23 at 8:43 AM in the main kitchen with the EC and CK 3, the large plastic bin with white thickener powder was still above the food prep sink unlabeled, undated, and uncovered without a lid. The EC stated he did not know where the lid was, but the large bin should be labeled, dated, and covered with a lid.
Review of the facility policy dated April 2019, titled Food Preparation and Service, indicated .1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness .potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk .4. Food and nutrition services staff .wash their hands before serving food to residents .
Review of the facility's log documents titled SNF Satellite Kitchen, dated 2/20/23-2/26, 1/9/23, and [DATE]-[DATE], showed the task: Calibrate thermometers was blank with no kitchen staff initials. The other remaining logs for dates in February 2023, January 2023 and December 2022 were missing and not provided.
Review of the facility policy dated April 2019, titled Food Preparation and Service, indicated .5. Food thermometers used to check food temperatures are clean, sanitized, and calibrated frequently .
Review of the facility undated document titled Registered Clinical Dietitian indicated, .Essential Duties and Responsibilities .completes clinical duties which include comprehensive and accurate, timely nutritional documentation as indicated. This includes annual assessments, quarterly progress notes as well as residents deemed as high risk .conducts sanitation audits of dietary dept. in conjunction with Dietary Service Director to ensure dept. is maintained in safe, clean, sanitary manner .Routinely audits food service areas and practices for compliance with current regulations and policies (includes sanitation reviews, meal service, nutritional documentation) .
Review of the Dietary Aide Job Description dated 3/8/20, showed the primary function of the position was to assist with serving, plating, and sometimes prepping food items based on the nutrition needs of their patients; performs tasks to ensure timely preparation and delivery of nutritious attractive meals and supplements to all residents according to physician's orders and in compliance with federal, state, and company requirements; duties and responsibilities: plating and serving meals, snacks, and beverages following procedures; utilizes Grove menus, extension sheets for therapeutic diets and
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to perform an interdisciplinary team (IDT, staff from different department who coordinates the residents care), assessment, and o...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to perform an interdisciplinary team (IDT, staff from different department who coordinates the residents care), assessment, and obtain a physician order for one of 39 residents (Resident 25) when
multiple prescribed topical creams were found in a blue container on top of resident's bedside table.
This failure had the potential for unsafe and improper administration of the topical cream medications.
Findings:
Review of Resident 25's admission Record indicated, diagnoses including hypertension (increase in blood pressure), Parkinson's disease (disease marked by tremor, muscle rigidity).
On 2/27/23 at 12:12 P.M., an observation in Resident 25's room and concurrent interview with the resident, an opened blue container was placed on the resident's bedside table. Inside the blue container were tubes of Clobatesol gel (skin treatment for psoriasis) hydrocortisone cream (medication to treat itching redness of the skin).
Resident 25 applied Clobatesol gel on his face. Resident 25 stated he applied the medication as often as he wanted to.
On 2/27/23 at 12:15 P.M., a concurrent observation and interview with licensed nurse (LN 32) was conducted. LN 32 confirmed Resident 25 had topical medication tubes of Clobatesol gel and hydrocortisone cream inside his blue container. LN 32 stated Resident 25 should have been assessed to determine if he could safely self-administer the topical medications.
During a concurrent interview and record review on 2/27/23 at 12:23 P.M. with LN 32, she stated Resident 25 should have been assessed by the licensed nurses and reviewed by the IDT (interdisciplinary team- a group of professionals all working collaboratively toward a common goal) to determine if he could safely administer the medication. LN 32 acknowledged there was no assessment and no physician order regarding the self-administration of medications.
A review of the facility's 2021 policy, Self- Administration of Medications, indicated As part of comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self - administering medications is safe and clinically appropriate for the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 345 was admitted to the facility on [DATE] with diagnoses which included, diabetes mellitus (high blood sugar level)...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 345 was admitted to the facility on [DATE] with diagnoses which included, diabetes mellitus (high blood sugar level), high blood pressure (elevated blood pressure reading), and post-op total right knee replacement (after surgery to replace the knee joint) per the admission Record History & Physical.
The Minimum Data Sheet (MDS) dated , 2/28/23 indicated, a Brief Interview for Mental Status (BIMS- a brief cognitive screening measure on orientation) score of 15, demonstrating no cognitive impairment. Further review of Section E, dated 2/28/23 indicated, no negative behavior was observed.
On 02/27/23 at 11:54 A.M., a concurrent observation and interview of Resident 345 was conducted. Resident 345 was sitting up in bed, alert and oriented, verbally responsive to questions, and with an unhappy look on her face. Resident 345 stated, four days since her admission, she had repeatedly asked and requested the nursing staff to space out certain medications such as:
1. Metoprolol (blood pressure medication) - to be given at bedtime (9:00 PM) instead of 5:00
P.M., ensuring a longer duration between doses.
2. Metformin (medication to lower blood sugar)- to be given prior to bedtime instead of at the
evening meal (5:00 PM).
3. Acetaminophen (pain relieving medication) - Two tablets (1000 mg) to be given at regular 8-
hour intervals (starting at 8:00 a.m. then 4: PM and midnight).
Resident 345 further stated despite her requests, which were important to her, there had been no adjustments in her medication schedule. Resident 345 stated she had to decline the acetaminophen dose on 2/27/23 at 6 A.M. because it had only been approximately six hours, since her last dose. Resident 345 stated she had to repeatedly ask for the acetaminophen, even though it was to be given regularly every 8 hours. At other times, she had to wait 1-2 hours after the scheduled time to receive the pain medication. In addition, Resident 345 stated on 2/26/23, one of the Licensed Nurses (LNs) had given her only one tablet, instead of two ordered tablets, at the scheduled administration time.
During the interview with the resident, Resident 345 became teary eyed multiple times and reported she had become increasingly frustrated with her requests not being answered. Resident 345 stated several facility staff had argued with her about the due time of her medications that could not be adjusted.
On 02/28/23 at 9:10 A.M., an interview was conducted with registered nurse (RN) 21. RN 21 confirmed the acetaminophen was 1000 mg (milligram), or 2 tablets every 8 hours and due at 8:00 A.M. on 2/28/23.
On 2/28/23 at 9:05 A.M., an observation and interview was conducted with Resident 345. Resident 345 was sitting in chair and stated her medications were scheduled to be given at 8:00 A.M. on Sunday (2/26/23) but were given at 11:00 A.M.
A review of Resident 345's physician's orders was conducted. The Physician orders dated, 2/23/23 indicated, .Metformin (a medication for DM) 1000 mg oral, twice a day. Metoprolol Oral Tablet 100 MG (a blood pressure medicine) tablet two times a day .Acetaminophen Oral Tablet (pain medicine) 1000 mg (2 tablets) by mouth every 8 hours for pain for 4 weeks .
A review of Resident 345's MAR on Metformin for the month of 2/2023 was conducted.
The MAR indicated, on 2/24, 2/25, 2/26, and 2/27/23, the medications were administered at 5:00 PM.
On 2/28/23 and remainder of stay, Metformin was administered at 9 P.M.
A review of the MAR on Metoprolol medication for the month of 2/2023 was conducted. The MAR indicated, on 2/24, 2/25, 2/26, and 2/27/23 the medications were administered at 9:00 A.M. and 5:00 P.M.
On 2/28/23 and remainder of stay, Metoprolol was given at 9 A.M. and 9 P.M.
A review of the MAR on acetaminophen for the month of 2/2023 was conducted. The MAR indicated, on 2/24, 2/25, and 2/26/23 the medications were administered at 6 A.M, 2 P.M., and 10 P.M.
On 2/27/23, acetaminophen was administered at 6 A.M.
On 2/27/23 at 6 A.M. through 11:59 P.M. (12 hours), no acetaminophen were given per the MAR.
On 2/28/23 and for remainder of stay, Acetaminophen were administered at 12 A.M., 8 A.M., and 4 P.M.
Per the History and Physical (H&P) dated, 2/23/23 indicated, Resident 345 did not want any changes to her analgesic regimen upon admission to the facility.
On 03/07/23 at 10:23 A.M., an interview with the Director of Staff Development (DSD) was conducted. The DSD stated she had been informed of Resident 345's requested adjustment to her medication schedule on 2/28/23. The DSD confirmed Resident 345 had appeared upset regarding her requests not being completed. The DSD acknowledged residents have the right to request their medication times to be adjusted to their preference and Resident 345 had waited four days to unnecessarily to have this done. The DSD stated the policy and procedure (P&P) was to notify the supervisor or physician if any resident's request was not possible.
On 3/7/23 at 10:30 A.M., an interview and record review with LN 32 was conducted. LN 32 confirmed she had been the charge nurse on 2/26/23 and was not aware of Resident 345's request for medication time changes. LN 32 agreed Resident 345's choices for Metformin, Metoprolol and Tylenol were not honored for four days.
On 3/08/23 at 3:47 P.M., an interview with the IDON (Interim Director of Nursing) and IDON 2 was conducted. The IDON stated her expectation was for staff to honor resident's choices, if possible. IDON 2 acknowledged Resident 345's requests were not addressed properly and Resident 345 should have had her choices honored.
A review of Resident 345's Care Plan, Alteration in Comfort, initiated on 2/23/23 indicated, A licensed nurse on each shift .will report to my MD, PA or NP if my pain medication are not meeting needs.
A review of the policy for Administering Medications, dated 4/2019, indicated, Medication administration times are determined by resident need and benefit, not staff conveniency. Facts that are considered are .honoring resident choices and preferences .
A review of the policy for Dignity, dated 2/2021 indicated, The facility culture supports dignity and respect for resident by honoring resident goals, choices .begins at admission and continues throughout the resident facility stay.
Based on observation, interview, and record review, the facility failed to address resident's needs and preferences for two of 12 sampled residents (345, 549) when:
1. Resident 549's call light was not within reach.
2. Resident 345's preferred time for administration of her medications were not honored as
requested.
These failures had the potential for resident's needs not being met. In addition, failure to honor the preferred time of medication administration resulted to Resident 345's refusals of medications and feelings of frustration and low self-worth.
Findings:
1. On 3/2/23 at 9:32 A.M., an observation and interview was conducted with Resident 549 in her room. Resident 549 was hitting her table and stated she cannot find her call light to call for help. The call light was on the floor far from her reach.
On 3/2/23 at 9:33 A.M., a concurrent observation of the call light inside Resident 549's room and interview with the assistant director of nursing (ADON) was conducted. The ADON acknowledged and stated, call light should always be near the resident.
During an interview with the interim director of nursing (IDON 2) on 3/8/23 at 4:33 P.M., the IDON 2 stated all residents call lights should be placed within their reach to call for assistance.
A review of Resident 549's admission Record dated, 2/21/23 indicated, diagnoses of weakness, difficulty in walking, need for assistance with personal care. Her minimum data set (MDS, an assessment tool) dated, 2/24/23 indicated, Resident 549 was cognitively intact.
A review of the facility's policy titled 'Answering the Call Light revised March 2021, indicated, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform a resident's representative of a significant change in physi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform a resident's representative of a significant change in physical status for one of one resident (20) reviewed for hospitalization.
This failure deprived resident 20's representative of the right of being informed of resident 20's change in physical condition.
Findings:
A review of resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with multiple diagnoses including paraplegia (inability to voluntarily move the lower half of the body.) The admission Record listed Emergency Contact #1 and Responsible Party as the resident's wife.
Resident 20 was transferred to the hospital on [DATE] due to syncope (fainting) and collapse.
On 3/6/23 at 9:08 A.M., a review of resident 20's SNF (skilled nursing facility) to Hospital Transfer Form (a form that provides information regarding a resident's clinical status/medical condition), dated 12/27/22 indicated, resident 20's wife was notified of the transfer but was not made aware of the residents change in medical condition.
On 3/6/23 at 3:55 P.M., an interview and review of Resident 20's record was conducted with Licensed Nurse (LN) 34. LN 34 stated there was no documentation in the medical record that Resident 20's wife was notified of the resident's change in condition.
On 3/7/23 at 9:19 A.M., an interview and record review was conducted with LN 32. LN 32 stated it was important for Resident 20's wife to be aware of the resident's change in condition. LN 32 also stated there was no documentation in the medical record showing the wife was notified of the changes in Resident 20's medical condition.
On 3/8/23 at 9:47 A.M., an interview and record review was conducted with the IDON (Interim Director of Nursing) 2. IDON 2 stated notifying the resident's representative was part of providing person centered care and conversations regarding a resident change in clinical condition must be documented in the medical record. IDON 2 also stated the SNF to Hospital Transfer Form, dated 12/27/22, did not indicate Resident 20's wife was notified of the significant change in Resident 20's condition.
The facility was unable to provide a policy related to communicating changes in a residents condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written bed hold notice to the resident's RP (responsible...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written bed hold notice to the resident's RP (responsible party - an individual authorized by the resident to act as an official representative) upon transfer to the hospital for one of one resident (20) reviewed for hospitalization.
This failure had the potential to result in Resident 20's RP being unaware of Resident 20's return to the facility after hospitalization.
Findings:
A review of resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included paraplegia (inability to voluntarily move the lower half of the body.) The admission Record listed the resident's wife as the RP.
Resident 20 was transferred to the hospital on [DATE] due to syncope (fainting) and collapse.
On 3/6/23 at 10:39 A.M., an interview was conducted with the HRD (Human Resources Director.) The HRD stated residents were provided a notification with the daily rates for private and semi-private rooms upon admission. The HRD stated the nurses were responsible for delivering the bed hold notification to the resident/residents representative at the time of transfer.
On 3/6/23 at 3:55 P.M., an interview and record review was conducted with LN (Licensed Nurse) 34. LN 34 stated there was no documentation in resident 20's medical record that a written bed hold notice was provided to Resident 20's RP. LN 34 stated she was not sure who's responsibility it was to provide the written bed hold notice when a resident was transferred to the hospital.
On 3/7/23 at 9:19 A.M., an interview and record review was conducted with LN 32. LN 32 stated the nurses verbally asked the RP at the time of transfer if they would like the facility to hold the resident's bed. LN 32 stated there was no documentation of this verbal conversation in Resident 20's medical record.
On 3/8/23 at 9:40 A.M., an interview and record review was conducted with the IDON (Interim Director of Nursing) 2. IDON 2 stated the expectation of the facility was for bed hold notifications to be given in writing at the time the resident leaves the facility. IDON 2 stated there was no documentation of Resident 20's RP being provided a written bed hold notification.
A review of the facility's policy titled Bed-Holds and Returns, revised March 2017, indicated Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a comprehensive assessments for one of 12 res...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a comprehensive assessments for one of 12 residents (9) reviewed for resident's assessments with a significant change in condition.
This failure had the potential to affect the provision of care and treatment/services to be provided to Resident 9.
Findings:
Resident 9 was re-admitted to the facility on [DATE] with diagnoses which included Pneumonia, Peripheral Neuropathy and Congestive Heart Failure according to the physician's progress notes dated 2/24/23.
On 3/1/23 at 8:22 A.M., an observation of Resident 9 was conducted. Resident 9 was in bed with eyes closed. The room had an odorous smell of urine.
On 3/1/23 at 8:24 A.M., an interview was conducted with Resident 9. Resident 9 stated he did not have the same control of his bowel and bladder. Resident 9 stated when he had to have a bowel movement, he now needed staff to come right away, otherwise he would lose control. Resident 9 also stated he can walk slowly with his walker with the assistance of the physical therapist. Resident 9 stated he did not trust other staff to assist him out of bed.
On 3/1/23 at 2:22 P.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated Resident 9 had a condom catheter (urine collection device with a tube that drains to a collection bag). CNA 1 stated Resident 9 required extensive assist of one person with transferring out of bed. CNA 1 stated Resident 9 stayed in bed until therapy came and stayed 30 minutes to 1 hour in the wheelchair after therapy. CNA 1 stated Resident 9 was cognitively intact and knew what was going on.
On 3/7/23 at 11:46 A.M., an interview with the MDS nurse (a minimum data set nurse who assess, monitor, and document patient's health) was conducted. The MDS nurse stated a significant change of resident's status was determined when if: Resident was admitted to hospice; decline in activities of daily living (ADL); or a significant weight loss. The MDS nurse stated if there was a significant change in a resident's status, an assessment could be done in MDS and the IDT (Interdisciplinary Team - a group of people with different functional expertise working toward a common goal) would be notified to complete their sections in the MDS. The MDS nurse stated the family would be notified and rehab, to screen the resident if indicated.
The MDS nurse stated Resident 9 was discharged to the hospital on 2/9/23 due to oxygen desaturation (low oxygen level), vomiting, a heart rate of 104 and lethargy (feeling of fatigue, weakness), and re-admitted to the facility on [DATE]. The MDS nurse stated it was important to identify and assess Resident 9's decline in medical condition to address the problem and changes in medical condition should have been reflected in the MDS to develop a care plan.
On 3/8/23 at 4:01 P.M., an interview with Interim Director of Nursing (IDON 2) was conducted. IDON2 stated Resident 9 should have been re-assessed to determine the changes in condition and address the plan of care for the resident based on the triggered areas in MDS. IDON2 stated if a SCSA (significant change of status assessment) was not completed, the care plan would not be accurate.
During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a screening and an assessment too...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a screening and an assessment tool) assessment was accurately coded for one of one resident (19) reviewed for MDS accuracy.
This failure had the potential to affect the care and services to be provided for Resident 19.
Findings:
Resident 19 was admitted to the facility on [DATE] with the diagnosis of Hepatobiliary Cancer (a group of malignancies (abnormal cells divide without control and invade nearby tissues) that includes liver, intra and extra hepatic biliary tracts, and the gall bladder) with Hospice care (care provided when there is no active or curative treatment) according to the physician's progress notes dated 1/12/23.
On 2/27/23 at 4:15 P.M., an observation of Resident 19 was conducted. Resident 19 was lying flat in bed with lunch tray at bedside. Resident 19 stated he did not like what was served today, 2/27/23 and had asked for something else. Resident's fingernails were long with blackish debris.
On 3/6/23, at 10:31 A.M., an interview was conducted with certified nursing assistant (CNA) 1. CNA 1 stated Resident 19 required set up with meals, extensive assist with transfers, grooming and hygiene. CNA 1 stated Resident 19 was on hospice care and hospice staff assisted Resident 19 to be up in the Geri chair (a large, padded chair designed to help the elderly with limited mobility).
On 3/7/23 at 11:46 A.M., an interview with the MDS (a minimum data set nurse who assess, monitor, and document patient's health) nurse was conducted. The MDS nurse stated Resident 19 was admitted to hospice on 1/10/23 per the physician's order. The MDS nurse stated a significant change of status assessment (SCSA) was completed on 1/12/23. The MDS nurse stated Resident 19's MDS should have been coded with hospice to have an accurate information.
On 3/9/18, at 2:38 P.M., an interview was conducted with Interim Director of Nursing (IDON 2). IDON 2 stated the MDS was a comprehensive assessment of the resident, and it was important for assessing and planning the care for a resident. IDON 2 stated it was an expectation the MDS assessments were accurate. IDON 2 stated it was important to reflect hospice in the MDS to coordinate Resident 19's care and other aspects of care that were critical. IDON 2 stated MDS inaccuracy affected the outcome of resident's care.
A review of the Physician's Orders dated 2/1/23-2/28/23 was conducted. The Physician's Orders dated, 1/10/23 indicated, Hospice Diagnosis: Malignant neoplasm of liver .
The facility did not provide a policy regarding accurate coding of the MDS.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. Resident 9 was re-admitted to the facility on [DATE] with diagnoses of Pneumonia (infection affecting the lungs), Peripheral...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2b. Resident 9 was re-admitted to the facility on [DATE] with diagnoses of Pneumonia (infection affecting the lungs), Peripheral Neuropathy (weakness, numbness and pain, usually in the hands and feet), and Congestive Heart Failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) according to the physician's progress notes dated 2/24/23.
During an interview and concurrent record review with the Social Service Director (SSD) on 3/6/23, at 3:54 P.M., the SSD stated he completed the sections of the care plan meeting for Resident 19, but the other team members did not complete their sections. SSD stated there was no documentation to indicate that Resident 9 nor the wife received a summary of the baseline care plan.
2c. Resident 19 was admitted to the facility on [DATE], with the diagnosis of Hepatobiliary Cancer (having to do with the liver, bile ducts, and/or gallbladder) with Hospice care according to the physician's progress notes dated 1/12/23.
During an interview and concurrent record review with the Social Service Director (SSD) on 3/6/23, at 3:54 P.M., the SSD stated Resident 19 was re-admitted to the facility on [DATE]. The SSD stated there was no baseline summary provided to Resident 19 and Resident 19's daughter
An interview was conducted on 3/08/23 at 8:03 a.m. with SSD and the MDS nurse regarding baseline care planning. The SSD stated he initiated the Social Service/Discharge/Transition Data Collection document which triggered care plans for discharge/transition plan and advance directives. The MDS nurse stated the nursing staff had another form to complete sections regarding basic care plans, ADLs, risk for skin breakdown, risk for falls and bowel and bladder. The MDS nurse stated once the document was completed, nursing staff will review the document with the resident if there was a change. The MDS nurse stated the facility did not provide residents and/or resident representatives a summary of their baseline care plans.
During an interview with the interim DON (IDON 2) on 3/08/23, at 4:01 p.m., the IDON 2 stated baseline care plans set the standard for care to be delivered to the resident. IDON 2 stated the baseline care plan should be person centered and the resident and the representative should know what to expect about the resident's care. IDON 2 stated the baseline care plan should be completed within 24 hrs or as soon as possible. IDON 2 stated if the resident or representative did not receive a summary, they will not know what to expect regarding care.
A review of the facility's policy titled Care Plans - Baseline, revised March 2022, 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 . 4. The resident and/or representative are provided a written summary of the baseline care plan . 5. Provision of the summary to the resident and/or resident representative is documented in the medical record.
Based on interview and record review, the facility failed to ensure a baseline care plan was developed and communicated to residents/residents representatives for three of 20 residents (44, 9, 19) reviewed for base-line care plan when:
1. Resident 44 did not have a completed baseline care plan created within 48 hours of admission.
2. Residents 44, 9 and 19 were not provided a written summary of their baseline care plans.
As a result of this deficient practice, there was potential for lack of continuity of care and communication among nursing staff. This deficient practice also denied residents and their representatives the opportunity to participate in their care planning process.
Findings:
1. A review of resident 44's admission Record indicated the resident was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy (damage or disease that effects the brain), pneumonia (infection of the lungs) and urinary tract infection.
On 3/6/23 at 3:55 P.M., an interview and record review was conducted with Licensed Nurse (LN) 34. LN 34 stated resident 44's care plan was incomplete. LN 34 stated it looked like the care plan was started but not finished due to an incomplete area of focus and two areas of focus with no interventions listed. LN 34 also stated it was important to create a care plan because it gives resident specific interventions to properly care for the resident. LN 34 stated the Minimum Data Set (MDS) nurse, medical records department, and Director of Nursing (DON) contributed to creating the baseline care plan.
On 3/7/23 at 9:31 A.M., an interview and record review was conducted with LN 32. LN 32 stated Resident 44's care plan was incomplete. LN 32 also stated it was not the responsibility of the admitting nurse to create the baseline care plan and the MDS nurse and DON also helped.
On 3/8/23 at 8:02 A.M., an interview and record review was conducted with the MDS nurse. The MDS nurse stated Resident 44's care plan was incomplete. The MDS nurse stated he was not involved in the baseline care plan creation but it should have been created within 48 hours of admission. MDS nurse also stated there was no one person assigned to ensure baseline care plans were created.
On 3/8/23 at 9:32 A.M., an interview and record review was conducted with the Interim Director of Nursing (IDON) 2. IDON 2 stated Resident 44's care plan was incomplete. IDON 2 also stated the baseline care plan must be created within 48 hours of admission.
2a. A review of Resident 44's admission Record indicated the resident was admitted to the facility on [DATE] with multiple diagnoses including encephalopathy (damage or disease that effects the brain), pneumonia (infection of the lungs) and urinary tract infection.
On 3/8/23 at 8:02 A.M., an interview and record review was conducted with the Social Services Director (SSD). The SSD stated he did not provide a written summary of the baseline care plan to any resident or resident's representative.
On 3/8/23 at 9:32 A.M., an interview and record review was conducted with the Interim Director of Nursing (IDON) 2. IDON 2 stated there was no documentation of a written summary being provided to the resident or residents representative. IDON 2 also stated it is important to give the resident or residents' representative a written summary of the care plan to give them an opportunity to share resident specific information that may have been missed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans were revised/updated for 2 of 12 re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans were revised/updated for 2 of 12 residents reviewed for care plans. (Resident 9 and Resident 19). This
failure had the potential for residents not to receive the care needed to meet their individualized needs for safety, the potential for delayed care, miscommunication among caregivers, and decreased psychosocial well-being.
Findings:
1.
Resident 9 was re-admitted to the facility on [DATE] with diagnoses of Pneumonia (infection affecting the lungs), Peripheral Neuropathy (weakness, numbness and pain, usually in the hands and feet), and Congestive Heart Failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) according to the physician's progress notes dated 2/24/23.
During an observation on 2/27/23, at 9:45 A.M., Resident 9's door was closed. Resident 9 had a visitor and requested for surveyor to return at another time.
During an observation on 2/28/23, at 3:54 P.M., Resident 9 was in bed with his eyes closed. An odorous smell of urine was noted in the room and the door was closed.
During an observation on 3/1/23, at 8:22 A.M., Resident 9 was in bed with his eyes closed and the room door was closed.
An interview with CNA 1 was conducted on 3/1/23, at 2:34 P.M. CNA1 stated Resident 9 was moody at times. CNA 1 stated Resident 9 was set in his ways and preferred to keep door closed. CNA 1 stated Resident 9 was able to use the call light and that was when he would check on the resident.
An interview and concurrent record review was conducted with LN 32 on 3/6/23, at 11:05 A.M. LN 32 stated Resident 9 preferred to keep his room door closed. Upon review of the electronic care plans for Resident 9, LN 32 stated there was no care plan regarding Resident 9's choice to keep his door closed. LN 32 stated a care plan was need for resident safety and staff to check on Resident 9 when passing by.
2.
Resident 19 was admitted to the facility on [DATE] with the diagnosis of Hepatobiliary Cancer (having to do with the liver, bile ducts, and/or gallbladder) with Hospice care according to the physician's progress notes dated 1/12/23.
A joint observation of Resident 19 was conducted with LN 34 on 3/6/23, at 4:30 A.M., Resident 19 was in bed reading the newspaper. Resident 19 was observed with long fingernails with black debris under the nails. LN 34 removed Resident 19's socks and stated Resident 19 also had long toenails. LN 34 stated hospice staff was responsible for providing showers and should also check fingernails & toenails.
An interview was conducted with CNA 1 on 3/6/23 at 10:31 A.M., CNA 1 stated Resident 19 required set up with meals, extensive assist with transfers, grooming and hygiene. CNA 1 stated Resident 19 was on hospice and hospice staff assisted Resident 19 to be up in the Geri chair (a large, padded chair designed to help the elderly with limited mobility).
During an interview and concurrent review of care plans with Licensed Nurse (LN) 32 on 3/6/23, at 11:05 A.M., LN 32 stated Resident 19's care plans have not been reviewed or updated. LN 32 stated there were multiple care plans overdue for review such as the care plans for UTI (urinary tract infection), respiratory status, behavior management, therapy participation, discharge plan, advanced directives, oxygen therapy, generalized weakness, and nutritional risk. LN 32 stated there was also no care plan which indicated Resident 19 was on hospice. LN 32 stated it was important to review and update care plans for staff to be aware of the Resident's plan of care. LN 32 stated without a hospice care plan for Resident 19 created confusion for the staff, and the care for the resident was no longer accurate.
During an interview with the interim DON (IDON 2) on 3/08/23 at 4:01 P.M., the IDON 2 stated care plan goals should be reviewed and revised according to the MDS protocol and as needed. IDON 2 stated if care plans were not reviewed, staff did not know if the resident was improving or declining.
During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A record review of Resident 350's medical chart was conducted on 2/28/23. Resident 350 was [AGE] year-old male admitted on [D...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A record review of Resident 350's medical chart was conducted on 2/28/23. Resident 350 was [AGE] year-old male admitted on [DATE], with diagnoses, that included but not limited to Right Hip Fracture (broken right hip bone), COVID 19 infection (virus infection), post- op wound infection (infection in area of surgery), seizures (uncontrollable movements) and meningioma (brain tumor). The Minimum Data Sheet (MDS), dated [DATE], reported a Brief Interview for Mental Status (BIMS) score of 15, demonstrating no cognitive impairment.
During concurrent observation and interview on 2/27/23, at 5:48 P.M., Resident 350 was sitting up in bed watching television. Noted to have a slightly malodors smell in the dark room.
During interview on 2/28/23 at 4:51 P.M., wife of Resident 350 reported Resident 350 had not been showered or tub bathed since 2/15/23. She stated because Resident 350 was occasionally incontinent it was even more important for him to be bathed regularly. Resident 350's family member (FM1) stated she had requested for Resident 350 to be showered, including shampooing his hair, multiple times. FM 1 stated Resident 350 smelled unwashed and bedside washing was not adequate for proper hygiene.
During an interview on 03/01/23, at 10:34 A.M., CNA 23 stated showers were given twice a week and when requested by the resident, per facility policy. CNA 23 reported shower days were determined by room number, with Resident 350 scheduled for a shower on Wednesdays and Saturdays. CNA 23 reported while Resident 350 could perform some hygiene needs, he required assistance to shower.
During interview on 03/01/23, at 2:34 pm, FM 1 reported a shower was given on 2/28/22, but his hair had not been washed. FM 1 stated his hair was so dirty, she gave up on the facility staff washing it, and washed it herself in the resident's room.
During a concurrent interview and record review on 3/7/23, at 11 A.M., LN 32 confirmed Resident 350 was scheduled for showers on Wednesday and Saturdays. A review of the facility binder labeled, Shower Schedule, with skin check documents, verified Resident 350 had a shower on 2/15/23 and 2/28/23. LN 32 confirmed showers were important for good hygiene, decrease risk of infection, as well as to ensure a full body check was done on each resident routinely. LN 32 acknowledged Resident 350 had not been showered or bathed per facility policy.
A record review was conducted on 3/7/23. The Physician Progress Note dated 2/17/23, indicated Resident 350 required significant supportive care due to memory impairment, in particular short-term memory. Physician Progress Note dated 2/21/23, indicated Resident 350 required moderate assistance for bathing and lower body dressing. Further record review of Task sheet for preferred bath every (q) Wednesday and Saturday, indicated activity was not done for the listed dates of 2/16/23, 2/17/23, 2/20/23, 2/21/23, 2/24/23, 2/27/23, 2/28/23, and 3/2/23 (other dates not documented). On review of the task record titled, Bladder Continence, it was documented Resident 350 had 12 occurrences of urinary incontinence (unintended leakage of urine).
A record review was conducted on 3/7/23. Resident 350's ADL Care Plan, dated 2/23/23, indicated staff were to assist with Resident 350 ADLs. Resident 350's Minimum Data Sheet (MDS) Section G indicated he required limited assistance needed for personal hygiene (bathing, dressing, grooming, and oral care) and bathing. Resident 350's ADL Care Plan, dated 2/23/23, indicated staff were to assist with Resident 350 ADLs. Resident 350's Minimum Data Sheet (MDS) Section G indicated he required limited assistance needed for personal hygiene (bathing, dressing, grooming, and oral care) and bathing.
During interview on 3/8/23 at 3:47 P.M., Interim Directory of Nursing 2 (IDON2) stated her shower expectation was for showers to be given twice weekly. IDON2 acknowledged showers were important for maintaining good resident hygiene, decreasing risk of infection and enabling staff to perform a vital skin assessment.
On review of facility policy titles, Activities of Daily Living (ADL's) Supporting, 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. In addition, the policy stated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently . including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).
Based on observation, interview, and record review, the facility failed to provide the necessary care to maintain good grooming and personal hygiene for 2 of 2 residents sampled for ADL care. (Resident 19 and 350).
This failure resulted in Resident 19 having long and dirty fingernails and Resident 350 did not have a shower as scheduled.
Findings:
1. Resident 19 was admitted to the facility on [DATE], with the diagnosis of Hepatobiliary Cancer (having to do with the liver, bile ducts, and/or gallbladder) with Hospice care according to the physician's progress notes dated 1/12/23.
A joint observation and interview of Resident 19 was conducted with LN 34 on 3/6/23, at 4:30 P.M. Resident 19 was in bed reading the newspaper. Resident 19 was observed with long fingernails with black debris under the nails. LN 34 removed Resident 19's socks and stated Resident 19 also had long toenails. Resident 19 stated he would like his fingernails and toenails trimmed.
During an interview with the Interim DON 2 (IDON 2) on 3/8/23, at 4:01 P.M., the IDON 2 stated nailcare should be provided to residents to maintain safe, smooth and consistent nails. The IDON 2 stated the Resident's dignity was affected if he or she had long and dirty fingernails.
A review of the facility's P&P dated March 2018, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care and services for two of two residents (Re...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care and services for two of two residents (Resident 549 and Resident 10) when the residents' skin condition was not monitored.
This failure resulted in progression of dermatitis (inflammation of the skin) and had the potential to cause further skin breakdown.
Findings:
1. Review of Resident 549's clinical record dated 2/21/23 indicated diagnoses of difficulty in walking, need for assistance with personal care, muscle weakness.
Review of Resident 549's Minimum Data Set (MDS, a standardized assessment tool), dated 2/24/23, indicated her cognition was intact. The MDS also indicated Resident had urine and bowel incontinent (inability to control urine and bowel movement).
On 2/27/23 at 11:58 A.M., a concurrent observation and interview of Resident 549 was conducted. Resident 549 was observed laying in bed grimacing and stated her buttocks was stinging. Resident 549 stated she had soiled her incontinence briefs for, Five hours.
During an observation with certified nursing assistant (CNA 11) on 2/27/23 at 12:05 P.M., inside Resident 549's room. Resident 549's incontinence brief was soaked with urine and feces. Her bilateral buttocks were observed to be red in color and inflamed (swollen).
During an interview with CNA 11 on 2/27/23 at 12:20 P.M., he stated the above stated time was the first event he changed Resident 549's brief since he came in at 7:30 A.M. CNA 11 further stated he should have checked and cleaned Resident 549 every two hours.
During a concurrent interview and record review with licensed nurse (LN 32) on 2/27/23 at 12:25 P.M., she stated the red colored and inflamed skin had no documentation and monitoring on the treatment activity record (TAR)
During an interview with LN 36 on 2/28/23 at 8:45 P.M., she stated Resident 549 developed dermatitis on her buttocks and should have been documented and monitored to prevent further skin complications
2. Review of Resident 10's clinical record dated 1/01/23 indicated diagnoses of displaced fracture of the third cervical vertebra (break in the bone of the neck), muscle weakness, chronic gout (repeated episodes of pain in the joints)
Review of Resident 10's MDS dated [DATE] indicated her cognition was intact. The MDS also indicated bowel incontinence.
During an interview with Resident 10 on 2/27/23 at 10:59 A.M., Resident 10 stated the staff did not change her dressing on the buttock for two days.
During an observation with LN 36 on 3/1/23 at 11:15 A.M., Resident 10's left buttock was observed pink in color. LN 36 dated the dressing on the left buttock 3/1/23.
During a follow up observation with LN 36 on 3/8/23 at 10:23 A.M. inside Resident 10's room. The dressing to left buttock was still dated 3/1/23. Resident 10's left buttock was noted reddish in color.
During an interview with LN 36 on 3/8/23 at 10:35 A.M., LN 36 stated the left buttock dressing should have been changed every shift per physician order.
Review of physician order dated 2/23/23 indicated, Cleanse incontinence associated dermatitis (skin inflammation) injury to left buttock every shift for wound care.
During an interview with the medical director (MD) on 3/8/23 at 11:45 A.M., the MD stated dermatitis can be prevented and treated with good incontinence care and following wound care treatment.
Review of facility's policy titled Medication/Treatment Orders dated 2014 indicated, . Documentation should specify the treatment, frequency and duration of the treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide appropriate interventions to prevent pressure ulcer for one of two sampled residents (Resident 13 ) when Resident 13's...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to provide appropriate interventions to prevent pressure ulcer for one of two sampled residents (Resident 13 ) when Resident 13's heels were not floated while in bed.
This failure had the potential to cause or worsen pressure ulcers.
Findings:
Review of Resident 13's admission diagnoses included, muscle weakness, and need for assistance with personal care.
Review of Resident 13's Braden score (Assessment tool to identify pressure sore risk) dated 2/1/23 indicated Resident 13 was, Moderate risk.
During an observation on 2/28/23 at 4:16 P.M., Resident 13's heels were not floated while in bed.
During a follow up observation and interview with certified nursing assistant (CNA) 15 on 2/28/23 at 5:51 P.M., Resident 13's heels were not floated in bed and heel protectors (padded device used to prevent, manage, treat pressure ulcers) were inside Resident 13's cabinet. CNA 15 acknowledged the observation and stated she was not aware that Resident 13's heels should be floated.
During a concurrent observation and interview with the infection preventionist (IP) on 3/6/23 at 4:39 P.M., Resident 13's heels were not floated, and Resident 13 was lying on a regular mattress.
During a concurrent interview and record review with IP on 3/6/23 at 4:45 P.M., the physician's order dated 2/27/23 indicated, Blanchable redness to left heel. Keep heels floated while in bed. The IP stated Resident 13's heels should have been floated to prevent pressure ulcer.
During a concurrent interview and record review with IP on 3/6/23 at 5:00 P.M., Resident 13's skin care plan dated 1/31/23 indicated, the resident needs pad assistive devices and pressure redistribution/reduction mattress. The IP stated Resident 13 should have been provided a reduction mattress to prevent pressure ulcer.
During an interview with the interim director of nursing (IDON 2) on 3/8/23 at 4:30 P.M., the IDON 2 stated all treatment orders and care plans should be followed by nursing staff to prevent, treat pressure ulcers.
Review of facility's policy titled, 'Prevention and Treatment of Pressure Ulcers/Injuries revised April 2020, indicated, Review and select medical devices with consideration to minimize tissue damage, including size, shape, its application and ability to secure the device.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide a timely bowel and bladder incontinence (inability to control urine and bowel movement) care for one of two sampled re...
Read full inspector narrative →
Based on observation, interview and record review, the facility failed to provide a timely bowel and bladder incontinence (inability to control urine and bowel movement) care for one of two sampled residents (Resident 549).
This failure had the potential to cause discomfort and skin impairment to all residents.
Findings:
A review of Resident 549's clinical record dated 2/21/2 indicated diagnoses of difficulty in walking, need for assistance with personal care, and muscle weakness.
Review of Resident 549's Minimum Data Set (MDS, a standardized assessment tool), dated 2/24/23, indicated Resident 549's cognition was intact. In addition, the MDS also indicated Resident 549 was urine and bowel incontinent.
During a concurrent observation and interview of Resident 549 on 2/27/23 at 11:58 A.M., Resident 549 was grimacing in bed. Resident 549 stated her buttocks were stinging then stated she was wet and soiled in for, Five hours.
During an observation with certified nursing assistant (CNA 11) on 2/27/23 at 12:05 P.M., inside Resident 549's room. Resident 549's incontinence brief was soaked with urine and feces. Resident 549's bilateral buttocks were observed to be red in color and swollen.
During an interview with CNA 11 on 2/27/23 at 12:20 p.m., he stated he did not check on Resident 549's incontinence brief since he came in. CNA 11 further stated he should have checked on resident frequently.
During an interview with the interim director of nursing (IDON 2) on 3/8/23 at 4:35 P.M., the IDON 2 stated incontinent resident should be frequently monitored.
Review of facility's policy dated 2/2018 entitled Perineal Care, . The purpose is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of two sampled residents (Resident 25) when the incorrect tube feeding formula (d...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of two sampled residents (Resident 25) when the incorrect tube feeding formula (delivery of a nutritionally complete feed, containing protein, carbohydrates, fat, water, minerals and vitamins directly into the stomach). was given to there resident.
As a result, the resident had the potential to not receive a nutritionally complete diet which could lead to other health complications.
Findings:
Review of Resident 25's clinical record indicated diagnoses of dysphasia (difficulty swallowing foods or liquids), dementia (loss of memory, language, problem solving abilities).
During a concurrent observation and interview with licensed nurse (LN 35) on 2/28/23 at 4:47 P.M., in Resident 25's room, an enteral feeding formula, Novasource renal bag, (brand name, liquid food product that is specially formulated to meet the needs of people with kidney disease) was observed infusing through Resident 25's enteral feeding pump (machine used to continuously deliver nutrition to patients). Licensed Nurse (LN 35) acknowledged the observation.
During a concurrent interview and record review with LN 35 on 2/28/23 at 4:49 P.M., she stated she hung the Novasource renal formula bag on 2/28/23 at 4:39 p.m.
Review of Resident 25's physician order dated 4/25/22 indicated, Enteral Feed Order: Isosource HN 1.5 (brand name, liquid food product to increase calorie needs). LN 35 stated she should have hung the correct feeding formula for Resident 25. LN 35 further stated, Resident 25 did not have a diagnosis of kidney disease.
During an interview with the Director of Nursing (DON) on 3/2/23 at 9:01 a.m., the DON stated, the licensed nurses should check the written enteral feeding physician orders.
Per the facility policy dated 11/2018, entitled Enteral Tube Feeding via Continuous Pump . Check the enteral nutrition label against the order before administration. Check the type of formula.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure the physician supervised and managed the care of one of one residents (Resident 19) who was reviewed for weight loss. ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure the physician supervised and managed the care of one of one residents (Resident 19) who was reviewed for weight loss. This failure had the potential for Resident 19's quality of life to be affected.
Findings:
During an observation on 2/27/23, at 4:15 p.m., Resident 19 was lying flat in bed with lunch tray at bedside. Lunch tray had uneaten, overcooked cabbage, small amount of mash potatoes and a small amount of meat eaten by Resident 19. Resident 19 stated he did not like what was served and had asked for something else. Resident 19 stated he did not know why he did not get an alternate. Resident 19 stated he did not know if he was losing weight.
During an interview on 3/6/23, at 10:31 a.m. with CNA 1, CNA 1 stated Resident 19 required set up for meal and ate 50% - 100% of meals. CNA 1 stated Resident 19 was able to use call light for assistance.
During a review of Resident 19's weight in the electronic medical record, the weight record indicated, 11/20/22 122.8 lb, 11/27/22 123.4 lb, 12/4/22 119.2 lb, 12/22/22 114.6 lb.
An interview and concurrent record review was conducted on 3/6/23, at 11:05 a.m., with LN 32. LN 32 stated resident weights were taken on the day of admission, then weekly on Sundays. LN 32 stated Resident 19's weights were not taken weekly and had weight loss. LN 32 stated Resident 19's last Nutritional review was on 11/25/22 and the care plan for nutritional risk was overdue for re-assessment and update.
During a review of the Physician's Progress Note, dated 1/12/23, the Physician's Progress Note indicated a visit diagnosis of Hepatobiliary cancer. The Physician's Progress Note did not indicate a decline in Resident 19's nutritional status.
During a review of the facility's P&P titled, Nutrition (Impaired) Unplanned Weight Loss- Clinical Protocol, dated September 2017, the P&P indicated, 1. The physician will review for medical causes of weight gain, anorexia and weight loss before ordering interventions. 6. The physician . will document relevant medical information regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations such as where multiple causes coexist.
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
Based on interview and record review, the facility failed to ensure Medication Regimen Review (MRR) recommendations were communicated with the physician for 39 residents. In addition, the facility fai...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure Medication Regimen Review (MRR) recommendations were communicated with the physician for 39 residents. In addition, the facility failed to keep pharmacy records of medication recommendation review.
As a result, pharmacy medication recommendations were not acted upon, which could affect the medication regimen for all the residents in the facility.
Findings:
During an interview with the facility's Pharmacy Consultant (PC) on 3/7/23 at 12:42 P.M., the PC stated a full year of MRR reports were sent to the Interim DON last week. The PC stated it was difficult to track if facility was following up on recommendations, and there were no paper trails to evaluate follow up. The PC stated the facility had short term residents, and on the next visit, those residents were already discharged . The PC stated the facility did not send any follow up recommendations to the physician.
The Interim DON (IDON 2) was interviewed on 3/8/23 at 4:01 P.M. The IDON 2 stated the MRRs were missing and therefore were not reviewed by the physicians. The IDON 2 stated the PC reviewed resident medications for irregularities. The IDON 2 stated the PC's recommendations should be brought up to the attending physician. The IDON 2 stated if the recommendations and irregularities were not brought up to the physician, the irregularity may be missed which would affect resident outcome.
During a review of the facility's MRR binder, there was no pharmacy medication recommendation review found from January 2022 until January 2023 (13 months total).
During a review of the facility's Policies and Procedure (P&P) titled Pharmacy Medication Regimen Review dated 10/2018, the P&P did not provide guidance regarding acting upon medication irregularities identified in the MRR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and/or labeled in accordance with current accepted professional principles and facility policies and procedures, for eleven sampled residents (Residents 28, 556, 19, 553, 551, 547, 14, 554, 551, 1) and a stock bottle of over-the-counter medication when:
1.
In 60s hall medication cart, a calcitonin (medication for osteoporosis) nasal spray for Resident 553 was observed laying on side not upright and did not have a use-by date and appropriate patient identifier labels, two opened latanoprost bottles for Resident 547 and an opened latanoprost bottle for Resident 14 did not have use-by date labels, an unopened latanoprost bottle for Resident 554 was being inappropriately stored with no use-by date label, a facility stock bottle of Vitamin A 3000 mcg (microgram- unit of measure) bottle was found to be expired with an expiration date of 12/22, two salmeterol/fluticasone 500/50 diskus for Resident 551 did not have use-by date labels, appropriate patient identifier labels, and one salmeterol/fluticasone 500/50 diskus was found to be discontinued, an ipratropium/albuterol (medication to help with breathing) Respimat (inhaler) for Resident 551 did not have a use-by date and appropriate patient identifier labels, an insulin lispro (medication for diabetes) KwikPen (prefilled pen) for Resident 554 was found to be discontinued and did not have a use-by date label, and an insulin lispro KwikPen for Resident 1 did not have a use-by date label;
2.
In 80s hall medication cart, a latanoprost ophthalmic (medication for eye condition that can cause blindness) bottle for Resident 28 did not have a use-by date label and was found to be discontinued, a ketorolac ophthalmic (eye medication for inflammation) bottle for Resident 556 did not have a use-by date label, a salmeterol/fluticasone (inhaler medication for lung disease) 250/50 diskus for Resident 19 did not have a patient identifier label.
These failures had the potential for resident specific medications to be administered past the discard date to Residents 28, 556, 19, 553, 551, 547, 14, 554, 1, and for facility stock bottle of Vitamin A 3000 mcg to be administered to all facility residents, which could result in less effective management of the residents' medical condition.
1. During a concurrent observation, record review, and interview on [DATE], at 10:11 a.m., with Licensed Nurse (LN) 31 at 60s hall medication cart, Resident 553's calcitonin bottle was found to have been partially administered, laying on its side, not upright, and did not have a use-by date and appropriate patient identifier labels; Resident 551's two salmeterol/fluticasone 500/50 diskus and ipratropium/albuterol were found to have been partially administered, did not have a use-by date and appropriate patient identifier labels; Resident 14's latanoprost ophthalmic bottle was found to have been partially administered and did not have a use-by date label; Resident 547's two latanoprost ophthalmic bottles were found to have been partially administered and did not have use-by date labels; Resident 14's latanoprost ophthalmic bottle was found to have been partially administered and did not have a use-by date label; Resident 554's latanoprost ophthalmic bottle was sealed in original manufacturer packaging and was being inappropriately stored with no use-by date label; a facility stock bottle of Vitamin A 3000 mcg was found to be expired with a date of 12/22. LN 31 acknowledged Resident 553's calcitonin bottle was not upright, and the expectation was for nursing staff to appropriately label resident specific medications and to remove expired medication from the medication cart. When asked about the expired facility stock bottle of Vitamin A 3000 mcg, LN 31 stated, No, expired meds should not be in cart, risk for patient, they have different effects after expiration date, don't want patient to have those effects. When asked about Residents 553, 551, 14, and 547's medications that did not have use-by date and appropriate patient identifier labels, LN 31 stated, Cannot tell how long they have been opened for because none of them have been dated . it could cause adverse reactions and can no longer be effective. We can have side effects we don't want. The eye drops can cause their eyes to burn, we need to know the date it was opened . no, not appropriate label, [medication] should have complete name, dob, medication name and direction . When asked about Resident 554's latanoprost that was being inappropriately stored, LN 31 stated, The one has not been opened needs to stay within appropriate temperature range.
During a review of Resident 553's Order Summary Report (OSR), dated [DATE], the OSR indicated, calcitonin salmon 1 spray in nostril one time a day . order status . active
During a review of Resident 551's OSR, dated [DATE], the OSR indicated,
Advair [salmeterol/fluticasone] 500/50 1 inhalation orally every 12 hours . order status . discontinued .
Wixela [salmeterol/fluticasone] 500/50 1 puff inhale orally twice a day . order status . active .
Combivent [ipratropium/albuterol] Respimat inhalation . 2 puff inhale orally two times a day . order status . active
During a review of Resident 14's OSR, dated [DATE], the OSR indicated, latanoprost solution . instill 1 drop in both eyes at bedtime . order status . active'
During a review of Resident 547's Medication Administration Record (MAR), dated [DATE] to [DATE], the MAR indicated, latanoprost ophthalmic solution . instill 1 drop in both eyes at bedtime . start date [DATE]
During a review of Resident 554's OSR, dated [DATE], the OSR indicated, latanoprost solution . instill 1 drop in left eye at bedtime . order status . active
During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for calcitonin stated, nasal . After opening, store for up to 35 days at room temperature of 20°C to 25°C (68°F to 77°F). Store in upright position.
During a review of Lexicomp, the manufacturer for salmeterol/fluticasone stated, Device should be discarded 1 month after removal from foil pouch, or when dosing indicator reads 0 (whichever comes first); device is not reusable.
During a review of Lexicomp, the manufacturer for ipratropium/albuterol Respimat inhaler stated, Soft mist inhaler: Store at 20°C to 25°C (68°F to 77°F). Excursions permitted to 15°C to 30°C (59°F to 86°F); avoid freezing. Discard 3 months after first actuation or after labeled number of actuations has been reached and locking mechanism is engaged, whichever comes first.
During a review of Lexicomp, the manufacturer for latanoprost stated, Store intact bottles under refrigeration at 2°C to 8°C (36°F to 46°F). Protect from light . Once opened, the container may be stored at room temperature up to 25°C (77°F) for 6 weeks.
During a concurrent observation and interview on [DATE] at 6:51 p.m., with LN 33 at 60s hall medication cart, Residents 1 and 554's insulin lispro KwikPens were found to be partially administered and did not have use-by dates. LN 33 acknowledged the Residents 1 and 554's insulin lispro KwikPens did not have use-by dates and stated, We don't want to give expired meds to the residents because the medication will not be effective.
During a review of Resident 1's OSR, dated [DATE], the OSR indicated, insulin lispro inject as per sliding scale . order status . discontinued [DATE]
During a review of Resident 554's OSR dated [DATE], the OSR indicated, insulin lispro inject as per sliding scale . order . active
During a review of Lexicomp, the manufacturer for insulin lispro KwikPen stated, Cartridges and prefilled pens that have been punctured (in use) should be stored at room temperatures <30°C (<86°F) and used within 28 days; do not freeze or refrigerate.
2. During a concurrent observation, record review, and interview on [DATE], at 11:35 a.m., with LN 36 at 80s hall medication cart, Resident 28's latanoprost ophthalmic bottle was found to have been partially administered and did not have a use-by date label, Resident 556's ketorolac ophthalmic bottle was found to have been partially administered and did not have a use-by date label, and Resident 19's salmeterol/fluticasone 250/50 diskus was found to have been partially administered and was inappropriately labeled. A review of Resident 28's electronic health record (EHR- database that contains digital medication information of a patient) indicated Resident 28's latanoprost order was discontinued on [DATE]. A review of Resident 556's EHR indicated Resident 556's ketorolac order was discontinued on [DATE]. A review of Resident 19's EHR indicated Resident 19's salmeterol/fluticasone 250/50 order was active as of [DATE]. LN 36 acknowledged Residents 28 and 556's discontinued medications should have been removed from the medication cart. When asked about the use-by date for latanoprost, LN 36 stated, I don't know expiration date . if they're expired, they can cause infection, have to write date opened and expiration date . medications discontinued, remove from cart because someone can mistakenly give it to another patient that it's not intended for. When asked about the patient identifier for Resident 19's salmeterol/fluticasone, LN 36 stated, . no patient identifier . it could end up in wrong box, can be used on wrong patient, their mouth goes on it, cross contamination and could be wrong medication . expect to see patient name, room number, with date open and expiration date.
During a review of Resident 28's OSR, dated [DATE], the OSR indicated, latanoprost . instill 1 drop in both eyes at bedtime for glaucoma . order status . discontinued [DATE].
During a review of Resident 556's OSR, dated [DATE], the OSR indicated, ketorolac . instill 1 drop in right eye two times a day .order status . discontinued [DATE].
During a review of Resident 19's OSR, dated [DATE], the OSR indicated, fluticasone-salmeterol . 1 inhalation inhale orally every 12 hours . order status . active.
During a concurrent interview and record review on [DATE] at 6:11 p.m. with Interim Director of Nursing (IDON) 1, IDON 1 stated, expectation is that when medication is opened, there should be an open date and expired date put on medications important so we are not giving expired medication, dose wouldn't be what it's supposed to be so chance resident would not be getting appropriate dose . expectation is that once its [salmeterol/fluticasone] open, label should be on diskus with open date . inappropriately labeled, could be given to wrong resident . expectation is to follow manufacturer specification, potential for potency to not be accurate, could damage medication . if you don't follow manufacturer specification, medication is not going to be what it's supposed to be, potency . expectation for expired medication to not be in stock, so you don't give it to resident because dosage wouldn't be accurate and could affect quality of medication.
During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, revised 4/19, the P&P indicated, Label for individual resident medications include all necessary information, such as: a. the resident's name . h. the expiration date when applicable .
During a review of the facility's P&P titled, Discontinued Medications, revised 4/07, the P&P indicated, Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 9 was re-admitted to the facility on [DATE] with diagnoses of Pneumonia, Peripheral Neuropathy and Congestive Heart ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 9 was re-admitted to the facility on [DATE] with diagnoses of Pneumonia, Peripheral Neuropathy and Congestive Heart Failure according to the physician's progress notes dated 2/24/23.
On 3/1/23, at 10:48 A.M., an observation and interview was conducted with Resident 9. Resident 9 did not have oxygen on. Resident 9 stated he had not received his morning medications, especially the Albuterol (a medication to treat or prevent narrowing of the airways in the lungs). At 10:58 a.m., LN 1 arrived and administered medications to Resident 9. LN 1 took the mask next to a nebulizer machine (a small machine which turns liquid medicine into a mist which can be inhaled via a mouthpiece or mask), added a medication into a cap connected to the mask, provided the mask to Resident 9, and turned on the nebulizer machine. LN 1 left Resident 9's room.
During an observation on 3/1/23, at 2:38 P.M., LN1 administered a nebulizer treatment (breathing treatment) to Resident 9 and left the room.
On 3/2/23, at 7:53 A.M., an interview with LN 1 was conducted. LN 1 stated Resident 9's medications were administered late and did not monitor Resident 9 during the nebulizer treatment. LN 1 stated he should have listened to Resident 9's lung sounds and should have had a timer when to remove the nebulizer mask from Resident 9. LN 1 stated if medications were given late, he would apologize to the resident for being late, and notate in progress note if the resident complained. LN 1 stated it was important to administer medications on time because of they were ordered by a physician. LN 1 stated he should have stayed with Resident 9 during the nebulizer treatment. LN 1 stated he did not receive training in the facility regarding administration of a nebulizer treatment or caring for residents with respiratory problems.
During a record review of Resident 9's Order Summary Report, dated 2/1/23 -2/28/23, the Order Summary Report indicated, Albuterol Sulfate Inhalation Nebulizer Solution (2.5 mg/3ml) 0.083% (Albuterol Sulfate) 3 ml (milliliter) inhale orally via nebulizer four times a day for Shortness of breath.
On 3/8/23, at 4:01 P.M., an interview with the Interim Director of Nurses (IDON 2) was conducted. The IDON 2 stated medications should be administered 1 hour before and after the scheduled time. IDON 2 stated residents should not be left during a nebulizer treatment, and the mask should be stored properly to maintain cleanliness. IDON 2 stated Resident 9 may have not received the full dosage of the treatment since the nurse did not monitor Resident 9 during the nebulizer treatment.
On 3/8/23, at 3:37 P.M., an interview with the Medical Records Director (MRD) was conducted. The MRD stated there was no in-service record regarding training licensed nurses on nebulizer treatment administration.
The facility's P&P, titled Administering Medications through a Small Volume (Handheld) Nebulizer, dated October 2010, was reviewed. The P&P indicated, 17. Remain with the resident for the treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. 19. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment.
2. A review of Resident 25's admission Record included diagnoses of hypertension (increase in blood pressure), Parkinson's disease (disease marked by tremor, muscle rigidity).
During an observation and interview with Resident 25 on 2/27/23 at 12:12 P.M., Resident 25 applied Clobatesol gel on his face. Resident 25 stated he applied the medication as often as he wanted to.
On 2/27/23 at 12:15 P.M., an observation and interview with licensed nurse (LN 12) was conducted. LN 12 confirmed Resident 25 had medication tubes of Clobatesol gel and hydrocortisone cream inside his blue container. LN 12 stated Resident 25 should have been assessed to determine if he could safely self-administer the medications.
During a concurrent interview and record review with LN 32 on 2/27/23 at 12:23 P.M., LN 32 stated Resident 25 did not have written physician orders for Clobatesol gel and hydrocortisone cream. She further stated the medications should have not been applied on the resident.
A review of the facility's policy dated 7/2016, Medication and Treatment Orders indicated, Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state.
3. During an interview with (DSD) on 3/8/23 at 8:08 A.M., the DSD stated CNA 11 was a registry CNA and started working on 2/27/23 day shift. The DSD further stated CNA 11 did not have a complete file and CNA 11 already started working in the facility.
On 3/8/23 at 8:10 A.M., a concurrent interview and record review with the DSD was conducted. The DSD stated CNA 11's training file was not available in his employee file in the facility.
On 3/8/23 at 4:35 P.M., an interview with the interim director of nursing (IDON 2) was conducted. The IDON 2 stated CNA trainings on abuse, neglect should be on file prior to a registry CNA working in the facility. She further stated the DSD was responsible for the registry CNA'S and should have ensured all documents were available in the employee file.
Based on observation, interview, and record review, the facility failed to ensure when:
1. Nursing staff were competent and knowledgeable about the proper disinfection of shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice and administration of nebulizer treatment (a liquid medicaine to help control breathing problems). Four out of Four nursing staff in three out of three nursing stations, did not know about the appropriate disinfectant product to use and/or the allowance of wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect) when disinfecting shared glucometers.
2. In addition, the facility failed to provide comprehensive nursing services for two of 39 sampled residents (25, 549) when Resident 25 medications were not ordered.
3. The director of Staff Development (DSD) did not review and ensure registry certified nursing assistant's (CNA's that are contractors from a staffing agency) employee file was complete prior to working in the facility.
4. Failed to ensure LN had the appropriate skills and competencies to administer nebulizer treatment.
These failures had the potential for widespread transmission of bloodborne diseases (such as Hepatitis B [a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids), Hepatitis C, and HIV (human immunodeficiency virus, is a virus that attacks the body's immune system) among residents.
In addition, these failures could affect the residents' safety and quality of care.
Findings:
1. During a concurrent observation and interview on 2/28/23 at 6:34 p.m., with Licensed Nurse (LN) 34 in the 90s hall, when asked by a surveyor to demonstrate how to disinfect the facility's shared glucometer, LN 34 was observed wiping the glucometer with Sani-Cloth Germicidal Disposable Wipes (disposable disinfection wipes for hard surfaces and medical devices) then placing the glucometer on a tissue paper laying on the medication cart. When asked about wet time, LN 34 stated it took eight to ten minutes for the glucometer to dry and was letting the glucometer dry on the tissue. LN 34 acknowledged she did not keep the surface of the glucometer wet for two minutes, and the glucometer was being shared between residents. When asked why it was important to appropriately disinfect the shared glucometer, LN 34 stated, bacteria can be transferred from one patient to another.
During a concurrent observation and interview on 2/28/23 at 6:51 p.m., with LN 33 in the 60s hall, when asked by a surveyor to demonstrate how to disinfect the facility's shared glucometer, LN 33 was observed wiping the glucometer with Alcohol Prep Pad wipes. LN 33 acknowledged the active ingredient for the wipes was isopropyl alcohol 70% which was antiseptic and not germicidal. LN 33 stated he did not know what wet time was and did not receive training on using the Sani-Cloth Germicidal Disposable Wipes that was located on the medication cart.
During a concurrent observation and interview on 3/1/23 at 4:13 p.m., with LN 36 in the 80s hall, when asked by a surveyor to demonstrate how to disinfect the facility's shared glucometer, LN 36 was observed wiping the glucometer with Sani-Cloth Germicidal Disposable Wipes then placing the glucometer on a tissue paper laying on the medication cart. LN 36 stated she was taught by the Regional Clinical Nurse Consultant (RCNC) to wipe down the glucometer then let air dry for two minutes. LN 36 acknowledged she did not keep the surface of the glucometer wet for two minutes, and the glucometer was being shared between residents. During a follow up interview with RCNC and Director of Staff Development (DSD), RCNC sated she taught five nurses in the facility to wipe down glucometer and let air dry for two minutes. DSD acknowledged the manufacturer specification for Sani-Cloth Germicidal Disposable Wipes was two minutes. DSD stated, Yes, Sani-Cloth states to leave wet for 2 minutes then air dry . will re-educate nurses to make sure glucometer is wet with Sani-Cloth solution for 2 minutes then air dry.
During an interview on 3/1/23 at 7:01 p.m., with Interim Director of Nursing (IDON) 2, IDON 2 stated the expectation for nursing staff was to follow CDC guidelines, manufacturer and facility policy. IDON 2 stated, [nursing staff should] make sure that you're eliminating any possibility of transferring pathogens from one resident to another . manufacturer has made product and tested it so important to follow their instructions . if glucometer not appropriate [disinfected] and used for another resident, it could transfer infection . important for staff to be competent because if they don't know they are not following proper instructions and patients at risk for infections.
According to the online publication titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration by the Center for Disease Control and Prevention (CDC), dated 3/2/2011, it indicated, An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV [hepatitis B virus], hepatitis C virus, and HIV) through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings . Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html; accessed 3/8/23)
During a review of the manufacturer instructions for use of Sani-Cloth Germicidal Disposable Wipes, the instructions indicated, If present, use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry.
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, Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 10/18, the P&P indicated, The infection prevention and control committee, medical director, director of nursing services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include . educating the staff and the public. Prevention of Infection . educating staff and ensuring that they adhere to proper techniques and procedures . following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a system of receipt and disposition of Controll...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a system of receipt and disposition of Controlled Substances (CS- a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) were established and implemented when:
1.
The facility did not have a system in place in sufficient detail to accurately reconcile disposition of all controlled drugs.
2.
The facility did not have a system in place to accurately periodically reconcile controlled drugs and account for controlled drugs for two out of two sampled residents (Residents 20, 555).
These failures increased the risk for loss and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of a Controlled Substance.
Findings:
1.
During a concurrent observation and interview on 2/27/23, at 11:23 a.m., with Interim Director of Nursing (IDON) 1 in the medication room, discontinued CS medication were observed locked in a separate cabinet, awaiting destruction. When a surveyor asked IDON 1 to describe how the facility ensured all CS medication awaiting destruction were accounted for and destroyed, IDON 1 stated, No, don't track narcotics [CS] discontinued for destruction, no log for discontinued narcotics . I make sure when narcotics come to me, I make sure that's it's right amount and right medication. That's when I sign sheets [control drug record sheet attached to medication] and put in cabinet . can't tell every narcotic received for destruction was destroyed.
2.
During a concurrent observation, and interview on 2/27/23 at 4:03 p.m., with IDON 1, IDON 1 acknowledged the facility did not have a system in place to accurately periodically reconcile controlled drugs. IDON 1 stated, If prn [ medications used on an as needed basis] narcotic goes missing, can't tell . want to have system in place so you don't have someone taking medication that should not be taking them.
During a concurrent record review and interview on 2/27/23 at 4:21 p.m., with IDON 1, Residents 20 and 555's clinical records were reviewed.
During a review of Resident 20's admission Record (AR), dated 2/18/23, the AR indicated Resident 20 was admitted to the facility on [DATE] with diagnosis including anxiety disorder (a mental condition where one feels worried, tense, or afraid).
During a review of Resident 20's Order Summary Report (OSR), dated 2/28/23, the OSR indicated an order dated 1/2/23 for lorazepam 0.5mg (milligram-unit of measure) every 8 hours as need for anxiety disorder.
During a review of Resident 20's Delivery Manifest (DM- sheet listing all medications delivered to facility) dated 1/21/23, the DM indicated a delivery of 90 half-tablets of lorazepam 1mg tablets to the facility.
During a review of Resident 20's Controlled Drug Record Sheet (CDRS- sheet used by nursing staff when taking out medication for administration to resident) dated 1/21/23, the CDRS indicated 90 half-tablets of lorazepam 1mg tablets were taken out by nursing staff for administration to Resident 90.
During a review of Resident 20's Medication Administration Record (MAR- used by nursing staff to document administration of medication to resident) dated 2/1/23 to 2/28/23, the MAR did not indicate administration of lorazepam 1 mg half-tablet to Resident 20 on 2/4/23 2:00 a.m., 2/5/23 6:00 a.m., 2/9/23 2:00 p.m., 2/12/23 10:49 a.m., 2/13/23 9:30 p.m., 2/20/23 7:30 p.m., 2/22/23 7:00 a.m., and 2/23/23 1:00 p.m.
During a review of Resident 555's AR dated 2/28/23, the AR indicated, Resident 555 was admitted to the facility on [DATE] with diagnosis including a break in one of the bones of the forearm.
During a review of Resident 555's OSR dated 2/28/23, the OSR indicated an order dated 1/5/23 for oxycodone 10 mg every 4 hours as need for pain.
During a review of Resident 555's DM dated 1/20/23, the DM indicated a delivery of 30 tablets of oxycodone 10 mg tablets to the facility.
During a review of Resident 555's CDRS dated 1/21/23, the CDRS indicated six tablets of oxycodone 10 mg tablets were taken out by nursing staff for administration to Resident 555.
During a review of Resident 555's MAR dated 1/1/23 to 1/31/23, the MAR did not indicate administration of oxycodone 10 mg to Resident 20 on 1/23/23 at 10:30 p.m.
IDON 1 was unaware of CS medication discrepancy for Residents 20 and 555 and was unable to provide documentation for administration of lorazepam 1 mg half-tablet to Resident 20 for dates not documented in MAR (2/4/23 2:00 a.m., 2/5/23 6:00 a.m., 2/9/23 2:00 p.m., 2/12/23 10:49 a.m., 2/13/23 9:30 p.m., 2/20/23 7:30 p.m., 2/22/23 7:00 a.m., 2/23/23 1:00 p.m.), and administration of oxycodone 10 mg tab to Resident 555 for date not documented in MAR (1/23/23 10:30 p.m.).
During an interview on 2/27/23 at 4:39 p.m., with IDON 1, IDON 1 stated, expectation is that there should not be errors whatsoever and they [nursing staff] should mark both places . log [CDRS] indicates narcotic has been pulled and the MAR indicates it's been given to patient . no documentation that meds in question pulled were administered to resident.
IDON 1 was unable to provide a facility policy and procedures for accurately accounting and disposing of all controlled drugs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure four of four sampled residents (Residents 547, 245, 3, 25) ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to ensure four of four sampled residents (Residents 547, 245, 3, 25) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when:
1.
Resident 547 was administered clonazepam (medication that works in brain to help with anxiety) without an appropriate end date.
2.
Resident 245 was administered alprazolam, no resident specific behavioral interventions were attempted or implemented prior to initiation and/or during use of alprazolam.
3.
Resident 3 was administered trazodone (medication for depression) without appropriate clinical justification for dose increase and no resident specific behavioral interventions were attempted or implemented prior to initiation and/or during use of trazodone.
4.
Resident 25 was administered sertraline (medication for depression) without appropriate clinical justification for dose increase, gradual dose reduction, and no resident specific behavioral interventions were attempted or implemented prior to initiation and/or during use of sertraline.
These failures resulted in unnecessary medications for Residents 547, 245, 3, 25, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.
Findings:
1. During a review of Resident 547's admission Record (AR), dated 2/28/23, the AR indicated, Resident 547 was admitted to the facility on [DATE], with diagnoses including depression.
During a review of Resident 547's Order Summary Report (OSR), dated 2/28/23, the OSR indicated a provider order dated 2/26/28 for clonazepam 1 mg (milligram- unit of measure) every 24 hours as needed for depression as manifested by sleeplessness.
During a concurrent interview and record review on 2/28/23 at 10:11 a.m., with Licensed Nurse (LN) 31, Resident 547's OSR was reviewed. LN 31 acknowledged Resident 547's clonazepam order did not have an end-date. LN 31 stated, No, order does not have end date, was started 2/26 . should have end date, she might need to be reevaluated .
During an interview on 2/28/23 at 6:11 pm, with Interim Director of Nursing (IDON) 1, IDON 1 stated, expectation is that prn [as needed] psychotropic medications have a 14 day end date, because resident needs to be reassessed by doctor to see if they need medication or qualify for a GDR [gradual dose reduction] . it change how they function, they might not be able to bounce back from long term effects psychotropics can cause .
During a review a Lexicomp, a nationally recognized drug database, the manufacturer for clonazepam indicated, the continued use of benzodiazepines, including clonazepam, may lead to clinically significant physical dependence. The risks of dependence and withdrawal with longer treatment duration and higher daily dose.
2. During a review of Resident 245's AR, dated 3/1/23, the AR indicated, Resident 245 was admitted to the facility on [DATE], with diagnoses including aphasia (when you lose ability to understand or speak because of brain damage), muscle weakness, and unsteadiness on feet.
During a review of Resident 245's OSR, dated 3/1/23, the OSR indicated a provider order dated 2/12/23 for alprazolam 1 mg two times daily for anxiety as manifested by combativeness and restlessness.
During a review of Resident 245's Medication Administration Record (MAR) dated 2/1/23 to 2/28/23, the MAR indicated monitoring of interventions for anxiety as: redirect, activity, return to room, toilet, food, fluids, change position, adjust position, adjust room temperature, backrub.
During a concurrent interview and record review on 3/1/23 at 2;21 p.m., with LN 32, Resident 245's Care Plan (CP) and MAR were reviewed. LN 32 was unable to provide documentation of resident specific non-pharmacological interventions for Resident 245's anxiety on the Resident 245's CP and MAR. LN 32 stated, these are interventions for patient on Xanax [alprazolam], these ones are general interventions [on MAR] . no, we do not have specific non-pharmacological interventions care planned or implemented for resident . yes, possible that combativeness and restlessness could be due to him not been able to speak or talk . no specific non-pharmacological interventions for when he's yelling or anxious to address inability to communicate . important to see if patient still need med, if non-pharm intervention effective can update doc to see if patient still need Xanax . can put resident at risk for fall, not meeting goal to improve .
During an interview on 3/1/23 at 3:48 p.m., with Resident 245's son, Resident 245's son stated Resident 245 gets agitated when not able to communicate with staff.
3. During a review of Resident 3's AR, dated 3/1/23, the AR indicated, Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including abnormalities of gait and mobility, and unspecified dementia (disease of brain that affects memory and ability to function).
During a review of Resident 3's OSR, dated 3/1/23, the OSR indicated a discontinued provider order for trazodone 12.5 mg at bedtime for insomnia (condition that affects ability to sleep) dated 11/10/22, and a current order for trazodone 100 mg at bedtime for insomnia started on 11/15/22.
During a review of Resident 3's MAR, dated 11/1/22 to 11/20/22, the MAR indicated, Resident 3 was administered trazodone 12.5 mg daily from 11/10/22 to 11/14/22, and administered trazodone 100 mg daily from 11/15/22 to 11/30/22.
During a review of Resident 3's MAR, dated 11/1/22 to 11/30/22, the MAR behavioral monitoring for sleeplessness, indicated four incidences of sleeplessness on 11/6/22, 11/7/22, 11/15/22, and 11/16/22.
During a review of Resident 3's MAR, dated 2/1/23 to 2/28/23, the MAR indicated Resident 3 was administered trazodone 100 mg daily (start date 11/15/22) from 2/1/23 to 2/28/23.
During a review of Resident 3's MAR, dated 2/1/23 to 2/28/23, the MAR behavioral monitoring for sleeplessness, indicated zero incidences of sleeplessness.
During a review of Resident 3's MAR, dated 11/1/22 to 11/30/22, and 2/1/23 to 2/28/23, the MAR indicated monitoring of interventions for sleeplessness as: redirect, activity, return to room, toilet, food, fluids, change position, adjust position, adjust room temperature, backrub.
During a concurrent interview and record review on 3/1/23 at 5:00 p.m., with LN 35, LN 35 acknowledged Resident 3 did not have resident specific non-pharmacological interventions implemented for Resident 3's insomnia, and stated Resident 3's daughter had suggested trazodone and was unable to provide documentation as to why Resident 3's trazodone dose was increased from 12.5 mg to 100 mg daily on 11/15/22. LN 35 stated, There's a lot of side effects to psychotropic medications, if you give too much their health conditions can get worse, you want to monitor to make sure it's helping and gradually take them off .
4. During a review of Resident 25's AR, the AR indicated, Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including major depressive disorder.
During a review of Resident 25's OSR, dated 3/1/23, the OSR indicated sertraline 100 mg daily 2/23/21 to 3/30/21 was increased to sertraline 150 mg daily 3/31/21 to 8/15/21, followed by an additional dose increase to sertraline 200 mg daily with a start date of 8/25/21.
During a review of Resident 25's MAR dated 3/1/21 to 3/31/21, the MAR behavioral monitoring for depression indicated 8 incidences (3/12, 3/16, 3/17, 3/18, 3/23, 3/24, 3/29, 3/30) of verbalization of sadness, during the period sertraline 100 mg daily was increased to sertraline 150 mg daily.
During a review of Resident 25's MAR dated 8/1/21 to 8/31/21, the MAR behavioral monitoring for depression indicated 4 incidences (8/2, 8/3, 8/9, 8/14) of insomnia/sleeplessness during the period sertraline 150 mg daily was increased to sertraline 200 mg daily.
During a review of Resident 25's MAR, dated 2/1/23 to 2/28/23, the MAR indicated, Resident 25 was administered sertraline 200 mg daily from 2/1/23 to 2/28/23.
During a review of Resident 25's MAR, dated 2/1/23 to 2/28/23, the MAR behavioral monitoring for depression, indicated zero incidences of facial sadness from 2/1/23 to 2/28/23.
During a review of Resident 25's MAR, dated 2/1/23 to 2/28/23, the MAR indicated monitoring of interventions for depression as: redirect, activity, return to room, toilet, food, fluids, change position, adjust position, adjust room temperature, backrub.
During a concurrent interview and record review on 5/1/23 at approximately 5:30 p.m., with LN 35, Resident 25's clinical record was reviewed. LN 35 was unable to provide documentation as to why Resident 25's sertraline dosage was increased in 3/21 and again in 8/21. LN 35 acknowledged Resident 25 did not have resident specific non-pharmacological interventions implemented for Resident 25's depression.
During an interview on 3/1/23, at 7:01 p.m., with Interim Director of Nursing (IDON) 2, IDON 2 stated expectation was for residents to have resident specific non-pharmacological interventions implemented. IDON 2 stated, Specifically look resident because everyone non-pharmacological intervention is not the same and will not be effective, if try not effective then try another . psychotropics have serious side effects on the elderly, goal is to have them least possible amount .
Regarding Resident 3's trazodone dosage increase, IDON 2 stated, . pretty severe jump, I would expect there would be slower increase in dose . could have negative side effect on resident, important to try least possible dose to make sure resident is getting desired effect, should be gradual . can't tell resident can tolerate lower dose and get desired effect if abrupt jump .
During an interview on 3/1/23, at 7:39 p.m., with Pharmacist Consultant (PC), PC stated she recommended a gradual dose reduction for Resident 25's sertraline 200 mg daily order on 4/22, 8/22, and 2/23. PC stated, dose increase to 200 mg on 8/21 and then I started following up on GDR . I did not get a response; response was negative for a dose reduction . I followed up again in August 8/22, and it was not a yes, I do not know what response was, the binder was not there for a couple of months, I looked for it they haven't had a DON that was consistently there . important to do GDR because people can have transient depression or get better and may need less of the drug so when possible you want to get less dose because you get less side effect . important for prescriber to document GDR so all the people who work there and take care of resident know reason .
During a review of Resident 25's Gradual Dose Reduction Note to Attending Physician/Prescriber (GDR Note), dated 4/4/22, 8/2/22, 2/2/23, the GDR Notes indicated, Please assess orders for Sertraline 200 mg QD [daily] since 8/21 when dose was increased. Must document rationale with regard to target .
During an interview on 3/1/23 at 8:01 p.m., with Assistant Director of Nursing (ADON), ADON acknowledged Resident 3, 25, and 245's non-pharmacological interventions were generalized and not resident specific. ADON stated, Each person is different, behavior intervention should be to his personality, it can potentially reduce amount of drug he's taking . When asked about the GDR documentation for Resident 25, ADON was unable to provide documentation of response from prescriber for GDR recommendation for 2021, 4/22, and 8/22.
During a review of the facility's policy and procedure (P&P), titled, Psychotropic Medication Use, the P&P indicated, Use of psychotropic medication may be considered appropriate in specific circumstances, as specified in F758.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure that the Facility Assessment (process used by facilities to assess the needs of its resident population and required resources to pr...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure that the Facility Assessment (process used by facilities to assess the needs of its resident population and required resources to provide the care and services the residents need) addressed the dietary aides' training and competencies in order to provide food and nutrition services in a competent and safe manner.
This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801)
Findings:
On 2/28/23 at 5:31 P.M., an immediate jeopardy was called due to the lack of oversight of dietetic and food services by a full-time dietetic services supervisor manager, which resulted in kitchen staff not having adequate training, skills, and tools to carry out the Food and Nutrition Services in a competent and safe manner.
A document review of the facility's Facility Assessment, updated on 3/7/23, was conducted. The Facility Assessment document indicated that one of the services offered by the facility was nutritional care. The document indicated, under nutritional care, the facility would provide, . liberal diets (relaxing the original diet prescriptions meant to control disease states like diabetes or hypertension), specialized diets (meal plans that control the intake of certain foods or nutrients), . cultural or ethnic dietary needs, assistive devices, fluid monitoring or restrictions, . The document also indicated, under the section of Facility Resources Needed to Provide Competent Support ., the list included the Food and Nutrition Services Certified Dietary Manager and the Registered Dietitian. The list did not include the facility dietary aides.
An interview and joint document review was conducted with the facility's Administrator (ADM) on 3/8/23 at 3 P.M. The ADM reviewed the Facility Assessment and stated that dietary aides were not listed in the facility staff list. The ADM also stated that the Facility Assessment did not address the training and competencies of the dietary aides. The ADM stated it was important that the dietary aides be included in the facility staff list, and their training and competencies addressed on the Facility Assessment, to ensure that the dietary aides were competent to provide the dietary services needed by the residents.
A review of the facility's policy and procedure titled Facility Assessment, revised on October 2018, was conducted. The policy indicated, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents day-to-day operations.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0841
(Tag F0841)
Could have caused harm · This affected multiple residents
Based on interview and document review, the facility Medical Director failed to ensure dietary policies and procedures and the Facility Assessment (process used by facilities to assess the needs of it...
Read full inspector narrative →
Based on interview and document review, the facility Medical Director failed to ensure dietary policies and procedures and the Facility Assessment (process used by facilities to assess the needs of its resident population and required resources to provide the care and services the residents need) policy were implemented, when dietary staff did not prepare the residents' meals in accordance with the physician's orders.
This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801 and F-838)
Findings:
On 2/28/23 at 5:31 P.M., an immediate jeopardy was called due to the lack of oversight of dietetic and food services by a full-time dietetic services supervisor manager, which resulted in kitchen staff not having adequate training, skills, and tools to carry out the Food and Nutrition Services in a competent and safe manner.
An interview with the Medical Director (MD) was conducted on 3/8/23 at 11:29 A.M. The MD stated that he was informed by the Administrator (ADM) of the concerns identified by the survey team regarding the dietary aides' competencies, and that wrong diets were being served to the residents. The MD stated that he was kind of involved in dietary services, and added that all disciplines were involved in the facility systems. The MD stated that he was not aware that the dietary aides and their competencies were not addressed in the Facility Assessment. The MD acknowledged that the residents should be served meals in accordance with the physician's order, and that failure to follow the physician's diet order could affect the residents' health and safety. The MD acknowledged that policies and procedures should be implemented in order to provide the necessary care and services to the residents.
A review of the undated policy titled Medical Director Services was conducted. The policy indicated, As requested by Company, Physician shall serve as Medical Director by taking responsibility for all administrative matters involving clinical services of the Facility by providing services: .Reviewing, approving, implementing nursing policies and procedures and resident and patient care policies and procedures, as well as assisting in the development and implementation of new clinical or resident and patient care policies and procedures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, an...
Read full inspector narrative →
Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) did not identify areas of improvement in the facility's dietary services, when dietary staff did not prepare the residents' meals in accordance with the physician's orders. In addition, the facility's QAPI program policy and procedure did not clearly describe all the elements required in accordance to the federal regulation.
This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801)
In addition, an unclear QAPI policy and procedure had the potential to affect the facility's ability to efficiently identify high-risk (refers to care or service areas associated with significant risk to the health or safety of residents), high-volume (refers to care or service areas performed frequently or affecting a large population), or problem prone (refers to care or services that have historically had repeated problems) issues, collect data, identify underlying causes, develop corrective actions, and monitor the improvements.
Findings:
On 2/28/23 at 5:31 P.M., an immediate jeopardy was called due to the lack of oversight of dietetic and food services by a full-time dietetic services supervisor manager, which resulted in kitchen staff not having adequate training, skills, and tools to carry out the Food and Nutrition Services in a competent and safe manner.
On 3/8/23 at 3:07 P.M., an interview with the Administrator (ADM) and Interim Director of Nursing (IDON) 2 was conducted to discuss the facility's QAPI program. The ADM reviewed the facility QAPI policy submitted to the survey team. The ADM acknowledged that the policy did not clearly describe how the facility gets feedback, collects data, and monitor improvements. The ADM stated that the facility conducted a mock survey (mimics the Long Term Care Survey Process and identifies survey risk areas) from 1/23/23 to 1/26/23. The ADM stated that the issues currently being worked on in the facility's QAPI program, were issues identified during the mock survey. The ADM stated the mock survey was conducted in different departments in the facility, which included the dietary department. The ADM stated that there were no concerns or areas of improvement identified in the dietary department. The ADM acknowledged that the concerns identified by the survey team in the dietary department should have been identified and brought to QAPI.
A review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, revised on February 2020, was conducted. The policy indicated, This facility shall develop, implement, and ,maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. During a staff interview on 2/27/23 at approximately 8:20 am, IDON 1 (Interim Director of Nursing) identified the quarantine/...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. During a staff interview on 2/27/23 at approximately 8:20 am, IDON 1 (Interim Director of Nursing) identified the quarantine/isolation area as the three rooms at the end of the first hallway. IDON1 stated the Red Zone (isolation area) had COVID precautions in place for the residents with COVID 19 (dangerous viral infection) diagnoses.
During observation on 2/27/23 at 9:09 am, the first hallway was observed to have a Red Zone laminated sheet attached to a post in front of the two Northeast (NE) rooms. In addition, three partially filled isolation carts, along with instruction sheets for donning Personal Protection Equipment (PPE), that included gowns, gloves, and mask, were observed outside of Resident 348, 349, and 350's rooms. Red Zone signs observed outside of Resident's 348 and 349's rooms.
An observation and record review were conducted on 2/27/23 of the medical charts for Residents 346, 347, 348, 349, and 350.
A. Resident 348's, diagnoses included a COVID positive infection and an exposure to Candida Auris (contagious fungal infection). No physician orders for COVID isolation were not found.
B. Resident 350's diagnosis included recent COVID positive, with a negative COVID test dated 2/24/23, along with an exposure to Candida Auris. Resident 349's physician orders dated 2/26/23, included an order for Covid isolation per protocol.
C. Resident 349's diagnosis included an infection of the skin and subcutaneous tissue (Shingles). Resident 349's physician orders dated 2/26/23 indicated the initiation of CRO (certain type of bacteria) contact precaution per protocol.
D. Resident 346 and 347's medical chart was did not include a current infectious illness diagnosis.
During observation and staff interview on 02/27/23 at 4:32 P.M., CNA 22 was observed to be exiting Resident 349's room with a blue disposable gown and face mask on. CNA 22 was further observed to discard her gown and gloves in the hallway trash cannister. No handwashing/hand hygiene observed after removal of PPE. CNA 22 stated she was trained to use one trash can for disposal of single use PPE for all three isolation rooms.
During concurrent observation and interview on 2/28/23 at 8:15 A.M., CNA 12 was observed about to entering Resident 348's room with gown and mask on. CNA 12 stated resident n isolation rooms were in his assignment, but he had not been informed of the reason for each resident's isolation. CNA 12 further stated he was unsure if he was required to use his goggles.
During interview on 3/1/23, at 2:35 P.M., CNA 23 stated the Red Zone was for Residents 348, 349 and 350 who were in isolation/quarantine for positive COVID 19. CNA 23 stated the CDC were monitoring Resident 350 for Candida Auris.
During observation and interview on 03/01/23 at 2:37 P.M., the Occupational Therapist (OT) (person who assists with learning daily living tasks) was observed leaving Resident 348's room. The OT stated the therapists learn which residents are contagious from independent review of the resident's medical chart. The OT further stated he understood Residents 348, 349 and 350 were on COVID isolation, with Resident 348, also, having had an exposure to a Candida Auris infection (a contagious fungal infection).
During observation on 03/01/23 at 5:08 pm, Resident 349 noted to be alert, and semi-reclined on a moving stretcher being wheeled by paramedics down the facility hallway, towards the exit, without a mask on.
During an observation and interview on 03/02/23 on 10:13 A.M., LN 11 was observed at a medication cart removing a blue isolation gown from Resident 348 isolation cart outside of his room. LN 11 put on the gown and started to enter Resident 346 and 367's room. LN 11 stated she assumed Residents 346 and 347 were on COVID isolation as their room was behind the Red Zone sign. LN 11 further stated she had not been informed of which residents were on isolation, nor their relevant diagnoses.
During interview and record review on 03/06/23 at 9:45 A.M., LN 32 stated Resident 348 was currently COVID positive, while Resident 350 was negative for COVID and needed to finish his 10 day quarantine/isolation. Review of Resident 350's physician orders dated 2/20/23 indicated Covid isolation started on 2/19/23. LN 32 further stated Resident 349 was on isolation for Shingles and not for COVID 19. LN 32 stated facility policy was to doff PPE prior to exit of resident's room and to use only resident's assigned isolation cart. LN 32 acknowledged the Red Zone signage was confusing since one of the four rooms behind the sign was not on isolation/quarantine. LN 32 stated staff confusion and lack of communication regarding not following isolation policy put the residents at risk for cross-contamination (catching another person's infection).
During an interview on 03/08/23 at 3:53 P.M., the Infection Preventionist (IP), stated he was not aware staff were not following isolation protocol. The IP stated the procedure was to don PPE prior to entering the room and doffing prior to exiting the resident's room. The IP agreed staff should be notified of residents in isolation, the relevant diagnoses, and how to follow the isolation policy and procedure. The IP further stated failure to follow facility isolation policy and poor staff communication increased the risk for cross-contamination.
On review of facility's policy titled Infection Control revised 10/2018, .Facility's infection control policies are intended to . help prevent and manage transmission of disease and infections . all personnel will be trained on our infection control policies and practices .
On review of facility policy titled Isolation - Categories of Transmission-Based Precautions revised 10/2018, .Transmission -base precautions (TBP) are initiated when a resident . has a laboratory confirmed infection and is at risk of transmitting the infection to other residents.
7. On 3/6/23, at 12:08 P.M., LN 36 was observed performing a wound treatment for Resident 9. LN 36 removed the dressing from Resident 9's coccyx (tailbone) and proceeded to cleanse the wound. LN 36 removed gloves and applied 2 pairs of gloves without washing her hands. LN 36 used another spray bottle and sprayed around the wound, then applied a cream to the coccyx and it's surrounding area. LN 36 removed one pair of gloves and applied a foam dressing on the coccyx, then wrote the date on the dressing. LN 36 removed the second pair of gloves and applied another pair of gloves without washing her hands. LN 36 then proceeded to assist CNA 1 with repositioning Resident 9.
During an interview with LN 36 on 3/8/23, at 8:50 A.M., LN 36 stated she did not wash her hands during treatment of Resident 9's pressure ulcer. LN 36 stated she should have used hand sanitizer or washed her hands to prevent the spread of infection.
8. During observation and interview on 3/1/23, at 10:48 A.M., LN 1 administered medications to Resident 9. LN 1 took the mask next to a nebulizer machine (a small machine which turns liquid medicine into a mist which can be inhaled via a mouthpiece or mask), added a medication into the cap connected to the mask. LN 1 then provided the mask to Resident 9, and turned on the nebulizer machine. LN 1 left Resident 9's room.
During an interview on 3/2/23, at 7:53 A.M., with LN 1, LN 1 stated Resident 9's nebulizer mask was not stored in a plastic. LN 1 stated the mask should have been stored properly for infection control.
During an interview with the Interim Director of Nurses (IDON 2) on 3/8/23, at 4:01 P.M., the IDON 2 stated nebulizer masks should be stored properly to maintain cleanliness.
Per the facility's policy and procedure titled Administering Medications through a Small Volume (Handheld) Nebulizer dated October 2010, . Steps in the Procedure 27. Rinse and disinfect the nebulizer equipment according to facility protocol . 29. When equipment is completely dry, store in a plastic bag with the resident's name and date on it.
3. During an observation on 2/27/23 at 9:27 A.M inside Resident 13'S room. Resident 13's IS mouth piece was touching the table surface.
During a concurrent observation and interview with licensed nurse (LN 12) on 2/27/23 at 9:30 A.M., LN 12 observed the IS mouth piece was touching the table surface. She further stated the IS hose should not touch the table surface and the IS should have been stored inside a clear bag when not in use to prevent contamination
During an interview with the infection preventionist (IP) on 3/8/23 at 10:28 A.M., the IP stated that the IS should have been kept inside a clean bag to avoid contamination of the mouth piece used by the resident.
Review of Centers for Disease Control and Prevention (CDC) policy titled Respiratory Health Spirometry Procedures Manual dated 1/2008 indicated, All hoses used or unused will be placed in a clear container.
4. During an initial observation on 2/27/23 at 9:27 A.M., Resident 13's nasal cannula (a tube that delivers oxygen) did not have a date of placement.
During a follow up observation and interview with LN 12 on 2/27/23 at 9:30 A.M., LN 12 acknowledged that Resident 13's nasal cannula did not have a date of placement. LN 12 further stated the nasal cannula tubing should have a date for staff to monitor when it should be changed.
During an interview with the IP on 3/8/23 at 10:29 A.M., he stated nasal cannula tubing should have been dated. LN 12 further stated monitoring should have been documented every shift to describe appearance of oxygen tubing.
During an interview with the interim director of nursing (IDON 2) on 10/14/22 at 8:50 A.M., the IDON 2 stated oxygen tubing should have been dated to alert the staff when the nasal cannulas should be replaced.
Review of the facility's policy dated 9/17/18,entitled Care and Handling of Respiratory Equipment indicated, . Change weekly: Nasal Cannula and humidifier, simple masks .
5. During a wound treatment observation with LN 36 on 3/1/23 at 11:15 A.M., LN 36 did not wash her hands before removing the foam dressing from Resident 10's left buttock. LN 36 cleansed the wound, then removed her gloves and reapplied a new pair without washing her hands. LN 36 applied a new foam dressing then removed her gloves and stepped out without washing her hands.
During an interview with LN 36 on 3/1/23 at 10:35 A.M., LN 36 stated she should have washed her hands before and after providing wound care treatment.
During an interview with the IP on 3/8/23 at 10:30 A.M., the IP sated staff should wash their hands before and after contact with residents.
Review of the Centers for Disease Control and Prevention dated 1/30/2020 indicated, Healthcare personnel should wash with soap and water immediately before touching a patient and after touching a patient.
6. During a dining observation on 2/27/23 at 12:56 P.M. in the residents' dining room, staff personal belongings were observed near the residents' refrigerator and microwave.
During a concurrent observation and interview with LN 36 on 2/27/23 at 12:58 P.M., LN 36 confirmed the observation and stated staff personal belongings should be kept in their personal lockers.
During an interview with IP on 3/8/23 at 10:30 A.M., the IP stated staff personal items should be stored in their personal lockers away from residents dining section.
According to the 2017 Food and Drug Administration (FDA) Food Code, Section 6-501.110 Using Dressing Rooms and Lockers and 6-403.11 Designated Areas, lockers or other suitable facilities shall be used for the orderly storage of employee clothing and other possessions; and lockers or other suitable facilities shall be located in a designated room or area where contamination of food, equipment, utensils, linens, and single service and single use articles cannot occur.
Based on observation, interview, and record review, the facility failed to implement infection control practices when:
1. Licensed Nurse (36) did not appropriately remove protective personal equipment (PPE), did not sanitize (to clean and make free of disease-causing elements) facility shared equipment after resident care, and did not provide appropriate PPE to visitor visiting facility.
2. Certified Nursing Assistant (CNA) 31 did not sanitized hands or facility shared equipment after or prior to resident care.
3. An incentive spirometer's (IS - medical device to improve lung function) mouth piece was touching the table surface.
4. A nasal cannula tubing (device used to deliver oxygen to a person) did not have a date of placement and monitoring sheet.
5. Licensed Nurse (LN 36) did not wash her hands before and after providing wound treatment,
6. Staff personal belongings were stored in the residents' dining room close to residents' refrigerator and microwave.
7. A Licensed Nurse, (LN 36) did not wash her hands during a wound treatment.
8. Resident 9's nebulizer mask was not dated or stored in a plastic bag.
9. Facility staffs failed to ensure infection control measures were consistently implemented per current infection control guidelines for five of five residents (Residents 346, 347, 348, 349, 350).
These failures had the potential to spread infection to other residents, staff and visitors.
Findings:
1. During a concurrent observation and interview on 2/28/23 at 11:09 a.m., with LN 36 in 80s hall, LN 36 was observed preparing Resident 348's medication on a tray and entering the room of Resident 348, located in the red zone of the facility. A visitor visiting Resident 348 was observed in Resident 348's room wearing a PPE surgical mask over face. LN 36 was observed exiting Resident 348's room. LN 36 was observed removing gloves in Resident 348's room and removing PPE gown in the 80s hallway and did not sanitize tray prior to putting away tray. LN 36 acknowledged the red zone designated COVID-19 (a highly contagious respiratory disease caused by a virus that can cause death) positive residents, and that Resident 348 was COVID-19 positive, and was also exposed to a fungal infection at the hospital. LN 36 acknowledged she did not remove her gown prior to leaving Resident 348's room and did not sanitize the tray used in Resident 348's room after use. LN 36 also acknowledged Resident 348's visitor was not wearing the appropriate PPE face mask and should have been wearing a PPE N-95 mask, which protected against COVID-19. LN 36 stated, After every use I'm supposed to wipe it [tray] down, I don't know why I didn't do that . Supposed to doff [take off] garb before I leave the room. I removed my gloves first when I was in the room then removed my gown after I came out of the room. I'm supposed to remove gown in room first, then remove gloves in room . resident's daughter has surgical mask on . important we don't want to cross contaminate and spread infection . residents that aren't sick can get infection by touching them or passing meds . yes, resident has COVID. By not appropriately doffing gown or wiping tray, I could infect other patients with COVID and fungal infections that I come in contact with . no, resident's loved one is not appropriately garbed, she should be wearing an N95 mask. She is exposed and can spread COVID .
During a review of Resident 348's admission Record (AR), dated 2/28/23, the AR indicated, Resident 348 was admitted to the facility on [DATE] with a diagnosis of COVID-19.
During a review of Resident 348's Progress Notes (PN), dated 2/20/23 at 2:45 p.m., the PN indicated, resident was tested positive on rapid test today . pt [patient] was moved to other room for droplet/airborne precaution.
During a review of Resident 348's PN, dated 2/27/23 11:46 p.m., the PN indicated, resident seen by CDC [Center for Disease Control and Prevention] Nurse [NAME] today to swab resident for Candida Auris [fungus that can be resistant to all antifungal treatments and can cause bloodstream infection and death]. Resident had an exposure while in the hospital.
2. During a concurrent observation and interview on 2/28/13 at 4:17 p.m., with CNA 31, CNA 31 was observed checking blood pressure for four residents (Residents 557, 19, 558, 247). CNA 31 was observing providing care to each resident without sanitizing hands and facility's shared blood pressure equipment prior to, or after administering care. CNA 31 acknowledged not sanitizing hands and facility's shared blood pressure equipment prior to, or after administering care to each resident. CNA 31 stated, I should have sanitized hands, no didn't sanitize cuff . important so you're not taking different germs from one resident to another.
During an interview on 2/28/23 R 6:11 p.m., with Interim Director of Nursing (IDON) 1, IDON 1 stated, equipment is supposed to be disinfected between residents, so you don't spread what's going on with one resident to another. Staffing is expected to doff inside room before they come out so that they don't carry whatever is inside room to another resident or hallway and expose everybody . anyone going into a positive COVID room should wear N95, nurse should have offered visitor an N95 so family doesn't catch COVID and so it doesn't spread. If you are using blood pressure cuff, have to sanitize it between each resident and their hands to stop the spread of germs.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, revised 10/18, the P&P indicated, The infection prevention and control committee, medical director, director of nursing services, and other key clinical and administrative staff review the infection control policies at least annually. The review will include . educating the staff and the public. Prevention of Infection . educating staff and ensuring that they adhere to proper techniques and procedures . following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). Those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment.
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, Reusable items are cleaned and disinfected or sterilized between residents . Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions.
During a review of the facility's P&P titled, Handwashing/Hand Hygiene, revised 8/19, the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure a qualified Infection Preventionist (IP- a person who coordinated the handling of facility's infection control practic...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure a qualified Infection Preventionist (IP- a person who coordinated the handling of facility's infection control practices) was employed full time.
As a result, the facility did not have a full time IP overseeing infection control practices for all the residents in the facility.
Findings:
During an interview with the Licensed Nurse (LN) 36 on 2/27/23, LN 36 she was the current IP.
A concurrent interview and record review of IP requirements on 2/27/23 was conducted with the Administrator (ADM). The ADM stated Licensed Nurse (LN) 36 did not have the required IP training and certificate. The ADM stated the contracted Interim Director of Nursing (IDON1) was the current IP for the facility. In addition, the ADM stated the Director of Staff Development (DSD) did not have the Infection Control Certificate required for the position.
During a concurrent interview and observation on 2/27/23 at 5:35 P.M., the IP was observed with a medication cart in the facility resident hallway. The IP stated he worked part time at the facility as a Licensed Nurse (LN), and worked as a full-time IP in another facility. The IP stated he was assigned to give medications to residents for the shift.
During an interview on 2/28/23 at 4:30 P.M., the IDON1 stated she was both the IP and IDON. IDON1 further stated she was a contract nurse and her last working day was today.
During an interview and record review on 2/28/23 at 5 PM, the ADM confirmed that this was IDON1's last day of employment at the facility. The ADM stated that the IP had assumed the full-time IP position today.
On concurrent interview and record review on 3/6/23 at 9:45 A.M., LN 32 stated that IP2 was the previous IP for facility. LN 32 further stated IP2 had stopped working at the facility 3-4 months previously. LN 32 stated the responsibilities of infection control and duties of the IP had been shared between the DSD, IDON1, and the charge nurses.
On concurrent observation and interview on 3/6/23, at 3:30 P.M., the IP was noted to be standing at a medication cart in resident hallway. The IP stated he was assigned to be the LN for medication pass for this shift.
During an interview and record review on 3/7/23 at 4:21 P.M., the IP stated he was in the process of being hired as a part-time IP by the facility. The IP further stated he was to share the full-time responsibilities with LN 32 when she completed and obtained her IP training certificate.
During an interview on 3/7/23 at 5:15 P.M., the ADM stated that IP was hired part-time. The ADM stated LN 32 and IP were to share the position once LN 32 completed the infection control training and received a certificate.
Per the facility's Covid Mitigation Plan dated 2/2023, . Infection Preventionist or designee will oversee the training of staff for IP and IC practices.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department when:
1.
A [NAME] (CK 1) and two diet aides (DA) 1 and DA 2 did not use standardized recipes and therapeutic menus in the kitchen to prepare and plate resident meals.
2.
A [NAME] (CK 2) and a diet aide (DA 3) did not use a therapeutic menu or guide to prepare pureed meals and thickened drinks.
3.
A [NAME] (CK 4) did not obtain or document the final cooking temperatures of prepared food for two months.
4.
A Diet Aide (DA 2) did not correctly plate meals for residents on therapeutically prescribed carbohydrate-controlled (CCHO) diets.
5.
A [NAME] (CK 3) did not know how to calibrate a food thermometer.
6.
CK 3 who also worked as a dishwasher, did not know how to test a high-temperature dish machine to ensure it was operating within the specified heat range according to manufacturer's guidelines.
7.
A [NAME] (CK 4) did not use proper sanitation techniques for disposing garbage from the food and nutrition services department, according to facility policy and standards of practice.
8.
A [NAME] (CK 4) did not wash vegetables with the correct level of antimicrobial sanitizer.
These failures had the potential for to alter the nutritional value and safety of food for 38 residents who consume food from the kitchen.
Cross reference F800, F801, F812, F814, F838
Findings:
1.
During an observation and interview in the main kitchen on 2/27/23 at 11:25 A.M., CK 1 was observed prepping the lunch meal for residents in the Skilled Nursing Facility (SNF). When asked what menu was used to cook and prepare meals for specialized diets, CK 1 stated he did not have a current meal spreadsheet or therapeutic menu. CK stated all he was given was the assisted living main menu, which he used for the day. CK 1 stated he determined the number of specialty diets needed for the day from a meal tally list, dated 2/7/23.
During an observation and interview in the satellite kitchen on 2/27/23 at 11:33 AM, DA 1 stated she had not been given a therapeutic menu to plate specialized diets for residents. DA 1 stated it was unusual for the satellite kitchen to be provided a therapeutic menu.
Review of facility policy dated April 2007, title Standardized Recipes, indicated Standardized recipes shall be used in the preparation of foods .1. Only tested, standardized recipes will be used to prepare foods. 2. Standardized recipes will be adjusted to the number of portions required for a meal. 3. The Food Services Director /CDM will maintain the recipe file and make it available to Food Services staff as necessary. 4. Recipes are periodically reviewed for revisions and updating.
Review of facility policy dated October 2017, titled Therapeutic Diets, indicated .4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: Diabetic/carb-controlled diet; No added Salt; Altered consistency diet .
2.
During an observation and interview in the main kitchen on 2/27/23 at 3:36 PM, CK 2 was preparing shredded barbeque chicken for pureed resident meals. CK 2 placed 3 scoops of shredded chicken in the blender and then added water directly from the faucet into the blender and blended the chicken before it was poured into a small silver shot pan, covered and placed it in the warming tray. CK 2 stated she did not always use thickener when preparing pureed meals because she would just eyeball the amount of powdered thickener by adding a little at a time until it reached a mashed potato consistency. CK 2 stated the facility had not provided her with a measurement guide or recipe to follow for preparing pureed or mechanical soft diets.
During an observation, interview in the satellite kitchen on 2/27/23 at 5:01 P.M., DA 3 was observed pumping 8 squirts of liquid gel thickener from a dispensing bottle into a small 8 oz. glass of water for a resident's dinner meal. DA 3 stated he was not trained on how to determine the amount of thickener he should use.
Review of the facility's policy and procedure titled, Menus, dated 10/2017, indicated, Policy Interpretation and Implementation: 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences). 2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance .5. If a mechanically altered diet is ordered the provider will specify the texture modification
Review of facility policy dated October 2017, titled Food and Nutrition Services, indicated Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .7. Food and nutrition services staff will inspect food trays to ensure the correct meal is provided to the resident .a. if an incorrect meal is provided to a resident .report it to the food service manager so a new tray can be issued .
3.
On 3/1/23 at 4:00 P.M. an concurrent observation, interview and record review was conducted with the RD, EC, and CK 4 in the main kitchen. A document, titled, [NAME] Pines Senior Living Temperature Log on a clipboard near the cooks' station was reviewed. No final cooking temperatures were recorded for the breakfast and lunch meal production. CK 4 stated he used to record final cooking temperatures and tray line holding temperatures but stopped doing this two months ago. CK 4 stated he stopped taking final cooking temperatures because the facility started using a new temperature log form that did not have a spot for him to record final cooking temperatures like the old form. The RD stated this was not an acceptable practice.
According to the 2022 Food and Drug Administration (FDA) Food Code, Section 3-501.16, titled Time/Temperature Control for Safety Food, Hot and Cold Holding, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) .135oF or above .or .may be held at a temperature of .130oF or above; or (2) At .41ºF or less.
According to the 2022 FDA Food Code, Section 3-403.11, titled Reheating for Hot Holding, .When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens have the opportunity to multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated .
Review of the facility document provided by ADM titled, [NAME] - Job Description, indicated .ESSENTIAL FUNCTIONS AND RESPONSIBILTIES: To perform this job successfully, an individual must be able to perform each key function satisfactorily .4. Prepares food using proper food handling and food safety techniques (including sanitation and temperature concerns) according to established policies and regulations.
Review of the facility's policy and procedure titled, Preventing Foodborne Illness - Food Handling, dated 7/2014, indicates, Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. Policy Interpretation and Implementation: 1. This facility recognizes that the critical factors implicated in foodborne illness are . b. Inadequate cooking and improper holding temperatures .3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .6. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms.
4.
During an observation and interview in the satellite kitchen on 3/2/23 at 7:45 A.M., DA 2 was observed plating a breakfast meal for a resident on carbohydrate-controlled (CCHO) diet. DA 2 placed a bowl of oatmeal and one sliced banana on the tray for the resident with a CCHO and placed it in the meal service cart. DA 2 stated she did not place any other food on the tray because the resident had only checked of oatmeal and sliced banana on her meal ticket. DA 2 stated she did not know all resident should be receiving a full meal. DA 2 stated she had not been trained on scoop use, plating food and diet types.
Review of the facility document, Server - Job Description, indicated .ESSENTIAL FUNCTIONS AND RESPONSIBILTIES: 1. Takes resident(s) meal orders and serves meals correctively and efficiently using exceptional customer service techniques .10. Demonstrates the ability to make independent decisions, solve practical problems that may or may not include a variety of concrete variables. This may require the ability to interpret instructions given in written, oral, diagram, or scheduled form.
Review of the facility's policy and procedure titled, Menus, dated 10/2017, indicated, Policy Interpretation and Implementation: 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences) .8. Menus provide a variety of foods form the basic daily food groups and indicate standard portions at each meal. 9.
If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified non-dairy alternatives).
5.
During an observation and interview in the main kitchen on 3/6/23 at 8:58 A.M., CK 3 was asked to show how he calibrated a thermometer. CK 3 was observed getting a glass of ice water and placing his thermometer in the ice water alongside CK 1. CK 3's thermometer had a reading of 33ºF in the ice water. CK 3 stated he did not know what the temperature thermometer should read during ice water calibration.
Review of the facility's policy and procedure titled Food Preparation and Service, dated 4/2019, indicated, .Food Preparation, Cooking, Holding Time/Temperatures .5. Food thermometers used to check food temperatures are clean, sanitized and calibrated for accuracy.
Review of the facility document provided by ADM titled, [NAME] - Job Description, indicated .ESSENTIAL FUNCTIONS AND RESPONSIBILTIES: To perform this job successfully, an individual must be able to perform each key function satisfactorily .4. Prepares food using proper food handling and food safety techniques (including sanitation and temperature concerns) according to established policies and regulations.
6.
During an observation and interview in the main kitchen on 3/6/23 at 9:18 A.M., CK 3 was working as the dishwasher for the day. CK 3 was asked to demonstrate how to test the temperature of the high-temperature dish machine. CK 3 stated he did not know how to check the temperature of the dishwasher using the temperature specific test strips at the dishwashing station. In addition, the temperature testing strips did not have an expiration date.
Review of the facility's policy and procedure titled Sanitization, dated 10/2008, indicated, .8. Dishwashing machines must be operated using the following specifications: High-Temperature Dishwasher (Heat Sanitization): a. Wash temperature (150º-165ºF) for at least forty-five (45) seconds; b. Rinse temperature (165º-180ºF) for at least (12) seconds .
7.
During an observation and interview on 3/6/23 at 12:39 P.M., CK 4 was observed taking the kitchen trash bin outside to empty the contents in the dumpster. An observation of the inside of the kitchen trash bin was conducted and the bin was dirty with food and debris. CK 4 brought the kitchen trash bin back inside. CK 4 placed a new trash bag in the bin without cleaning the food and debris from the interior of the bin; which was observed by the National Culinary Dietary Manager (NCDM). The Regional CDM stated the cook should have cleaned the kitchen trash bin before placing a new bag inside. The Regional CDM stated she was unable to find documentation of kitchen staff in-services on food safety that had been completed.
Review of the facility's policy and procedure titled Sanitization, dated 10/2008, indicated, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .
8.
During an observation and interview with CK 4 in the main kitchen on 3/6/23 at 1:02 P.M., CK 4 was observed washing asparagus for dinner in the main kitchen sink. CK 4 stated he used the antimicrobial Ecolab solution attached to the wall to wash produce. CK 4 stated he washed produce by letting the antimicrobial solution mix with water and site for one and a half minutes and then removed the produce. CK 4 stated he did not check the strength of the solution with a test strip appropriate for testing the produce sanitizing solution. The test strips were expired, dated 3/2/2021.
Review of the sanitizing strips instructions on the wall in the main kitchen titled, Antimicrobial Fruit & Vegetable Treatment, indicated, Step 2 .Test Solution: Obtain a cup sample of solution from filled sink. Immerse test strip in solution sample for 1 or 2 seconds (do not shake off excess liquid). Evaluate color immediately after removing test strip from sample (note more than 15 seconds). Match center of test strip to Color Chart to determine concentration (see product label for recommended concentrations and discard strip after use) .
During an interview with the MD on 3/8/23 at 11:33 A.M., the MD stated it is the expectation that all SNF staff should be trained to perform their tasks correctly. The MD further stated it was necessary for dietary staff to be competent in their roles.
During an interview with the ADM and IDON on 3/9/23 at 3:05 P.M., stated their expectation was for the kitchen staff to be trained to retain the skills for their jobs. The ADM stated her expectation was for the kitchen staff to follow correct standardized recipes and dietary menus to feed the residents. The ADM and the IDON both stated their expectation was the resident's medical diet orders, diet tray tickets, and therapeutic menus match.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record reviews the facility failed to ensure the use of standardized recipes and therapeutic menus approved by a Registered Dietitian were used for skilled nursi...
Read full inspector narrative →
Based on observations, interviews, and record reviews the facility failed to ensure the use of standardized recipes and therapeutic menus approved by a Registered Dietitian were used for skilled nursing home residents on therapeutic diets.
This practice led to residents receiving meals did not match their physician ordered diet, or medical condition, which had the potential to compromise their nutrition status and other health consequences such as choking or death.
Cross references: F800, F801, F804, F809
Findings:
During an interview on 2/27/23 at 8:46 AM with CK 1 in the main kitchen, CK 1 stated he was the main cook in the mornings that prepares breakfast and lunch meals for the facility's residents, including the skilled nursing facility (SNF). CK 1 stated this morning he prepared 2 pureed (i.e. foods blended to a thick mashed potato texture for patients with difficulty swallowing), 5 mechanical soft (i.e. foods blended to a smaller pieces for ease in chewing and swallowing), 6 ground (i.e. food blended to a softer chewable texture for patients with difficulty chewing and swallowing), and 30 regular diet meals for the SNF side. CK 1 stated he got the count for how many pureed, mechanical soft, and ground diets to prepare from DA 1 every day because she works over there. CK 1 stated he used the regular assisted living menu to prepare the meals for the SNF residents. CK 1 stated he did not have or use a therapeutic menu spreadsheet or standardized recipes to prepare meals for the SNF residents.
During an interview with CK 1 on 2/27/23 at 11:25 AM in the main kitchen, CK 1 was asked by the surveyor if he had a menu for the week and day that he used to prepare the residents' meals, including the SNF residents. CK 1 showed the surveyor a weekly menu with breakfast, lunch, and dinner meals on it that was used for the assisted living, memory care, and SNF residents. The menu did not have therapeutic diets on it for the SNF residents. CK 1 then pointed to a menu sheet taped to the top left side of the cook's prep station that he said he used to prepare diet pureed, ground or mech soft diet meals for SNF residents. The menu sheet was dated 2/7/23 and had specialty diet and allergy information for residents in the SNF. CK 1 stated this was the last menu sheet with any therapeutic diet information on it he had. CK 1 stated he did not have any other therapeutic menu or menu spreadsheet to prepare resident meals.
A review of the facility's general menu on 2/27/23 for the assisted living indicated the lunch meal was pork tenderloin, rosemary chicken thigh, rice pilaf, roasted Brussel sprouts, peach cobbler and beverage of choice.
On 2/27/23 at 03:36 PM, an interview of the PM [NAME] (CK) 2 was conducted. The surveyor asked CK 2 about the dinner meal preparation for the SNF residents. CK 2 stated she typically gets all the meal numbers for the facility residents, including the skilled nursing unit resident meals for dinner, handwritten on a piece of paper from DA 1.
On 2/27/23 at 3:43 PM, an observation and interview with CK 2 and EC were conducted in the main kitchen of the dinner meal preparation. CK 1 stated they had to serve the shredded barbecue chicken in the container from the walk-in refrigerator to some residents. CK 2 stated, to her knowledge, the shredded chicken was cooked within the last few days, but she acknowledged there was no label or date on the chicken. The EC confirmed the shredded chicken was cooked a few days ago by a different cook. The EC also stated there should have been a label and date on it. CK 2 continued with dinner food preparation and made the pureed shredded BBQ chicken. CK 2 stated she had not seen any therapeutic menus or recipes since she's worked there. CK 2 stated she did not always use thickener for pureed meals because she may use broth or water. CK 2 took the metal food processor pitcher off the base and added water from kitchen prep sink faucet to the shredded BBQ chicken, then blended it. CK 2 stated she just eyeballs the amount of water or thickener and will add a little scoop from the large plastic bin of thickener until it reaches the proper consistency. CK 2 stated she had not received any training or in-services on how to measure the thickener powder or gel.
On 2/27/23 at 4:49 PM, an observation and interview with DA 2 was conducted in the main kitchen. DA 2 added 8 pumps of liquid thickener to 4 cups of pureed vegetables. DA 2 stated he had not been trained on how to prepare pureed diet foods. DA 2 stated he was helping CK 2 with meal preparation because she was behind with the cooking. DA 2 stated he had not been trained on how to properly prepare pureed food items using powder or gel thickener, or other methods.
On 2/27/23 at 4:59 P.M., an observation of the SNF satellite kitchen dining room was conducted. The SNF dining room did not have a main menu posted for the day, week, or month for the residents. DA 2 confirmed there were no menus posted in the SNF dining room.
During an observation and interview on 2/28/23 at 7:43 AM in the main kitchen with CK 3, CK 3 stated there were no puree meals made or sent to the SNF kitchen this morning. CK 3 stated he made mechanical soft sausage for 3 residents in the SNF and used 6 sausages with water in the blender to make them. CK 3 stated he did not use a therapeutic menu or special recipe to prepare the breakfast meal for the SNF residents. CK 3 stated sometimes he used a document dated 2-7-23 taped to the top shelf counter above the cook's prep station with therapeutic meal counts numbers listed for pureed, mechanical soft, and ground diets for the SNF residents if he doesn't get the tally from DA 1.
On 2/28/23 at 9:00 AM, DA 1 and DA 3 were plating meals for residents in the SNF satellite kitchen. DA 1 was asked by the surveyor for a therapeutic menu for the day, and she stated could not find any therapeutic menus.
According to the 2022 Federal Food Code, section 2-103.11, an important duty of the Person in Charge (PIC) is to make sure that any required temperatures are achieved or maintained when foods are cooked, cooled, thawed, or held in a food establishment. By making it a duty of the Person in Charge to ensure that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced.
According to the 2022 Federal Food Code, section 8-201.14, titled Contents of a HACCP Plan, .A categorization of the types of TCS foods that are to be controlled under the HACCP PLAN .(D) The ingredients, recipes or formulations, materials and equipment used in the preparation of each specific food and methods and procedural control measures that address the food safety concerns involved .
Review of facility policy dated April 2007, title Standardized Recipes, indicated Standardized recipes shall be used in the preparation of foods .1. Only tested, standardized recipes will be used to prepare foods. 2. Standardized recipes will be adjusted to the number of portions required for a meal. 3. The Food Services Director /CDM will maintain the recipe file and make it available to Food Services staff as necessary. 4. Recipes are periodically reviewed for revisions and updating.
Review of facility policy dated October 2017, titled Menus, indicated .2. Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance .4. The Dietitian reviews and approves all menus
Review of facility policy dated October 2017, titled Therapeutic Diets, indicated .4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: Diabetic/carb-controlled diet; No added Salt; Altered consistency diet .
Review of the undated Cook Job Description, showed the primary function of the position was to prepare and serve nutritious meals in an organized manner, as well as in accordance with current federal, state, local regulations, corporate standards, and guidelines. The essential functions of this position included but was not limited to: prepares and serves meals for assigned shifts using provided menus and recipes; avoids wasted by properly measuring recipe quantities and ensures all leftovers are properly covered, labeled, dated, and stored in the proper place; prepares food using proper food handling and food safety techniques, including sanitation and temperature control according to policies and regulations; cleaning work station and all equipment utilized; reporting all equipment repair and hazardous issues immediately to the supervisor; and assisting in maintaining food storage areas in a clean and properly arranged manner at all times.
Review of the undated document titled SNF Dietary Manager Job Description, indicated .Essential functions and responsibilities included but not limited to: .1. plans, develops, organizes, implements, evaluates, and directs Dietary Department programs and activities in accordance with departmental policies and current federal, state, and local regulations .2. Supervise dietary department employees . responsibility for training competent personnel, evaluate employee performance; ensure that quality food service and nutritional care is always provided for each resident; .3. Completes management duties including schedules and/or conducts routine in-services for department personnel in conjunction with the registered dietitian; Routinely audits dietary areas and practices for compliance with current regulations and policies (i.e. meal service, sanitation, weight loss, nutrition risk, food temperatures, etc.); establishes food service production procedures to ensure meals are served on time and efficiently; .4. Completes meal service duties .Adheres to corporate menu/recipe program and ensures the menus are in compliance with physician orders. Obtains registered dietitian menu approval, Assures preplanned menus are implemented .according to the menu and diets, and standardized recipes are utilized. Assures menus are posted for residents and dated menus are maintained per state regulations .
Review of the facility undated document titled Registered Clinical Dietitian indicated, .Essential Duties and Responsibilities .completes clinical duties which include comprehensive and accurate, timely nutritional documentation as indicated. This includes annual assessments, quarterly progress notes as well as residents deemed as high risk .conducts sanitation audits of dietary dept. in conjunction with Dietary Service Director to ensure dept. is maintained in safe, clean, sanitary manner .Routinely audits food service areas and practices for compliance with current regulations and policies (includes sanitation reviews, meal service, nutritional documentation) .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when:
1.
Standar...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when:
1.
Standardized recipes and therapeutic menus were not followed for residents receiving pureed diets.
2.
Holding temperatures on the tray line and resident test tray were below acceptable range and three residents complained of cold food.
This failure had the potential to result in decreased intake and further compromise the nutritional status of 38 residents receiving therapeutic diets from the facility's kitchens.
1.
During an observation and interview in the main kitchen on 2/27/23 at 3:36 PM, CK 2 was preparing shredded barbeque chicken for pureed resident meals. CK 2 placed 3 scoops of shredded chicken in the blender and then added water directly from the faucet into the blender and blended the chicken before it was poured into a small silver shot pan, covered, and placed on the warming tray. CK 2 stated she did not always use thickener but when she did, she would just eyeball the amount of powdered thickener by adding a little at a time until the puree reached the proper consistency. CK 2 stated the facility had not provided her with a measurement guide or recipe to follow for altering diet consistency.
During an observation, interview, and record review in the main kitchen on 03/06/23 at 08:42, CK 1 stated he did not have a therapeutic menu available and was just using the recipes that were given to him. A concurrent record review of the recipes CK 1 stated he was using for meals on 3/6/23 was conducted and the record indicated there were no directions provided for how much thickener should be utilized for pureed meals or other altered consistency diets.
During an observation and interview in the main kitchen on 03/07/23 at 8:14 A.M., with CK 3. CK 3 stated he had prepared two pureed meals and sent them to the satellite kitchen for breakfast. CK 3 was unable to state how he prepared and cooked the pureed meals using a standardized menu or therapeutic menu spreadsheet.
A record review of the SNF's diet manual titled Grove Menus Diet Manual signed by the consultant RD and MD dated 3/6/23, indicated the specific instructions on how to prepare pureed foods with serving size measurements with liquid and powder thickener using portion amounts.
A review of the facility policy titled, Therapeutic Diets, dated 10/2017, indicated, Policy Interpretation and Implementation .4. A 'therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example .Altered consistency diet. 5. If a mechanically altered diet is ordered, the provider will specify the texture modification.
A review of the facility policy titled, Standardized Recipes, dated 4/2017, indicated, Policy statement: Standardized recipes shall be developed and used in the preparation of foods.
2.
During an interview on 2/27/23 at 5:37 P.M., Resident 349 stated the food at the facility was not served hot.
During an interview on 2/28/23 at 4:51 P.M., Resident 350 stated the food and the coffee were served cold Resident 350's significant other had to reheat it with the microwave in the dining room.
During an observation and interview on 3/7/23, at 12:00 P.M., DA 2 was observed taking temperatures of pureed foods on the tray line. The pureed entrée, roasted rosemary pork tenderloin, had a holding temperature of 124.6ºF and the pureed sugar snap peas had a holding temperature of 124.6ºF. DA 2 stated she would put the pureed roasted rosemary pork and the sugar snap peas back in the warming cart to heat them up.
During an observation on 03/07/23 at 1:09 PM the first meal cart left the satellite kitchen and was brought to hallway.
During an observation on 03/07/23 at 1:32 PM all trays had been passed and all residents were observed to be eating first hallway.
During a test tray observation and interview on 3/7/23 at 1:32 PM, with NCDM, the regular diet hot food items were noted to be cold, and the cold drinks were warm. The NCDM took temperatures of the foods on the test tray with a facility thermometer:
Entrée: Seasoned Chicken (99.5ºF)
Side 1: Roasted Potatoes (108ºF)
Side 2: Sugar Snap Peas (95ºF)
Drink 1: Milk (61.4ºF)
Drink 2: Juice (60.4ºF)
The NCDM stated it was the expectation that beverages be prepared and poured so that they are 41ºF and below when served and the holding temperature of tray line food be 130ºF to 135ºF when served.
During an observation and interview on 3/7/23, at 1:45 P.M. Resident 196 was observed with a lunch tray on the bedside table. Resident 196 stated the food was cold when it arrived for lunch. Resident 196 further stated the food was usually cold when it arrived.
According to the 2022 Food and Drug Administration (FDA) Food Code, Section 3-501.16, titled Time/Temperature Control for Safety Food, Hot and Cold Holding, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) .135oF or above .or .may be held at a temperature of .130oF or above; or (2) At .41ºF or less.
According to the 2022 FDA Food Code, Section 3-403.11, titled Reheating for Hot Holding, .When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens have the opportunity to multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated .
Review of the facility policy titled, Food Preparation and Service, dated 4/2019, indicated, .Food Preparation, Cooking, Holding Time/Temperatures: 1. The danger zone for food temperatures is between 41ºF and 135ºF. This temperature range promotes rapid growth of pathogenic microorganisms that cause foodborne illness . 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF (potentially hazardous food) must be maintained below 41ºF or above 135ºF .7. Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135ºF .11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135ºF during preparation or they are reheated to 165ºF for at least 15 seconds.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure a meal span of less than fourteen (14) hours between a substantial evening meal and breakfast the following day.
This ...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure a meal span of less than fourteen (14) hours between a substantial evening meal and breakfast the following day.
This failure had the potential to increase hunger and negatively affect the nutrition status of 38 residents who consume meals at the Skilled Nursing facility.
Cross reference F800, F804
Findings:
A record review of the facilities scheduled mealtimes provided by EC on 2/27/28 indicated, breakfast was served at 7:30 A.M., Lunch was served at 11:15 A.M. and dinner was served at 4:15 P.M.
On 2/27/23 at 4:45 P.M., an observation of the SNF satellite kitchen dining room was conducted. The SNF dining room did not have a main menu posted for the day, week, or month for the residents. DA 2 confirmed there were no menus posted in the SNF dining room.
During an observation on 2/28/23 at 7:40 A.M., the satellite dining room did not have any meal carts being loaded.
During an observation on 2/28/23 at 8:00 A.M., no meal carts were observed being delivered.
During an observation and interview on 2/28/23 at 8:28 A.M., Resident 557 was observed to not have a breakfast meal in his room. Resident 557 stated he was worried he missed breakfast. Breakfast was observed being delivered at 8:40 A.M. to Resident 557's bedside.
During an observation on 2/28/23 at 8:43 A.M., Resident 19 was observed being served breakfast in Resident 19's room.
During an observation on 2/28/23 at 9:00 A.M., DA 1 and DA 2 were observed plating breakfast meals in the satellite kitchen.
During an interview on 3/1/23 at 10:29 A.M., CNA 23 stated, lately breakfast has been late due to turnover in the kitchen.
During an observation and interview on 3/1/23 at 2:06 P.M., Resident 9 was observed eating lunch in his room. Resident 9 stated they just brought lunch and breakfast was served at 9:00 A.M.
During an observation on 3/2/23 at 9:20 A.M., Resident 14 was observed being served a breakfast tray in the satellite dining room.
During an observation on 3/2/23 at 9:36 A.M., a breakfast cart was observed arriving in hallway 160.
During an interview on 3/8/23 at 4:24 P.M., DSD stated it was important for meals to be served timely, so the residents receive them warm. DSD stated meals were delayed because the CNA staff were busy with other tasks.
A review of the facility's policy titled, Frequency of Meals, indicated, .Policy Interpretation and Implementation .1. The facility will serve at least three (3) meals or their equivalent daily at scheduled times. There will not be more than a fourteen (14) hour span between the evening meal and breakfast.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility po...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when:
1.
A white powdered substance was stored in the main kitchen unlabeled and undated in a large plastic bin.
2.
Breadcrumbs were opened and undated with no cover or closure device.
3.
The walk-in refrigerator and satellite kitchen refrigerator had multiple TCS (time/temperature control for food safety foods- meats, dairy, pasta, etc.) foods that were stored uncovered, unlabeled, and/or undated.
4.
The temperature of milk stored in the satellite kitchen refrigerator was 44.8F when tested.
5.
A dirty rag with brown stains was on tray with nine 8 oz. glasses of juice on it in the satellite kitchen reach-in refrigerator.
6.
The dish machine sanitizer solution in the satellite kitchen was not maintained at the correct concentration; the chemical sanitizer testing strip indicated there was no sanitizer solution entering the dish machine during the wash cycle.
7.
Eighteen expired renal supplements were stored in the medication room and available for use.
8.
The ice machines in the main kitchen and skilled nursing facility (SNF) satellite kitchen were not properly maintained and cleaned per manufacturer guidelines.
These deficient practices exposed the facility's residents in the SNF to potentially hazardous and contaminated food and equipment which had the potential to cause foodborne illness and disease in 38 residents who receive food from the main and satellite kitchens.
Cross reference F800, F801, F802, F804, F814, and F908
Findings:
1.
During an observation of the cook's food prep area in the main kitchen on 2/27/23 at 8:34 A.M., there was a large clear plastic storage container uncovered, unlabeled, and undated filled with white powder on top of the counter above the food prep sink.
2.
During a kitchen observation of the dry storage room on 2/27/23 at 9:39 A.M. a bag of Panko (breadcrumbs) was opened, unsealed and undated, in its original packaging.
3.
On 2/27/23 at 8:34 A.M, an observation of the facility's walk-in refrigerator and walk-in freezer was conducted in the main kitchen. The walk-in refrigerator had multiple uncovered, unlabeled, and/or undated potentially hazardous and Time Control for Food Safety (TCS) foods (i.e. meat, dairy, etc.) stored unsafely including: a medium sized plastic storage container with black olives half full without a lid, a medium sized plastic container ¾ full of pickles in juice uncovered dated 1-12-23 without a lid, a medium sized metal pan with chopped pulled barbecue chicken unlabeled and undated with plastic wrap, a large sheet pan of a brown soup or liquid dish with plastic wrap on the top shelf unlabeled and undated, five limes with black gray spots resembling mold in a case of brownish green colored limes, and a metal pan with green leaf lettuce in it covered with plastic wrap with no label or date. The walk-in freezer had three large 1/3-gallon ice cream tubs- strawberry, vanilla, and mint chocolate chip flavors on the shelf uncovered with bent lids falling off the sides. The ice cream was semi-soft, partially melted and not rock solid.
During an observation on 2/27/23 at 9:50 A.M., inside the facility's satellite kitchen reach-in refrigerator and reach-in freezer, there were two medium sized plastic containers of pineapple and melon fruit chunks that were unlabeled and undated. There was an unlabeled and undated medium size container 1/4 full of a cream-colored pudding. In the reach-in freezer there was an unlabeled and undated tan colored pastry ring in a clear plastic bag.
According to the 2022 US FDA Food Code, Section 3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .
Review of the facility's policy and procedure titled Food Receiving and Storage, dated 10/2017, indicated, .7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .
4.
During the satellite kitchen observation and interview on 2/27/23 at 9:50 A.M. with DA 1, the reach-in refrigerator's internal thermometer temperature was 50 degrees Fahrenheit (F). The Surveyor took the temperature of glass of milk. The surveyor's thermometer was 44.8 degrees F. DA 1 stated sometimes the refrigerator gets warmer than 40 degrees.
A review of the facility's policy and procedure titled Food Receiving and Storage, dated 10/2017, indicated, .10. Refrigerated foods must be stored below 41º F unless otherwise specified by law.
Review of the facility's policy and procedure titled Food Preparation and Service, dated 4/2019, indicated, .Food Preparation, Cooking, Holding Time/Temperatures: 1. The danger zone for food temperatures is between 41ºF and 135ºF. This temperature range promotes rapid growth of pathogenic microorganisms that cause foodborne illness . 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF (potentially hazardous food) must be maintained below 41ºF or above 135ºF.
5.
During the satellite kitchen observation and interview on 2/27/23 at 10:01 AM with DA 1, there was dirty rag with brown stains was on a tray with ten glasses of 8 oz. glasses of juice and milk. DA 1 stated she forgot to remove the rag from the tray after wiping the inside of the refrigerator.
Review of the facility's policy and procedure titled Sanitization, dated 10/2008, indicated, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish . 6. Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution .
6.
During an observation and interview on 2/27/23 at 10:06 A.M., in the satellite kitchen., DA 1 tested the dish machine sanitizing solution during a final rinse cycle with three separate Ecolab (manufacturer of test strip) testing strips and the amount of sanitization solution read 0 parts per million (ppm) on each testing strip.
Review of the facility's policy and procedure titled Sanitization, dated 10/2008, indicated, .8. Dishwashing machines must be operated using the following specifications: .Low-Temperature Dishwasher (Chemical Sanitization) .b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds.
7. During an observation and interview on 3/2/23 at 8:26 A.M., in the medication room with DON, 18 individually packaged café mocha Renal supplements had expired on 2/27/23. The DON stated these should have been removed and the expectation is that rooms containing formulas be checked weekly at minimum.
Review of the facility's policy and procedure titled Food Receiving and Storage, dated 10/2017, indicated, .7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in- first out system .
8.
During an observation and interview on 3/6/35 at 10:38 A.M., with DA 1 and the Maintenance Director (MDR), there was black, brown and white residue noted on the spouts and surrounding ice and water guards of the satellite kitchen ice machine. DA 1 stated she wipes the outside of the machine with sanitizing solution daily but does not clean the interior of the machine, spouts or surrounding ice and water guard. DA 1 stated she did not the specific date of the last internal cleaning. During the observation, the MDR removed the cover to the machine and a yellow indicator light next to the words time to clean was glowing.
An observation and interview on 3/6/23 at 11:06 A.M., was conducted with the Maintenance Director (MDR), RD, NCDM, and EC in the main kitchen. The MDR removed the ice machine cover and visible rust and black, brown and white residue was noted on multiple surfaces inside the machine including the internal ice trays and ice shoot. A pink residue was observed on a paper towel after the underside of the ice shoot was wiped.
A record review of the maintenance logs for the main kitchen ice machine and the satellite kitchen ice machine were conducted. The record indicated the last full sanitization service was performed for the main kitchen ice machine on 5/18/22. The log did not indicate a company or individual that had completed the sanitization on 5/18/22 and the log was not signed. The facility was unable to provide any service records for sanitization of the satellite kitchen ice machine.
During an interview on 3/7/23 at 8:20 A.M., ADM stated the facility was unable to locate any invoices or contracts verifying the last date of service for the satellite kitchen ice machine or the main kitchen ice machine.
Review of the facility's policy and procedure titled Sanitization, dated 10/2008, indicated, .12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions.
Review of the manufacturer's service manual for the SNF Countertop ice machine titled Ice Making and Dispensing System Cleaning Instructions, dated 10/2020, indicated, .Frequency: Recommended minimum time between cleanings is 6 months. To aid in determining if the machine has not been cleaned in 6 months, a Time To Clean light will glow after 6 months of power up time.
A review of the facility's policy and procedure titled Preventing Foodborne Illness - Food Handling, dated 7/2014, indicated, Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure a kitchen garbage bin was kept clean and free of debris. This failure had the potential to promote an unsanitary envir...
Read full inspector narrative →
Based on observation, interview, and record review, the facility failed to ensure a kitchen garbage bin was kept clean and free of debris. This failure had the potential to promote an unsanitary environment that harbors pests and expose to unsafe conditions.
Cross reference F800, F802, 812
Findings:
During the initial tour of the main kitchen on 2/27/23 at 8:26 A.M., an observation was conducted. The main kitchen was cluttered and with multiple empty cardboard boxes, empty food containers, chemical bottles scattered on the floor, along with wrappers, trash and other debris on the floor along the walkway from the kitchen entrance to the food equipment area.
During an observation and interview on 3/6/23 at 12:39 P.M., CK 4 was observed taking the kitchen trash bin outside to empty the contents in the dumpster. An observation of the inside of the kitchen trash bin was conducted and the bin was dirty with old food and debris. CK 4 brought the kitchen trash bin back inside without cleaning or washing out the old food waste. CK 4 placed a new trash bag in the bin; which was observed by the NCDM. The NCDM stopped CK4 from putting the new trash bag in the bin and asked CK 4 what should be done prior to placing the new bag. CK 4 stated he never cleans the garbage bin before putting a new one in the bin. The NCDM stated, CK 4 should have cleaned the kitchen trash bin before placing a new bag inside. The NCDM 3stated she was unable to find documentation of kitchen staff in-services on food safety that had been completed.
According to the 2022 FDA Food Code, Section 4-601.11, It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
According to the 2022 FDA Food Code, Section Annex 4-602.13, .the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . and section 4-602.13, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
A review of the facility's policy and procedure titled Sanitization, dated 10/2008, indicated, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches flies and other insects . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .
A review of the facility's policy titled Food-Related Garbage and Refuse Disposal, dated 10/2017, indicated, Policy Statement: Food-related garbage and refuse are disposed of in accordance with current state laws .3. Housekeeping personnel will empty garbage and refuse containers daily and will clean the containers at least daily on the outside and weekly on the inside.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interview, and document review, the facility failed to ensure two ice machines and the skilled nursing facility (SNF) kitchen dish machine were maintained in a safe, operating, a...
Read full inspector narrative →
Based on observation, interview, and document review, the facility failed to ensure two ice machines and the skilled nursing facility (SNF) kitchen dish machine were maintained in a safe, operating, and fully functioning manner, according to the manufacturer's guidelines and standards of practice.
These failures had the potential to expose 38 residents to unsafe, unsanitary ice, which could lead to foodborne illnesses and further compromise their health.
Cross reference F800, F801, F802, F812
Findings:
1. SNF Satellite and Main kitchen Dish machines
On 2/27/23 at 10:06 AM, a concurrent observation and interview was conducted with DA 1 in the satellite kitchen. DA 1 demonstrated how the low temperature dishwasher operated for the wash and rinse cycles. DA 1 showed how to check the chemical chlorine sanitizer with the manufacturer's test strips. DA 1 dipped a test strip from the first set of strips inside the dish machine solution and it was white, without a color change. DA 1 tried a different set of test strips, and there was no color change, and the container indicated the sanitizer reading was 0 ppm (parts per million). DA 1 tried one last set of test strips and got the same result of no color change. DA 1 stated they do not work. DA 1 stated she may be using the wrong test strips, but she didn't know where the other test strips were. DA 1 was asked when the last time the sanitizer in the dish machine was checked and she said yesterday, I believe.
On 2/27/23 at 10:30 A.M., a joint observation and interview was conducted with DA 1 and EC in the satellite kitchen. EC brought a small ring of test strips down to the satellite for DA 1 to test the chemical sanitizer of the dishwasher. DA 1 tore of an inch of the orange strip from the ring and dipped it into the dish machine solution. The test strip did not turn a different color, so both DA 1 and EC stated the chemicals must not be working or it's the wrong test strip. DA 1 stated there are usually other types of test strips in the satellite kitchen but she did not know where any of those strips were. EC stated he could not confirm when the dish machine sanitizer level was checked or if it was at a safe level since he started working at the facility a week ago.
On 2/27/23 at 12:35 P.M., an interview was conducted with the ADM about the SNF satellite kitchen dish machine sanitizer test strips occurrence. The ADM stated she would get a company to the facility to test the sanitizer level and told kitchen staff not to use the dish machine.
According to the 2022 Federal FDA Food Code, section -2-103.11, the person in charge (PIC) is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of chemical concentration and temperature for chemical sanitizing. In addition, a warewashing machine and its auxiliary components are to be operated in accordance with the machine's data plate and other manufacturer's instructions. A test kit or other device that accurately measures the concentration of sanitizing solution is to be provided. The Food Code Annex indicate, the PIC is to ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. The effectiveness of chemical sanitizers is determined primarily by the concentration and pH of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. In addition, the Food Code Annex explains epidemiological outbreak data repeatedly identify contaminated equipment as a major risk factor related to employee behaviors and preparation practices in food service establishments as contributing to foodborne illness.
According to the 2022 Federal Food Code, section 4-302.14, titled Sanitizing Solutions, Testing Devices, testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic.
According to the 2022 Federal FDA Food Code, section 4-501.11 Good Repair and Proper Adjustment, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk . Adequate cleaning and sanitization of dishes and utensils using a warewashing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize . A chemical sanitizer will not sanitize a dirty dish; therefore, the cycle times during the wash and rinse phases are critical to sanitization.
According to the 2022 Federal FDA Food Code, section 4-501.15, titled Warewashing Machines, Manufacturers' Operating Instructions, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly .
Review of the undated document titled SNF Dietary Manager Job Description, indicated .Essential functions and responsibilities include but not limited to: .1. plans, develops, organizes, implements, evaluates, and directs Dietary Department programs and activities in accordance with departmental policies and current federal, state, and local regulations .2. Supervise dietary department employees . responsibility for training competent personnel, evaluate employee performance .3. Completes management duties including schedules .conducts routine in-services for department personnel in conjunction with the registered dietitian; Routinely audits dietary areas and practices for compliance with current regulations and policies (i.e. meal service, sanitation .food temperatures .); reports all hazardous conditions/equipment to the Administrator immediately .
Review of facility policy dated October 2008, titled Sanitization, indicated The food service area shall be maintained in a clean and sanitary manner .8. Dishwashing machines must be operated using the following specifications: .Low-temperature dishwasher chemical sanitization .final rinse with 50 parts per million (ppm) hypochlorite chlorine for at least 10 seconds .
2. Ice machines - SNF kitchen and Main kitchen
During an observation in the SNF satellite kitchen and interview on 3/6/23 at 10:38 A.M. with DA 1 and the Maintenance Director (MDR), there was thick black, brown, and white residue build-up noted on the spouts and surrounding ice and water guards. DA 1 stated she wipes the outside of the machine with sanitizing solution daily but does not clean the interior of the machine, spouts or surrounding ice and water guard. DA 1 stated she did not the specific date of the last internal cleaning. The MDR removed the cover to the machine and a yellow indicator light next to the words time to clean was glowing. The ADM and RD acknowledged the level of dirt build-up and both stated it should have been clean.
?
During an observation and interview on 3/6/23 at 11:06 A.M. with the MDR, RD, NCDM, and EC in the main kitchen, the MDR removed the ice machine cover and there was visible rust, black, brown, and white residue noted on multiple surfaces inside the machine including the internal ice trays and ice shoot. A pink residue resembling pink slime was observed on a paper towel after the underside of the ice shoot was wiped. The RD and NCDM acknowledged the level of unclean build up in the machine and stated it should have been clean.
?
During a review of the maintenance logs for the main kitchen and satellite kitchen ice machines indicated the last full sanitization service was performed for the main kitchen ice machine on 5/18/22. The log did not indicate the company name or individual who performed the ice machine cleaning and sanitization on 5/18/22, and the log was not initialed or signed.
?
During an interview on 3/7/23 at 8:20 A.M. with ADM, the ADM stated the facility was unable to provide invoices or contracts verifying the last date of sanitization service for both ice machines in the satellite and main kitchen.
?
According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-204.17 titled; Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines. Liquid drain lines passing through the ice bin are, themselves, difficult to clean and create other areas that are difficult to clean where they enter the unit as well as where they abut other surfaces. The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin.
According to the 2022 Federal FDA Food Code, section 4-501.11, titled Good Repair and Proper Adjustment .EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.
Review of the SNF satellite ice machine equipment service manual's guidelines dated October 2020, for Model numbers HID312, HID525, HID540 titled Ice Making and Ice Dispensing System Cleaning Instructions, indicated .Recommended minimum time between cleanings is 6 months .Mix a solution of 12 ounces of manufacturer's ice machine scale remover with .clean, potable water .
Review of the main kitchen ice machine equipment service manual's guidelines dated November 2012, for Model numbers C0322 through C1030 titled Air and Water Cooled User Manual Use and Operation, indicated .Indicator Lights & Their Meanings .Yellow .Time to de-scale and sanitize .Blinking Yellow .In cleaning mode .
Review of the manufacturer's service manual for the SNF Countertop Ice machine titled Ice Making and Dispensing System Cleaning Instructions, dated 10/2020, indicated, .Frequency: Recommended minimum time between cleanings is 6 months. To aid in determining if the machine has not been cleaned in 6 months, a 'Time To Clean' light will glow after 6 months of power up time .Mix a solution of the manufacturer's machine cleaning scale remover with 12 ounces of clean, potable water .
Review of the facility's policy and procedure titled Sanitization, dated 10/2008, indicated, .12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions .
Review of the facility's policy and procedure titled Preventing Foodborne Illness - Food Handling, dated 7/2014, indicated, Policy Statement: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.
A policy on general equipment maintenance was requested on 3/7/23 but was not provided by the facility.
Feb 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their abuse policy when one resident's Respons...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their abuse policy when one resident's Responsible Party (RP) was not notified of an alleged sexual abuse for one resident (1).
In addition, the facility's Social Services Director (SSD) did not assess, evaluate, and follow up with Resident 1 after an allegation of sexual abuse.
As a result, Resident 1's RP was not aware of the alleged sexual abuse.
Findings:
Resident 1 was admitted to the facility on [DATE] with diagnoses which included alcohol abuse and delirium (disturbance in thinking abilities) per the facility's admission Record.
On 2/7/23 at 9:45 A.M., and interview with Resident 1's RP was conducted. The RP stated this was the first time he heard of the sexual abuse allegation. The RP stated no one from the facility contacted him about the incident. The RP stated he was the first contact person and responsible for making decisions for Resident 1.
On 2/7/23 at 10:35 A.M., a joint interview and review of Resident 1's was conducted with the Social Services Director (SSD). The SSD stated he did not call Resident 1's RP. The SSD stated he did not assess or talked to Resident 1 after the sexual abuse allegation incident. The SSD stated, I should have, it slipped my mind. In addition, the SSD stated there was no documentation about the follow up visit because he did not do it.
On 2/7/23 at 11:10 A.M, an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated after a sexual abuse allegation, the SSD should do a follow up and document to ensure the resident was taken cared of.
On 2/7/23 at 11:45 A.M., an interview was conducted with LN 2. LN 2 stated SSD was always notified for any kind of abuse. LN 2 stated SSD should see the resident and notify the RP.
On 2/7/23 at 12:40 P.M., a joint interview and record review of Resident 1 was conducted with the Director of Nursing (DON). The DON stated there was no documentation from the SSD or any follow up investigation about the allegation of sexual abuse. The DON further stated, I'm not going to lie, I have no excuse.
Per the facility's policy and procedure titled Abuse, Neglect, Exploitation . revised 4/2021, .2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: . c. The resident's representative .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to initiate a resident-centered care plan for one of one ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to initiate a resident-centered care plan for one of one sampled resident (1) involved in an allegation of sexual abuse.
This failure had the potential for Resident 1 to repeat the same allegation and staff unaware of the situation.
Findings:
Resident 1 was admitted to the facility on [DATE] with diagnoses which included alcohol abuse and delirium (disturbance in thinking abilities) per the facility's admission Record.
Resident 1's clinical record was reviewed. Per the hospital's history and physical dated 1/24/23, Resident 1, Was noted to sundown with some confusion at night.
On 2/7/23 at 9:40 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated if there was an allegation of sexual abuse, everything must be documented, and care plan should be initiated for staff to know about the behavior.
On 2/7/23 at 10:35 A.M., a joint interview and record review of Resident 1 was conducted with the Social Services Director (SSD). The SSD stated Resident 1's care plan was not updated to reflect the sexual allegation and, It should have been.
On 2/7/23 at 11:10 A.M., a joint interview and record review of Resident 1 was conducted with LN 1. LN 1 reviewed Resident 1's care plan then stated, I did not see any care plan about sexual abuse allegation for Resident 1. LN 1 stated it was important to have a care plan because staff could use it as a communication tool.
On 2/7/23 at 11:45 A.M., a joint interview and record review of Resident 1 was conducted with LN 2. LN 2 stated any sexual allegation should be documented and have a care plan. LN 2 reviewed Resident 1's clinical record then stated, There was no care plan documented for Resident 1 about sexual abuse allegation.
On 2/7/23 at 12:40 P.M., a joint interview and record review of Resident 1 was conducted with the Director of Nursing (DON). The DON stated whenever there was a risk management or a change in condition entry in the resident's record, a care plan was triggered. The DON reviewed Resident 1's clinical record then stated, I did not see any care plan. The DON further stated it was important to have a care plan for staff to know what was going on with the resident.
The facility was unable to provide a policy about initiating a care plan for allegation of sexual abuse.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident centered pressure ulcer (skin damage) care plan ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident centered pressure ulcer (skin damage) care plan for one of two sampled residents (1).
Failure to develop a wound care plan had the potential to affect the treatment and coordination of care for Resident 1, and staff unaware of resident's pressure ulcer.
Findings:
Resident 1 was admitted to the facility on [DATE] with diagnoses which included pressure ulcer of the sacral region (skin damage at the bottom of spine) per the facility's admission Record.
Resident 1's clinical record was reviewed. The physician's order dated 1/3/23, Cleanse stage 2 pressure injury and surrounding redness with mild soap and water.
The facility's Minimum Data Set Section M (an assessment tool) dated 1/5/23, Resident 1 had, One or more unhealed pressure ulcer .
Per the physician's progress notes dated 1/12/23, .Skin- no skin lesions or open areas .
Per the Registered Dietitian's note dated 1/12/23, Skin: Stage 2 pressure injury (PI).
The following information was obtained from the facility's form titled Daily Skilled Note:
On 1/9/23, a Licensed Nurse (LN) documented, . D. Skin 1. Pressure ulcer present [No].
On 1/12/23, a Licensed Nurse (LN) documented, . D. Skin 1. Pressure ulcer present [No].
On 1/14/23, a Licensed Nurse (LN) documented, . D. Skin 1. Pressure ulcer present [No].
On 1/17/23, a Licensed Nurse (LN) documented, . D. Skin 1. Pressure ulcer present [No].
On 1/9/23 at 11:24 A.M., an interview was conducted with the Certified Nurse Assistant (CNA). The CNA stated Resident 1 did not have any pressure ulcer.
On 1/19/23 at 12:11 P.M., a joint interview and record review of Resident 1 was conducted with the Wound Care Nurse (WCN). The WCN stated Resident 1 was admitted to the facility with a stage two pressure ulcer on the sacral area. The WCN stated it was important to have a skin integrity or wound care plan for staff to know if the treatment was effective or not.
The WCN reviewed Resident 1's care plan then stated, There was no care plan about pressure ulcer. In addition, the WCN stated care plans assisted the licensed nurses in communicating about resident's problems to other staff and physicians.
On 1/9/23 at 12:30 P.M., an interview was conducted with the LN. The LN stated Resident 1 had, Skin issues on her bottom. The LN stated care plans were started on admission day and on the day a problem was identified. The LN stated care plans were updated and modified to reflect the effectiveness or current treatments for the resident.
Per the facility's policy titled Care Plans, Comprehensive Person-Centered dated 2001, .2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the MDS assessment .3. The care plan interventions are derived form a thorough analysis of the information gathered as part of the comprehensive assessment .
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 changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $150,597 in fines, Payment denial on record. Review inspection reports carefully.
- • 52 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $150,597 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Bayshire Torrey Pines Post-Acute's CMS Rating?
CMS assigns BAYSHIRE TORREY PINES POST-ACUTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Bayshire Torrey Pines Post-Acute Staffed?
CMS rates BAYSHIRE TORREY PINES POST-ACUTE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 50%, compared to the California average of 46%.
What Have Inspectors Found at Bayshire Torrey Pines Post-Acute?
State health inspectors documented 52 deficiencies at BAYSHIRE TORREY PINES POST-ACUTE during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 51 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Bayshire Torrey Pines Post-Acute?
BAYSHIRE TORREY PINES POST-ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BAYSHIRE SENIOR COMMUNITIES, a chain that manages multiple nursing homes. With 45 certified beds and approximately 38 residents (about 84% occupancy), it is a smaller facility located in SAN DIEGO, California.
How Does Bayshire Torrey Pines Post-Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, BAYSHIRE TORREY PINES POST-ACUTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (50%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Bayshire Torrey Pines Post-Acute?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Bayshire Torrey Pines Post-Acute Safe?
Based on CMS inspection data, BAYSHIRE TORREY PINES POST-ACUTE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 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 Bayshire Torrey Pines Post-Acute Stick Around?
BAYSHIRE TORREY PINES POST-ACUTE has a staff turnover rate of 50%, 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 Bayshire Torrey Pines Post-Acute Ever Fined?
BAYSHIRE TORREY PINES POST-ACUTE has been fined $150,597 across 24 penalty actions. This is 4.4x the California average of $34,585. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Bayshire Torrey Pines Post-Acute on Any Federal Watch List?
BAYSHIRE TORREY PINES POST-ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.