How many inspection deficiencies does CASA DE LAS CAMPANAS have?

CASA DE LAS CAMPANAS has 35 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at CASA DE LAS CAMPANAS?

CASA DE LAS CAMPANAS has a four-star staffing rating from CMS with 0.74 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CASA DE LAS CAMPANAS located?

CASA DE LAS CAMPANAS is located in SAN DIEGO, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CASA DE LAS CAMPANAS have?

CASA DE LAS CAMPANAS has 99 certified beds.

Who owns CASA DE LAS CAMPANAS?

CASA DE LAS CAMPANAS is a non profit - other facility and operates independently (not part of a chain).

What questions should families ask when visiting CASA DE LAS CAMPANAS?

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

How does CASA DE LAS CAMPANAS compare to other nursing homes?

CASA DE LAS CAMPANAS has a 3-star overall rating, which is average compared to other nursing homes in CA. Consider visiting multiple facilities before making a decision.

CASA DE LAS CAMPANAS

Name: CASA DE LAS CAMPANAS
Address: 18655 W. BERNARDO DRIVE, SAN DIEGO, CA, 92127, US
Telephone: (858) 451-9152
Rating: 3.0

18655 W. BERNARDO DRIVE, SAN DIEGO, CA 92127 · (858) 451-9152

Non profit - Other 99 Beds Independent Data: November 2025

Trust Grade

60/100

#545 of 1155 in CA

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Last Inspection: June 2024

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

Overview

Casa de las Campanas has a Trust Grade of C+, indicating it is slightly above average but not outstanding. Ranking #545 out of 1155 facilities in California places it in the top half, while its county rank of #59 out of 81 suggests there are only a few better local options. The facility is improving, having reduced issues from 17 in 2024 to just 2 in 2025. Staffing is a strength, with a rating of 4 out of 5 stars, indicating a relatively stable environment, although the turnover rate is average at 47%. While there have been no fines issued, which is a positive sign, there are concerns about food safety practices, including inadequate training for kitchen staff and several sanitation issues, which could pose health risks for residents.

Trust Score: C+
In California: #545/1155
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets 44 minutes of Registered Nurse (RN) attention daily — more than average for California. RNs are trained to catch health problems early.
Violations: 35 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★☆

4.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 17 issues

2025: 2 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, quality measures, fire safety.

The Bad

3-Star Overall Rating

Near California average (3.1)

Meets federal standards, typical of most facilities

Staff Turnover: 47%

Near California avg (46%)

Higher turnover may affect care consistency

The Ugly 35 deficiencies on record

Aug 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the plan of care for one of three residents (Resident 1) reviewed for falls.This failure had the potential for Resident 1 to experience subsequent falls and/or injuries.On 8/22/25 Resident 1's facility's record was reviewed. The admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included fracture of right femur (a broken thigh bone) and generalized muscle weakness. A review of the Fall Evaluation dated 6/5/25 indicated Resident 1 was at high risk for falling. During a review of Resident 1's Progress Notes, the Fall Note dated 8/1/25 at 10:19 A.M. indicated, .found resident on the floor, left side of the bed, head slightly under the bed. When asked, [Resident 1] stated he wanted to reach his wheelchair to go to the bathroom and hit his head on the side of the bed. Assessment done, skin tear on the back of the head slightly bleeding, and pain with level of 7 on the right hip. The Progress Note indicated Resident 1 was transported to the hospital via 911, per physician's order.On 8/22/25 at 9:50 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated she was the supervising nurse on duty when Resident 1 sustained a fall on 8/1/25. LN 1 stated she assessed Resident 1 while he was still on the floor. LN 1 stated Resident 1's call light was not activated when she entered his room. LN 1 stated resident was sent to the hospital immediately, and returned the same day. LN 1 stated the new interventions initiated by the facility to prevent Resident 1 from sustaining any additional falls include, .we reiterated that he needs to press the call light. If he's in bed it needs to be in the lowest position, and fall mats. LN 1 stated she does not remember if the interventions were implemented when Resident 1 returned to the facility.On 8/22/25 at 10:23 A.M., a joint interview and record review was conducted with the Interim Director of Nursing (IDON). The IDON stated there were no new interventions documented in Resident 1's record when he returned from the hospital. The IDON stated, I would have done something like move him closer to the nurses station. The IDON stated Resident 1's care plan should have been accelerated to reflect the fall. The IDON stated it was important to prevent future falls, to try to avoid injury and cause harm to the resident.On 8/22/25 the facility's policy was reviewed. The facility's policy titled Falls- Clinical Protocol revised March 2018, the policy indicated, The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

Aug 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview and Record Review, the facility failed to keep one of five sampled residents (Resident 1) safe from medication errors. This failure caused Resident 1 to receive the wrong medication and posed a risk to Resident 1's health and safety.Findings:Per the facility's admission Record, Resident 1 (Res 1) was admitted to the facility on [DATE]. Resident 1's admission diagnosis was Myasthenia Gravis (a chronic disorder that affects where nerves communicate with muscles). Per the Minimum Data Set (MDS - a resident assessment tool) assessment, Section K0520 indicates that Resident 1 had a G-Tube (a tube that goes into the stomach through the abdominal wall for nutrition, medication, and hydration) present on admission and while a resident in the facilityPer a record review of Res 1 electronic medical record (EMR) on 7/24/2025, the change of condition note dated 3/20/2025 at 4:15 P.M. LN2 documented that Resident was sitting by door disconnected from feeding tube. Nurse gave crushed meds with applesauce by mouth causing resident to choke. Three nurses alerted, suction used on mouth and oxygen given. 911 called.Resident 1's record was reviewed on 7/24/2025. During a review of Res 1's Order Summary Review, the record indicated a new order was placed for medication via G-Tube. The record further indicated that the medications were discontinued and reordered on 2/13/2025, 2/15/2025, and 3/6/2025. Thus, the record showed that there had been no recent changes to the medication orders and that the medications had been administered via the appropriate route (g-tube). LN1 did not give Res1's medications by the ordered route. (g-tube).During an observation and interview on 7/24/2025 at 9:15 A.M. Medication Nurse 1 (MED1) was observed passing medications. MED1 checked medications against the physician's orders, dispensed medications to plastic cups, verified patient, medication, dosage, route, and time. MED1 stated the policy for G-Tube medication administration: Check the Medication Administration Record (MAR); verify patient, medication, dose, route, and time; verify that medications can be crushed.During an interview with the Director of Nursing (DON) on 7/24/2025 at 10:05 A.M., the DON stated Resident 1 was a tube fed resident. On 3/19/2025, R1 was seated in a chair in the hall. The tube feeding had been turned off. Licensed Nurse 1 (LN1) saw R1 seated in the hall and offered her medications, R1 asked for them to be crushed. LN1 crushed the medications, mixed them in applesauce and gave them to R1 by mouth. R1 began to choke and coughed out the applesauce and medications. Staff took R1 into her room, suctioned her, and called 911.The DON stated, LN1 did not verify the name of the resident prior to giving medications. The DON continued She (LN1) broke many, many things related to our medication administration policies. Nurses are expected to follow the Five Rights when passing medications. The DON further stated that LN1 did not properly identify the resident, the medications, or the correct route.The DON further stated that all facility staff who pass medications are observed by the pharmacist to ensure safety at least every six months. Registry staff are observed based on how frequently they work.During a record review on 7/24/2025 at 9 A.M. The document titled PharMerica Medication Administration Observation Report indicated the most recent observation of LN1 was on 11/25/2024.On 7/30/2025 at 12:45 P.M., R1's attending physician (MD) was interviewed. R1's MD stated that R1 was tube fed, and she was not to have anything by mouth. The MD further stated that this incident had the potential for a very bad outcome, but I saw her the following day, and she was ok.During a review of the facility policy titled Administering Medications dated April 2019, indicated .9. The individual administering medications verifies the resident's identity before giving the medications. Methods of identifying the resident include a. checking identification band; b. checking photograph attached to the medical record; and c. if necessary, verifying resident identification with other facility personnel. The policy continues .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper medication administration for one of three residents (Resident 1) observed during medication pass when a medication for an overactive bladder (a condition where there is a frequent sensation of needing to urinate) was not administered per the physician's order. This deficient practice had the potential to cause the resident harm. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses that included overactive bladder. On 11/14/24 at 9:16 A.M., a medication pass was observed with Licensed Nurse (LN) 1. Resident 1 ' s Oxybutynin Chloride (a medication to treat overactive bladder) was not available in the medication cart. A review of Resident 1 ' s Order Summary indicated, Oxybutynin Chloride ER Oral Tablet Extended Release 24 Hour 5 MG Give 1 tablet by mouth one time a day for Overactive Bladder. A review of Resident 1 ' s Medication Administration Record (MAR) dated November 2024 was conducted. The MAR indicated, on 11/14/24 at 9 A.M, Oxybutynin was administered to Resident 1. On 11/14/24 at 12:44 P.M., a joint interview and record review was conducted with LN 1. LN 1 stated she did not administer Oxybutynin on 11/14/24. LN 1 stated, . (the medication) is not available. We follow up with the pharmacy but they haven ' t sent it yet . LN 1 stated she should not have documented the medication as given. LN 1 further stated if a medication was not given as ordered, .we should tell the doctor and write a progress note that it [the medication] wasn ' t given . On 11/14/24 at 1:40 PM., an interview was conducted with the Director of Staff Development (DSD). The DSD stated, if a medication is not available and not given, .they should be writing a note indicating what they did. They need to follow up with the pharmacy. If the medication is not given, or arrives later, the nurses need to let the physician know and document it. On 11/14/24 at 2:11 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, if a medication is unavailable, .we have to notify the physician. We have procedures, such as an urgent pharmacy form to fill out so they [licensed nurses] can get medications right away. The DON stated it was important for residents to receive all prescribed medications to avoid any health complications. A review of the facility ' s policy titled Medication Administration General Guidelines revised 7/2014 indicated, If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .an explanatory note is entered .

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, and interview the facility failed to ensure staff followed infection control precautions when staff were observed without face masks. This failure had the potential for the spread of infection to residents, staff, and visitors. Findings: On 9/24/24 an unanounced visit was made to the facility in response to a report of a Covid-19 outbreak. On the entrance door a sign noted the presence of Covid-19 in the facility and directed visitors to not visit if they had symptoms of illness and to wear a mask while in the facility. On 9/24/24 at 5 A.M. an observation and interview was held with LN 1. LN 1 was sitting at nursing station 1, not wearing a surgical mask. LN 1 stated there is one resident infected with Covid-19 in the facility at this time. Certified Nursing Assistant (CNA) 1 and CNA 2 were observed entering the hallway from resident rooms. CNA 1 was carrying a bag of disposable items, and put the bag into the trash receptacle in the dirty utility room. CNA 1 and CNA 1 were observed not wearing masks. On 9/24/24 at 5:06 A.M. CNA 1 and CNA 2 were interviewed. CNA 2 stated masks need to be worn to prevent the spread of Covid-19. CNA 2 also stated it was important to wear masks because a person could have Covid-19 and have no symptons. CNA 1 stated she had been in a resident room and should have been wearing a mask. On 9/24/24 at 5:50 A.M. the Infection Preventionist (an RN with specialized training in the management and prevention of infection spread) (IP) was interviewed. The IP stated, as of 9/24/24 one resident was still on precautions for Covid-19. On 9/24/24 at 2:20 P.M. an interview was held with the Director of Nursing (DON). The DON stated it is the policy and expectation that all staff wear surgical masks while on duty for infection control during this Covid-19 outbreak. The DON stated LN 1, CNA 1 and CNA 2 should have been wearing masks during their shift, to prevent the spread of infection to the residents.

Jun 2024 14 deficiencies

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comfortable environment to one of 13 residents (Resident 216) when Resident 216's room temperature was 88°F (degrees Fahrenheit - unit of temperature measurement). This failure had the potential to negatively impact the resident's comfort and well-being. Findings: Resident 216 was admitted to the facility on [DATE] with diagnoses which included right knee pain and history of fall per facility's admission Record. A review of Resident 216's Minimum Data Set (MDS - assessment tool), Section C dated 6/1/24 indicated Resident 216 was cognitively intact. An observation and interview were conducted on 6/4/24 at 9:43 A.M. inside Resident 216's room. Resident 216 was observed fanning himself with a table napkin. Resident 216 stated It is hot in here. An observation and interview were conducted on 6/4/24 at 10:05 A.M. with the facility's maintenance technician (MT) inside Resident 216's room. The MT used the facility thermal gun (device to check room temperature) and registered a reading of 88°F. The MT further stated Resident 216's desired room temperature was 79°F. An interview was conducted on 6/6/24 at 11:00 A.M. with the Director of Plant Operations (DPO). The DPO stated Resident 216 and all residents' room temperature should have been kept between 71°F to 81°F. The DPO further stated it was important to maintain the temperature between 71°F to 81°F to keep the facility residents comfortable. A review of the facility's policy titled Homelike Environment revised 2/2021 indicated Policy: .2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .h. comfortable and safe temperatures (71°F - 81°F) .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement safe administration of medications for one of 13 residents (Resident 500) when Licensed Nurse (LN) 31 administered Resident 500's medications prepared by LN 2. This failure had the potential for unsafe medication administration and affect the resident's well-being. Findings: Resident 500 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease (disorder that affects movement), muscle weakness, and restless legs per facility's admission Record. An observation was conducted on 6/6/24 at 9:30 A.M. with LN 31 inside Resident 500's room. Resident 500 was observed asking LN 31 what medications were in the medication cup. LN 31 responded she did not prepare the medications, and will ask LN 2 what medications were prepared to be administered. An interview was conducted on 6/6/24 at 9:33 A.M. with LN 31. LN 31 stated she should have not administered Resident 500's medications because she did not prepare the medications. LN 31 further stated LN 2 prepared the medications and should have administered Resident 500's medications to provide a safe medication administration. An interview was conducted on 6/6/24 at 10:34 A.M. with LN 2. LN 2 stated she prepared Resident 500's medications, and should have administered the medications to Resident 500. LN 2 further stated she should have not asked LN 31 to administer Resident 500's medications to prevent unsafe medication administration. An interview was conducted with the Director of Nursing (DON) on 6/7/24 at 11:04 A.M. The DON stated the licensed nurse who prepared the medications should administer the medications to the resident to prevent confusion and be able to provide a safe setting to the resident. A review of the facility's policy titled Administering Medications revised 4/2019 indicated Policy: .10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and the right method (route) of administration before giving the medication.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 55 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM - high levels of sugar in the blood), acute embolism (blockage) of the left lower extremity (leg) per facility's admission Records. A review of Resident 55's physician order dated 6/4/24 indicated Cleanse wound to the left medial lower leg with NS (Normal Saline), pat dry, apply Silver Alginate (medication) and cover with bordered foam dressing daily. An observation was conducted on 6/4/24 at 8:47 A.M. with Resident 55 inside the resident's room. Resident 55's left lower leg was observed with an undated dressing. A follow up observation and interview were conducted on 6/6/24 at 11:05 A.M. with Resident 55. Resident 55 stated her left lower leg dressing was not changed since 6/4/24. Resident 55 futher stated the nurse should have changed the left lower leg dressing daily. A joint interview and record review were conducted on 6/6/24 at 3:02 P.M. with Licensed Nurse (LN) 33. LN 33 stated per Resident 55's treatment activity record (TAR - documentation of skin treatment) indicated the treatment of Resident 55's left lower extremity was not done on 6/4 and 6/5/24. LN 33 stated there was no documentation that Resident 55 refused the skin treatment. LN 33 further stated the skin treatment should have been implemented daily per physician's order, to identify changes in the wound and to provide the adequate care. An interview was conducted on 6/7/24 at 11:21 A.M. with the Director of Nursing (DON). The DON stated skin treatments were to be implemented by nursing staff per physician's order to monitor and prevent wound deterioration. A review of the facility's policy titled Scope of Practice (undated) indicated .Responsibilities: LN's provide basic nursing care under the direction of a physician. Their tasks include medication administration, wound care, and monitoring patient status. 2) Resident 45 was admitted to the facility on [DATE] with diagnoses which included Esophageal Obstruction (a blockage in the stomach) severe protein-calorie malnutrition per facility's admission Record. On 6/4/24 at 9:28 A.M., a review of Resident 45's Physician Order dated 2/6/24 was conducted. The Physician's order indicated, Daily Weights in the morning. On 6/6/24 at 9:30 A.M., an interview and record review with Restorative Nursing Assistant (RNA) 25 was conducted. RNA 25 stated NOC (Night) shift RNAs were responsible for weighing residents in the facility. RNA 25 stated RNAs would report to the Licensed Nurses (LN) the resident's weight and this will be documented by LN in the Electronic Medical Record (EMR). RNA 25 futher stated there were no daily weights recorded for Resident 45 on: 6/5, 6/3, 5/30, 5/28, 5/25, 5/21, 5/20, 5/17, 5/15, 5/14, 5/12, 5/9, 5/6, and 5/3/24. RNA 25 stated if Resident 45's weights were not recorded, then Resident 45 was not weighed. On 6/6/24 at 9:50 A.M., an interview and record review with LN 2 was conducted. Resident 45's physician orders dated 2/6/24 included Daily Weights in the morning. LN 2 stated there were no weights recorded on dates : 6/5, 6/3, 5/30, 5/28, 5/25, 5/21, 5/20, 5/17, 5/15, 5/14, 5/12, 5/9, 5/6, and 5/3/24. LN 2 stated Resident 45 refused to be weighed on those dates. LN 2 stated the process was for LNs to notify the Physician if resident refused the daily weights. LN 2 stated Physician was not notified of Resident 45's refusal for daily weights. LN 2 stated it was important to notify the Physician of Resident 45's refusal of daily weights to determine Resident 45's reason for refusing, discuss to the resident potential outcomes/consequences and possible alternative options. On 6/7/24 at 9:35 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the Physician should have been notified of Resident 45's daily weight's refusal. The DON stated it was important to notify the Physician to be informed be able to talk to the resident about the importance of monitoring weight accurately and possible water retention. A review of the facility's policy titled, Requesting, Refusing and /or Discontinuing Care or Treatment revised 2/2021 indicated, Policy: .10. The healthcare practitioner must be notified of refusal of treatment . Based on observation, interview, and record review, the facility failed to ensure the physician's orders were implemented and the physician was notified for 3 of 13 residents (Resident 61, Resident 45 and Resident 55) when: 1. Resident 61's physician order for physical therapy (PT) was not done and was refused. 2. Resident 45's physician order for daily weights was not done and was refused. 3. Resident 55's physician order for wound treatment was not provided. These failures had the potential for further decline in the residents' health and well-being as physician's ordered treatment and services were not provided. Findings: 1. Resident 61 was admitted to the facility on [DATE] with diagnoses which included fracture (broken) of left femur (left hip) per facility's admission Record. A review of physician order dated 5/8/24 indicated Physical Therapy to treat 5 times per week for 60 days for skilled services to include Physical Therapy Evaluation . An interview was conducted on 6/6/24 at 8:37 A.M. with Resident 61. Resident 61 stated I do not feel comfortable working with Rehabilitation Manager (RM) and refused physical therapy (PT) treatments for the past 3 days. An interview was conducted on 6/6/24 a 3:12 P.M. with the RM. The RM stated Resident 61 felt mistreated and slighted, was upset with him and refused PT treatments when the RM participated with Resident 61's care. The RM stated Resident 61 refused PT treatment on 6/3, 6/4 6/5, and 6/6/24. The RM stated the physician was not notified of Resident 61's refusal of PT treatment. An interview was conducted on 6/7/24 at 8:05 A.M. with the Director of Nursing (DON). The DON stated the physician should have been notified when Resident 61 refused the PT treatment the first time because the physician ordered the treatment, and it was not done or performed. A review of facility's policy and procedure titled Requesting, Refusing, and/or Discontinuing Care or Treatment revised 2/2021 indicated .Policy Interpretation and Implementation: .10. The healthcare practitioner must be notified of refusal of treatment .

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 61 was admitted to the facility on [DATE] with diagnoses which included fracture (broken) of left femur (left hip) per facility's admission Record. Resident 61's physician's order dated 5/31/24 indicated Zinc Sulfate 220 milligrams, (mg unit of measurement) , one tablet every day for wound healing. An observation was conducted on 6/6/24 at 9:21 A.M. with License Nurse (LN) 34. LN 34 did not administer Resident 61's Zinc Sulfate during medication administration. A record review of Resident 61's Medication Administration Record (MAR) indicated, LN 34 did not administer Resident 61's Zinc Sulfate during medication administration. An interview was conducted on 6/6/24 at 3:21 P.M. with LN 34. LN 34 stated the Zinc Sulfate was not available in the medication cart. LN 34 further stated the medication should have been made available for Resident 55 to receive the prescribed medication. An interview was conducted on 6/6/24 at 4:20 P.M. with the facility's Pharmacy Consultant (PC). The PC stated physician ordered medications should be made available and administered to all residents. An interview was conducted on 6/7/24 at 11:07 A.M. with the Director of Nursing (DON). The DON stated all medications should be readily available at all times for the residents to receive the necessary prescribed medications. A review of facility policy and procedures titled Administering Medications revised 4/2019 indicated Policy Statement: Medications are administered in a safe and timely manner and as prescribed .Policy Interpretation and Implementation: .4. Medications are administered in accordance with prescriber orders Based on observation, interview, and record review, the facility failed to ensure procedures for accurate acquiring, receiving, dispensing, and administering of medications for 4 of 13 residents (Resident 314, Resident 315, Resident 316 and Resident 61) when: 1. Resident 314 and 315's pro re nata (PRN - as needed) medication for pain did not have parameters for medication administration. 2. Resident 316's medication was not administered timely per physician's order. 3. Resident 61's Zinc sulfate (supplemental mineral) was not made available and administered per physician's order. These failures had the potential for the facility to provide unsafe medication administration and inability to provide treatment to the residents. Findings 1. Resident 314 was admitted to the facility on [DATE] for diagnoses which included displaced fracture of the left olecranon process (left elbow) per facility's admission Records. A review of Resident 314's physician orders dated 5/30/24 indicated Roxicodone Oral Tablet 5 MG. Give 1 tablet by mouth every 4 hours as need for mild pain; Roxicodone Oral Tablet 5 MG. Give 2 tablet by mouth every 4 hours as need for moderate pain; Roxicodone Oral Tablet 5 MG. Give 3 tablet by mouth every 4 hours as need for severe pain. Resident 315 was admitted to the facility on [DATE] for diagnoses which included compression fracture of the first lumbar spine (break of bone in the back) per facility's admission Records. A review of Resident 315's physician orders dated 5/28/24 indicated Norco oral tablet 5-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 4 hours as needed for compression fracture related to wedge compression fracture of first lumbar vertebra . An interview was conducted on 6/7/24 at 8:05 A.M. with the Director of Nursing (DON). The DON stated physician ordered PRN medication should have a clear indication or reason for administration. The DON further stated if mild, moderate and severe were used, it should have a parameter or pain scale. An interview was conducted on 6/7/24 at 2:15 P.M. with the Director of Staff Development (DSD). The DSD stated the PRN pain medications should have an indicated numeric pain level. A review of facility's policy and procedure titled Medication Orders revised 11/2014 indicated Recording Orders .2. PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength, and the reason for administration. 2. Resident 316 was admitted to the facility on [DATE] with diagnoses which included gastroenteritis (inflammation of the lining of the stomach and intestines) and colitis (inflammation of the colon) per facility's admission Records. A review of Resident 316's physician order dated 5/21/24 indicated Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa). Give 1 tablet by mouth three times a day for Parkinson's. Take 1 tablet PO (oral) 3 times a day. Take 60 minutes before each meal. An interview was conducted on 6/5/24 at 12:49 P.M. with Resident 316. Resident 316 stated he told the staff multiple times, I take Parkinson medicine (Carbidopa-Levodopa) three times a day and takes it 1 hour before my meals. Resident 316 stated throughout my stay here in the facility, Carbidopa-Levodopa medication was not given to me 1 hour before meals and sometimes was provided after meals. A concurrent interview and record review of Resident 316's electronic Medication Administration Record (MAR) and mealtimes of the unit was reviewed on 6/6/24 at 4:07 P.M. with the Minimum Date Set Coordinator (MDSC). The reviewed MAR indicated the Carbidopa-Levodopa medication administration was scheduled at 7:30 A.M., 11:30 A.M., and 4:30 P.M. The reviewed mealtimes of the unit indicated Tray Service .Breakfast at 7 A.M. to 8:15 A.M., Lunch at 11:30 A.M. to 12:45 P.M., and Dinner at 5 P.M. to 6:15 P.M. The MDSC stated the medication administration should have been scheduled and administered 1 hour before the scheduled mealtime at 6 A.M., 10:30 A.M., and 4 P.M. per physician orders. The MDS Coordinator further stated the medication was not administered 1 hour before the scheduled meals from 5/23 to 6/6/24. An interview was conducted on 6/7/24 at 8:05 A.M. with the Director of Nursing (DON). The DON stated the physician's order to give the Carbidopa-Levodopa 1 hour before meals should have been followed. The DON further stated if the ordered medication was as 1 hr before meals, the medication should have been scheduled and administered 1 hour before the scheduled meal. A telephone interview was conducted on 6/7/24 at 2:45 P.M. with the facility's Pharmacy Consultant (PC). The PC stated the Carbidopa-Levodopa should be administered 1 hour before meals per physician orders. The PC further stated the importance of administering the medication per physician order was to ensure that the treatment plan of the physician was followed. A review of facility policy and procedures titled Administering Medications revised 4/2019 indicated Policy Statement: Medications are administered in a safe and timely manner and as prescribed .Policy Interpretation and Implementation: .4. Medications are administered in accordance with prescriber orders, including any required time frame .5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect .b. preventing potential medication or food interactions c. honoring resident choices and preferences, consistent with his/her care plan .7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility had a medication error rate of 6.67% when two medication errors occurred out of 30 opportunities during medication administration. These failures resulted in medications not given to residents in accordance with the physician's orders. Findings: 1. Resident 61 was admitted to the facility on [DATE] with diagnoses which included fracture (broken) of left femur (left hip) per facility's admission Record. Resident 61's physician's order dated 5/31/24 indicated Zinc Sulfate 220 milligrams, (mg unit of measurement) , one tablet every day for wound healing. An observation was conducted on 6/6/24 at 9:21 A.M. with License Nurse (LN) 34. LN 34 did not administer Resident 61's Zinc Sulfate during medication administration. A record review of Resident 61's Medication Administration Record (MAR) indicated, LN 34 did not administer Resident 61's Zinc Sulfate during medication administration. An interview was conducted on 6/6/24 at 3:21 P.M. with LN 34. LN 34 stated the Zinc Sulfate was not available in the medication cart. LN 34 further stated the medication should have been made available for Resident 55 to receive the prescribed medication. 2. A review of Resident 501's Physician Order dated 5/30/24 indicated Thera M Plus one tablet orally daily for supplement. During the medication pass observation on 6/6/24 at 9:47 A.M. with LN 34. LN 34 was not able to administer Thera M (brand name, multivitamins). An interview was conducted on 6/6/24 at 3:23 P.M. with LN 34. LN 34 stated Resident 501 should have received the supplement during the morning medication pass. An interview was conducted on 6/7/24 at 11:08 A.M. with the Director of Nursing, (DON) . The DON stated all prescribed medications should be given by nursing staff per physician orders. A review of facility policy and procedures titled Administering Medications revised 4/2019 indicated Policy Statement: Medications are administered in a safe and timely manner and as prescribed .Policy Interpretation and Implementation: .4. Medications are administered in accordance with prescriber orders

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure medications were securely locked inside a medication cart when a medication drawer was left open and unattended by a nursing staff. This failure had the potential for unauthorized persons to gain access to medications. Findings: During an observation on 6/4/24 at 9:27 A.M. in the facility hallway. A medication cart's drawer containing residents medications was left unlocked and unattended by a nursing staff. A joint observation and interview were conducted on 6/6/24 at 9:29 A.M. with Licensed Nurse (LN) 34. LN 34 stated the medication cart's drawer was unlocked and was unattended by staff. LN 34 further stated all medication cart's drawers should be securely locked when unattended by nursing staff to prevent unauthorized people to gain access to medications. An interview was conducted on 6/7/24 at 11:17 A.M. with the Director of Nursing (DON). The DON stated the nursing staff should always securely lock the medication carts to prevent residents and unauthorized personnel to gain access to the stored medications. A review of the facility's policy titled Administering Medications revised 4/2019, indicated, Policy: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide .

CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure food served was in a palatable, flavorful manner that maintained the nutritional value of the menu items served. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 50. Findings: During a dining observation on 6/4/24 at 12:00 P.M., the following resident food concerns occurred: - One resident reported she did not like the food that was being served (Pizza and mashed potatoes). - One resident stated, the salad sucks. - One resident stated, the food is dry. Review of the facility's Resident Council meeting minutes dated February 2024, March 2024, and April 2024 the following dietary concerns were identified: .beef and pork at dinner to tuff [sic] to eat. Soup is not good and meat to cook [sic] or under cook. Need help with menus and get food I need [sic]. Food needs more flavor. During an interview on 6/5/24 at 4:22 PM with the resident council president (Resident 3), Resident 3 stated the meat items served at the facility seemed overcooked and tough to eat. Resident 3 stated concerns about food was often discussed during the meetings and the menus were confusing with words that were hard to pronounce or foods that were unfamiliar. A review of Resident 3's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 5/5/24, indicated that Resident 3 made herself-understood or understood others, and had no cognitive (mental process involved in knowing, learning, and understanding things) deficits. Review of the facility's menu dated 6/5/24 indicated the Regular Diet was served chilled pea and mint soup, barbequed (BBQ) chicken, collard greens, garlic paprika chickpeas, yogurt gelatin dessert, and milk. The Pureed Diet was served pureed chilled pea and mint soup, pureed BBQ chicken, pureed collard greens, mashed potatoes, yogurt gelatin and milk. On 6/5/24 at 12:35 PM, a test tray observation and interview with the Dietary Supervisor (DS) and the Food and Beverage Director (FDB) were conducted. The regular diet BBQ chicken tasted dry, a little over cooked, and lacked flavor. The FDB and DS agreed the chicken was dry and the FDB stated it could have had more seasoning. During an interview on 6/6/24 at 2:58 PM with the Registered Dietitian (RD) and the DS. The RD stated the residents have had mixed reviews about the facility foods and the meals were boring. The RD further stated she heard concerns the meat was tough sometimes and confirmed one of the residents did state the chicken was dry. The DS stated she was unaware of the resident council's dietary and food concerns. The DS also stated an in-service should have been done with kitchen staff on ways to make the menu for more palatable. The RD also agreed the residents on pureed diets who received the mashed potatoes instead of the quinoa for lunch, did not receive the same nutritionally equivalent meal as the residents on a Regular diet. The RD stated the diet meals should be the same. During a review of the facility policy titled Test Trays/Meal Rounds, dated 2013, the policy indicated .It is the policy of the community to serve food that is palatable, attractive .4. Food complaints will be addressed as they arise on an individual basis.

CONCERN (D)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the dietary recommendations for the finger food diet for an unsampled resident, (Resident 60), reviewed for weight loss. This failure had the potential to negatively impact Resident 60's food intake which could further impair nutrition status and lead to weight loss. The facility census was 50. Findings: A review of Resident 60's admission Record indicated the resident was initially admitted to the facility on [DATE] with diagnoses which included, paroxysmal atrial fibrillation (an irregular heart rhythm that cause symptoms of shortness of breath, pounding heart beats, and weakness). A review of Resident 60's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 5/10/24, indicated that Resident 60 usually made herself-understood or understood others, and had moderate impairment in cognitive (mental process involved in knowing, learning, and understanding things) skills. Resident 60 required substantial or maximum (helper does MORE THAN HALF the effort) assistance with eating. A review of Resident 60's Nutritional Evaluation dated 5/9/24 completed by the facility's Registered Dietitian (RD), the evaluation indicated, .about 25%, poses high nutritional risk for continued weight loss as she has already lost 3.8# over the past 6 days. Labs reviewed reflective of anemia. Nutrition dx (diagnosis): At risk of involuntary weight loss RT (related to) poor intake and lack of self-feeding ability . A review of Resident 60's dietary progress note dated 5/13/24 completed by the Dietary Supervisor (DS), the progress note indicated, .resident eats well when meals are finger food. Will update preference to encourage better meal intake . During a dining observation of Resident 60's lunch meal tray on 6/5/24 at 12:12 P.M., Resident 60 received one ½ meat sandwich with lettuce, two chicken legs, a bowl of split pea and mint soup, a banana and 8-ounce carton of milk. During an interview with CNA 2 on 6/5/24 at 12:15 P.M., CNA 2 stated Resident 60 can eat some foods without assistance but needs assistance for others like sandwiches. During a concurrent interview and record review on 6/6/24 at 2:53 P.M. with the RD and DS, the DS stated Resident 60 preferred finger foods and was on a regular texture diet. The RD and DS reviewed the facility's Finger Food policy titled Finger Food Diet, dated 2009. The policy indicated, .Meats are sliced and placed between bread to serve as a sandwich cut into fourths prior to meal service . The RD and DS acknowledged that the sandwich served was not cut in fourths and the RD stated the resident should have received the food in the correct form to encourage food intake and prevent weight loss. Per the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, .Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death . https://www.nutritioncaremanual.org/ During a review of the facility's policy titled Scope of Service dated 2013, the policy indicated, .2. The staff is adequately trained and educated in food preparation and service .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure a staff adhered to proper infection control practice for one of 13 residents (Resident 1) when the staff did not perform hand hygiene (HH- washing hands with soap and water or use of hand sanitizer to kill microorganisms) before entering a resident's room. This failure had the potential for cross contamination (spread of germs and bacteria) and infection to residents, staff and visitors. Findings : On 6/4/24 at 9:24 A.M., an observation was conducted inside of Resident 1's room. The Medical Records Staff (MRS) entered Resident 1's room to answer the call light. The MRS did not perform HH before entering the Resident 1's room. On 6/4/24 at 9:30 A.M., an interview was conducted with the MRS. The MRS stated she should have performed HH before entering Resident 1's room. On 6/6/24 at 8:35 A.M. an interview was conducted with the Director of Staff Development (DSD). The DSD stated the MRS should have performed HH before entering Resident 1's room. The DSD further stated all staff should perform HH before entering a resident's room to prevent risk of cross contamination. On 6/6/24 at 11:25 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated the MRS should have performed HH before entering Resident 1's room to prevent cross contamination. On 6/7/24 at 9:30 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated the MRS should have performed HH before entering Resident 1's room. The DON further stated HH before entering the resident room was important to prevent cross contamination and to protect the residents. A review of the facility's policy and procedure titled Handwashing/Hand Hygiene revised 10/2023 indicated Policy: .2. All personell are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and policy review, the facility failed to ensure kitchen equipment was maintained in safe operating condition when two reach-in refrigerators and an ice machine were not maintained according to standards of practice and facility policy. This failure had the potential to expose the facility's 50 residents to potential contaminants that could cause widespread foodborne illness. Cross Reference 812 Findings: 1. During an initial kitchen tour observation on 6/4/24 at 9:41 A.M. in the health facility, a reach-in refrigerator door gasket (a gasket helps to create a vacuum and air-tight seal, forming a barrier for the cool inside your refrigerator and freeze) was worn, with tears at the top and bottom right corners and detaching on the sides. During an observation and interview on 6/4/24 at 2:45 P.M., with the Dietary Supervisor (DS) and the Food and Beverage Director (FBD) in the health facility kitchen, the DS and FBD acknowledged the torn and detached reach-in refrigerator door gasket and stated it needed to be replaced. During an observation and interview in the main production kitchen facility on 6/5/24 at 9:55 A.M. with the DS and FBD, the reach-in refrigerator used for the health facility had a heavily worn door gasket with pieces torn off the sides and detaching from the top right and bottom corners. The DS and FDB acknowledged the worn and detached door gasket on the reach-in refrigerator and the FBD stated it will be replaced. Per the 2022 Federal Food and Drug Administration (FDA) Food Code, sections 4-601.11, and Annex 4-602.13, .non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, 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 . Per the 2022 Federal FDA Food Code, section 4-202.16, titled Nonfood-Contact Surfaces, Non-FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 2. During an initial kitchen tour on 6/4/24 at 9:41 A.M., an ice machine in the main kitchen had a broken plastic missing piece on the outer right corner bin door that left a large gaping hole opening. There rubber seals in the right and left upper corners of the ice bin exterior were covered with white calcium-like deposits and were torn and detaching. The inside of the ice machine baffle (a part in the ice machine that is used to catch formed ice to land smoothly to the ice machine bin) showed some yellowish and black spotted discoloration. During a record review on 6/4/24 at 9:53 A.M. of the facility's ice machine maintenance log titled [Facility Name] ICE MACHINE LOG UNIT ID: [NAME] KITCHEN MAINTANANCE, date started 1/16/23. The maintenance log recorded filters due on 6/25, 8/21, 12/15, and 5/31. During an observation and interview on 6/4/24 at 3:19 P.M., with the DS and FBD of the ice machine in the main production kitchen, the FBD acknowledged the broken plastic piece on the ice bin and hole in the right corner, the worn rubber seals and the calcium-like deposits on the bin exterior. The FBD and the DS agreed the ice machine needed to be fixed or replaced. During an interview on 6/6/24 at 11:07 A.M., with Director of the Plant Operations (DPO). The DPO stated he expected all equipment to be working operationally and on a preventive maintenance cleaning schedule. Per the 2022 Federal FDA Food Code, section 4-602.11 titled Equipment Food-Contact Surfaces and Utensils, Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold . Per the 2022 Federal FDA Food Code, .Ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. During a review of the facility policy titled, Equipment Maintenance dated 2013, the policy indicated .It is the policy of the community to maintain the equipment according to manufacturer's instructions .1. All food service equipment will be operated, maintained, serviced and cleaned according to manufacturer's directions

CONCERN (E)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure the kitchen staff received appropriate training in food sanitation and food safety according to standards of practice and facility policy when: 1. Three dietary aides did not demonstrate the proper method of testing the sanitizer solution used for sanitization (the process of safely removing waste to prevent disease transmission and improve hygiene) on equipment and prep surfaces to prevent cross contamination. 2. Two Cooks did not correctly verbalize the 2-step cool down process for foods that require a cool down process prior to serving. 3. Staff In-services were not being conducted by a qualified kitchen staff member with the proper credentials and to carry out in-service trainings. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The facility census was 50. Cross references F812. Findings: 1. A) During the initial Skilled Nursing Facility (SNF) Health center kitchen tour on 6/4/24 at 8:56 AM, a Dishwasher Dietary Aide (DA 1) was observed using a low temperature (a dishwasher machine that uses a low heat of 140 degrees Fahrenheit in the rinse cycle) dish machine. DA 1 demonstrated how to test the chlorine solution levels needed to sanitize dishes in the dish machine with a chlorine test strip. DA 1 dipped the test strip inside the top end opening of the dish machine door. DA 1 also took a strip and dipped it inside the tank holding the dish machine solution. DA 1 stated both methods will give an accurate test of the sanitizer solution. B) During a food production kitchen tour on 6/05/24 at 11:07 A.M., an observation and interview was conducted with DA 2 at the health center section food prep area. DA 2 demonstrated how he tested the sanitizer in the red buckets. DA 2 dipped an ammonia test strip a red sanitizing bucket with ammonia solution for 16 seconds then pulled it out and stated the reading was 300-400 ppm. DA 2 stated he used the red buckets with sanitizer to wipe food prep counter surfaces, food carts, and the food production sink. DA 2 stated he does not write down the test results on a log sheet in the kitchen and did not know where the results are logged. DA 2 stated he only logged the sanitizer test levels for the residential dining areas when he works there. C) During a food production kitchen tour on 6/5/24 at 11:32 A.M., DA 3 was observed in the dishwashing station at the three compartment sink cleaning pots and pans. DA 3 stated that he needed to check the sanitation levels at the beginning of his task and throughout the day at about every two hours. DA 3 demonstrated strip testing with results at 300. DA 3 stated that it should be a 200 and stated that he would need to tell management because it was not at the level it should be. During an interview on 6/6/24 at 3:30 P.M., with the Dietary Supervisor (DS) and Registered Dietitian (RD), the DS stated that a Contractor/Vendor did an in-service with the kitchen staff on the use of test strips for testing the sanitizer solution. The DS stated the kitchen staff were taught to use the appropriate process when testing sanitizer levels in for the dish machine and red the buckets. The DS and RD stated they expected the kitchen staff to follow the correct process for testing the sanitizer levels in the dish machine and the red sanitizer buckets. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-501.116, titled Warewashing Equipment, Determining Chemical Sanitizer Concentration, .Concentration of the sanitizing solution shall be accurately determined by using a .other device . During a review of the facility's sanitation log document titled POTS AND PANS DISHWAHER MACHINE SANTITZING SOLUTION STRENGTH LOG, dated June 2024, the sanitation testing was not recorded or signed during the AM shift on 6/5/24. The 6/1/24 through 6/4/24 red bucket sanitizer test results were recorded as 200 parts per million (ppm). During a review of the facility's policy and procedure (P&P) titled, SANITATION, dated 2013, the P&P indicated .4. Food Service personnel will follow cleaning schedules and procedures in all areas for which they are responsible . During a review of the facility's policy and procedure (P&P) titled, DISHWASHING and SANITIZING, dated 2015, the P&P indicated .Proper dishwashing and sanitizing is necessary in the prevention of foodborne diseases . 2. During an interview in the production kitchen on 6/5/24 at 9:41 AM with [NAME] (CK) 1, CK 1 stated he does not always cook the meats but if he were to cook them, he would use the cool down process. CK 1 stated the cool down process was cooking the meat to 170 degrees then cool it down to 41 degrees in four hours. CK 1 stated he used a blast chiller machine to cool down foods but he did not know how long it took to cool down the foods. CK 1 stated if the blast chiller machine was not working he would have to use a cool down process. During an interview on 6/6/24 2:36 P.M. with the DS and RD, both the DS and RD stated they expected the Cooks to know the proper methods to safely cook and cool down foods. According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 3-501.14, titled Cooling, indicated .Bacteria rapidly grows between the temperatures of 40 degrees and 140 degrees Fahrenheit (F). Therefore, the cool down process is a method to prevent bacteria growth by safely reducing the temperature of cooked and prepared foods for later consumption. The Federal FDA Food Code identifies cooling as an essential control measure for food safety, particularly after cooking meats or preparing perishable foods with ingredients that are at ambient temperatures. When cooling cooked foods, after it reaches a safe minimum final internal cooking temperature (> than 145 degrees F), within two hours the temperature shall reach 70 degrees F or less, and within an additional four hours, it should reach 41 degrees F or less. For foods prepared with ingredients at ambient temperature, such as canned tuna, the food shall be cooled to a temperature of 41 degrees F or less within 4 hours. During a review of the facility's policy and procedure (P&P), FOOD HANDLING GUIDELINES (HACCP) undated, indicated .Potentially hazardous food shall be cooled from 140*F (60*C) to 70 (21*C) as measured at its center within two hours from 70*F (21*C) to 41*F (5*C) within an additional four hours for a total cooling time of six hours . 3. During an interview on 6/5/24 at 11:35 A.M., with the Sous Chef (SC) in the 2nd floor kitchen dishwashing station. The SC stated an outside contractor [Contractor Name] was the one who does in-services and that he also did in-service for kitchen sanitation. The SC stated he did not have a Certified Dietary Manager (CDM) credentials. During an interview on 6/6/24 2:36 P.M., with the Registered Dietitian (RD), the RD stated the kitchen sanitation and food safety in-service trainings should be provided by a qualified kitchen staff member including a RD or CDM. During an interview and record review on 6/6/24 2:40 P.M. with the DS, the DS acknowledged a document titled SHOW TIME dated 6/21/21 indicated .Refrigerators the inside and outside, at the same time refrigerator gaskets needs to be clean after lunch and dinner . The DS stated that that this was the in-service for refrigerator gaskets by the SC. The DS stated there was no documentation of specific kitchen staff in-services conducted between January 2021 and January 2024 on food safety and sanitation topics by a qualified kitchen staff member. The DS acknowledged the SC did not have the CDM credentials. During a review of the facility's kitchen staff in-services binder, there was no documentation of in-services on food safety and sanitation to support in-services provided to staff from 6/21/19 until 4/24/24. During a review of the facility policy titled, IN-SERVICE EDUCATION dated 2013 indicated .1. In-service education will be provided to all food service personnel at least monthly. 2. Topics will include, but not limited to, the following: a. Sanitation/Food borne illness .

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, staff interview, and document review, the facility failed to ensure an emergency menu with the appropriate food and water supplies was developed to meet the nutritional and therapeutic needs of the residents, according to facility policy and regulation standards. This failure had the potential to result in further compromising the nutritional and health status of the facility's 50 medically vulnerable residents, or its 97 licensed beds. Cross reference F804 Findings: During a concurrent observation and interview on 6/6/24 starting at 9:11 A.M of the facility's emergency food and water supplies, the AADM (Acting Administrator), the STD (Safety and Transportation Director), Dietary Supervisor (DS), Food and Beverage Director (FBD), Executive Chef (EC), and Sous Chef (SC) stated the facility did not have a therapeutic menu for three days to feed the facility 50 residents. The AADM, DS, and SC the facility abides with the regulations to have a 3-day food supply. The AADM stated the skilled nursing facility-health center's 3-day food supply was combined with all the emergency foods for the entire senior residential care community buildings. There were 11 pallets of 60 cases per pallet with 12 units of one-liter (1L) containers of water. There were 15 per tier and 12 per box of rehydrated (dried foods that require water to turn into a nutritious food) meals. The AADM and DS acknowledged the meal count needed to be calculated for health center facility beds, and the water supply needed to be calculated for the residents and enough to rehydrated meals. The DS stated there need to have 873 meals to feed 97 residents, three meals per day, for 3 days. During a record review and interview on 6/6/24 at 3:17 P.M. with the RD and DS, both the RD and DS acknowledged the day 1 Emergency menu plan list of foods did not include the facility residents on therapeutic diets or clearly provide instructions for how to feed residents on therapeutic and textured diets with appropriate tools needs. The RD stated it was important to have a sufficient menu to meet the medical and therapeutic needs of the health center facility residents and include staff and visitors, in the event of an emergency. Review of the untitled and undated facility document indicated In the event of a loss of utilities, water may be unavailable as it may be contaminated and in need to purification. In either case, the dietary department will need to have on hand an adequate supply of water. This water will be used for cooking, cleaning, and drinking by residents and staff. A minimum of three-day supply will be available. The quantity of water that is needed has been determined by the following calculation: MRE's (meals ready to eat) =48 oz of water per #10 can. We have 124 cans of MRE's total for Health Center. The total water requirement for MRE's will be 5,952 ounces of water or 46.5 gallons. (176.28 liters). TOTAL NEED = 346.5 Gallons . Review of the undated facility document titled Disaster indicated In the event of a disaster and the utilization of our disaster supply is needed, you will be expected to know what to do so we can continue to provide meals to the residents and staff onsite . Review of the 2013 and 2015 facility policy and procedure (P&P) titled Menu Planning indicated It is the policy of the community that menus be planned in advanced .4. All menus will be approved by the Consultant Dietitian. 5. Menus will be planned with consideration of cultural background and food habits of residents. 6. All meal substitutions and menu changes will be documented on the dietary census . Guidelines .5. Therapeutic diets will be planned and served in accordance with the state-approved Diet Manual. Therapeutic diets must be prescribed by the attending physician. 6. A preplanned emergency menu will be available. These food items must be stored in a separate location and rotated with new product every 12 months . Review of the 2015 facility policy and procedure (P&P) titled Therapeutic Menu Planning indicated .Purpose: Therapeutic diets are also called modified or special diets and indicate a change from a regular diet. Often times, there is a problem in providing adequate nutritional care for geriatric residents. As a result of many years of living (often years of abuse), there are changes that occur in organ systems of the geriatric resident. These changes affect the planning of nutritional care for both the health center and independent residents .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. Two ice machines were not cleaned and maintained according to manufacturer's instructions. 2. Three ice machines and one dish machine did not have a proper air gap system to adequately prevent backflow of contaminated fluids. 3. Two reach-in refrigerators used to store facility resident food contained a brownish colored sticky grimy debris on the door gasket (inner rubber sealant that helps to create a vacuum and air-tight seal, forming a barrier to cool the inside of the refrigerator and freezer); and one reach-in refrigerator door had several black and grayish spots on the inside door panel. 4. Four green, three white and three red rubber cutting boards had white discoloration and severely worn with large cuts and groves in the center. 5. Multiple food items including individual desserts, were left uncovered during transport from the production kitchen to the health center kitchen for facility residents. These failures had the potential to cause widespread food borne illness among all 50 residents who receive food from the kitchen. Cross reference F802 Findings: 1. During an observation and interview on 6/4/24 at 3:10 P.M. with the facility contractor (FC) in the health facility kitchen, the FC stated does maintenance cleaning every month for the facility's ice machines in the kitchens and on the units. FC demonstrated how he cleaned the Health center kitchen ice machine and stated I remove the spout from the ice machine or the top, and clean with a cleaning solution. Per the FC, he uses about 12 ounces of water in a bowl to dissolve a sanitizer solution packet, then pours the mixture in the top of the ice making part. Next, he stated he pours delime wash solution in the top, then flushes it with water x3 times to catch the dirty water. Finally, he stated he runs another sanitizer/water mixture through the machine for 30 minutes to make sure the drain is clean and before new water is turned on to make ice. The FC stated he used a clean rag from the red sanitizer bucket to wipe down the outside of the ice machine, along with the side filter, and inner condenser. A record review on 6/4/24 at 9:53 A.M. of the health center kitchen's ice machine maintenance log titled [Facility Name] ICE MACHINE LOG UNIT ID: [NAME] KITCHEN MAINTANANCE, indicated the last cleaning date started 1/16/23. The maintenance log recorded filters due on 6/25/23, 8/21/23, 12/15/23, and 5/31/23. Per the maintenance log indicated filters would need to be cleaned twice a month. During a main production kitchen observation and interview tour on 6/04/24 at 3:30 PM with the Executive Chef (EC), Dietary Supervisor (DS), Food and Beverage Director (FBD), and the FC, the ice machine had some yellow pinkish colored spots on the inside left and right side corner wall touching the baffle (a part in the ice machine that is used to catch formed ice to land smoothly to the ice machine bin). The FC then lifted the ice machine bin door and there was small black speckled sized debris visible inside five ice cubes siting at the top of the pile of ice. When the FC opened the top ice machine cover, the ice machine curtain had black and grayish colored mold looking spots on the top edges. The FC demonstrated how he cleaned the ice machine and stated he removed the curtain (front panel that is used as an insulation) and water tray of the ice machine, then would pour a cup of water mixed with three ounces of ice machine delime cleaning solution in the top ice making part of the machine to run through the grid. The filters connected to the ice machine had a label that stated installed 3/21 without a replacement date. Per the FC, the [Contractor Business Name] does not clean the baffle inside the ice bin or change out the water filters. The DS, FSB, and EC each acknowledged all the dirty areas with discolored debris in the ice machine, including the ice cubes with black speckles inside them, and the expired water filters attached to the ice machine. Per the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 4-602.11 titled Equipment Food-Contact Surfaces and Utensils, .Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to prevent the accumulation of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . During a review of the facility policy titled, FOOD STORAGE dated 2013, the policy indicated .9. All refrigeration equipment is thoroughly scrubbed weekly and cleaned daily . 2. During the initial kitchen tour observation of the health center kitchen on 6/4/24 at 8:45 AM, the ice machine air gap system was piped directly through a food production sink pipe underneath the sink station. During an initial tour observation on 6/4/24 at 9:38 AM of the main production kitchen ice machine air gap, a white narrow PVC (polyvinyl chlorinated) pipe attached to the ice machine was extended into a floor sink drain next to the ice machine. During a main production kitchen observation and interview on 6/04/24 at 3:49 PM with the DS and FBD of the main production kitchen ice machine air gap system, the DS and FBD acknowledged the white PVC pipe was pushed down into the floor sink drain. The FBD stated it should be raised higher. During an observation in the main kitchen of the dish machine air gap system on 6/6/24 at 11:24 AM, the dish machine had a copper pipe extended directly from the back of the machine into the left-side floor sink drain. During an observation in the nurse's station 2 nourishment room ice machine air gap system on 6/6/24 at 2:24 PM, the ice machine had a long white PVC extended directly from the back of the machine into the front right side floor sink drain. During an interview on 6/6/24 at 11:07 AM with the Director of Plant Operations (DPO), the DPO reviewed the photos or air gaps in the main kitchen and health center kitchen. The PO agreed that there needed to be an air gap space between the floor sink drain and the pipes. Ice machine in main kitchen. He said he expects all equipment to be working operationally and on a preventive maintenance cleaning schedule. Per the 2022 Federal FDA Food Code, section 5-202.13 titled Backflow Prevention, Air, .An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, Or nonfood EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). 3. During an observation and interview in the health facility kitchen on 6/5/24 at 9:25 A.M. with the DS and EC, the reach-in refrigerator door gasket had two lines of brown sticky grime and debris along the left, right, and top of the gasket. The DS and EC acknowledged the dirty grime on the gasket inner door, and both stated it should be cleaned. During an observation on 6/5/24 at 9:41 AM in the main production kitchen's reach-in refrigerator, the door gasket had brown and black sticky grime on each side and several black and grayish spots on the inside door panel. The DS and EC acknowledged the dirty grime on the gasket inner door, and both stated it should be cleaned. During an interview on 6/6/24 2:36 P.M., with the DS and RD, the RD stated that sanitation audits were started in April 2024 by the DS. The RD stated she was unaware of the kitchen cleaning and sanitation concerns identified in both the health center kitchen and the main production kitchen. The DS stated all the reach-in refrigerator door gaskets should have been on both kitchens' daily and weekly cleaning schedules. During a record review of a health center kitchen staff in-service titled SHOWTIME, dated 6/21/19, the policy indicated .refrigerators the inside and outside, at the same time refrigerators gaskets needs to be clean . The facility's cleaning schedules and logs for the main production kitchen and health center kitchen reach-in refrigerators was requested but not provided. During a review of the facility policy titled; FOOD STORAGE dated 2013 indicated .1. Food storage areas shall be clean at all times [sic] . 2. All exposed foods should be tightly covered.9. All refrigeration equipment is thoroughly scrubbed weekly, and cleaned daily . 4. During a production kitchen observation on 6/5/24 at 9:34 A.M. with the DS, FDB and EC, the health center food prep station had a rack with twelve multi-colored rubber cutting boards stored underneath the counter. There were four green, three white and three red cutting boards stored with heavily worn deep knife cuts and groves, along with large white discoloration in the center of the boards. The FDB, DS, and EC acknowledged the discoloration on the cutting boards and heavily worn areas and stated it was from the sanitizer in the high temperature dish machine. The FDB and DS stated the cutting boards needed to be replaced. Per the 2022 Federal Food Code, Section 4-601.11, titled Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . During a review of the facility policy titled, FOOD STORAGE dated 2013 indicated .1. Plasticware, China, and glassware that cannot be properly sanitized due to chips or cracks will be discarded . 5. During a production kitchen observation on 6/5/24 at 9:45 A.M. with the DS and EC of the health facility reach-in refrigerator, a long metal tray with 20 individually sliced chocolate mini dessert cakes on separate plates stored uncovered on the 5th shelf row of the rack. The 6th shelf had a tray with additional slices of uncovered. The FDB and DS stated that the mini-dessert cakes needed to be covered to prevent cross contamination. During an observation on 6/6/24 at 3:49 P.M. at the elevator kitchen leading to the main production kitchen, two dietary aides (DAs) were seen pushing a food cart with a tray of uncovered cookies on the bottom shelf of the open food cart and additional desserts on another tray of uncovered on the cart. Both DAs stated they were in a rush to get the food item from the main production kitchen to the health center kitchen and declined an interview. During a review of the facility policy, titled FOOD STORAGE, dated 2013, the policy indicated .1. Food storage areas shall be clean at all times [sic] . 2. All exposed foods should be tightly covered .

CONCERN (E)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected multiple residents

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Based on record review, observation, and interview, the facility failed to ensure implementation of their policy regarding use and storage of foods brought in from the outside food to ensure safe and sanitary storage, handling, and consumption was followed. This failure had the potential to contaminate residents' outside food stored at the facility, which may result in foodborne illness. The facility census was 50. Findings: During a concurrent interview and observation on 6/5/24 at 4:24 P.M. with Certified Nursing Assistant (CNA) 1, at nursing station 2, CNA 1 stated outside food or food brought in by family members for residents is stored in the nursing station nourishment room in the fridge. CNA 1 stated food items must be labeled with the resident's name and date on the container to identify who the items belong to. The CNA stated that outside food items should not be kept more than a week. An observation of the nourishment room refrigerator with CNA 1 indicated a large 32-ounce bottle of unopened orange juice labeled with a room number, and best if used by 10/2023. CNA 1 stated the orange juice was not correctly labeled and was expired. During an interview on 6/6/24 at 10:29 A.M. with the Director of staff Development (DSD), the DSD stated outside food items brought in for residents should be signed, dated, and discarded after 72 hours. The DSD stated she did not specifically provide in-service trainings to the nursing staff regarding outside food and/or food brought in by family members. The DSD stated, I agree that we should have an in-service on our outside food policy it should be discarded within 72 hours and not one week. The DSD was notified regarding a bottle of expired orange juice was left in the nourishment fridge that was only labeled with a resident's room number. The DSD stated she would not have thrown away the orange juice if it was sealed. During an interview with the Director of Nursing (DON) on 6/6/24 at 03:59 P.M., the DON stated outside foods brought in by family for residents should not be stored at the fridge by the nursing station and should be in the dining room in a separate resident nourishment fridge. The DON stated they need to update their policy to reflect the correct practice to prevent cross contamination with items that should not be stored in the nursing fridge. The DON stated her expectations for expired food items is it should be treated like medications and thrown away to prevent food-borne illnesses. The DON stated nursing staff should know to discard any outside food items within 72 hours. During a review of the facility policy and procedure (P&P) titled Foods Brought in by Family/Visitors dated 2013, the P&P indicated .Foods that must be kept under refrigeration must be labeled with the resident's name, room number, and date. These food items should be stored in the nurses' refrigerator. Foods will be discarded within 72 hours . During a review of the facility policy and procedure (P&P) titled Outside Food dated 2015, the P&P indicated .5. Food items will not be stored in the medication refrigerators .

Mar 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 3 of 3 Residents were not cared for according to their physician orders and plan of care when staff failed to administer medications to treat chronic conditions, as ordered by physicians. This failure had the potential to have negative affect on residents health and placed residents at risk. Findings: On 1/26/24 a complaint was received that on 1/14/24, day shift medications were not received for a group of residents. On 2/8/24 at 4:10 P.M., an interview was conducted with the Director of Nursing (DON) the Administrator (ADM), and the Director of Staff Development (DSD). The DON stated that she was aware of two nurse call-ins (would not arrive for work) on the evening of 1/13/24, and was able to cover one shift with a nurse from a staffing agency. On 1/14/24 the DON was notified approximately 7-7:30 A.M. that the nurse from the agency had not shown up. There were two nurses on the unit for the 60 residents. The DON reports she directed the nurses to each take half of the residents for care, while she made calls to get another staff member. This was unsuccessful. The DON further stated that she was notified when the next shift came on that there were residents that did not receive their medications for the eight-hour day shift. On February 9, 2024, documentation was reviewed of chart notes for 11 affected residents that reflected the MD was notified of missing medications, no new orders, continue to monitor. On February 9, 2024, a request was made for the specific medications that were missed on January 14, 2024. On February 29, 2024, a record review of Resident 1 was conducted. According to the admission record, Resident 1 was admitted on [DATE] with health conditions that included: orthostatic hypotension (a sudden drop in blood pressure with a change in position that may cause dizziness, fainting); paroxysmal atrial fibrillation (an irregular heart rhythm that causes symptoms of fainting or dizziness and increased risk of blood clots, leading to heart attack or stroke); right heart failure (blood backs up in circulation causing shortness of breath, swelling in the feet or legs); diastolic (congestive) heart failure( a chronic incurable condition where the heart pumps ineffectively, causing fluid build up in the lungs and lower extremities-symptoms include shortness of breath lying down, fatigue, difficulty breathing, swelling in the legs and feet); primary pulmonary hypertension (a rare disorder of high blood pressure in the blood vessels between the lungs and the heart – symptoms include shortness of breath, chest pain, fatigue). Resident 1 ' s physician order, dated 1/8/24, for Digoxin (a medication to strengthen the heart beat and to promote a regular rhythm), give 125 mcg orally every other day for congestive heart failure. The pulse rate was also monitored for this medication. This dose was given as ordered 1/12/24, and the pulse recorded was 74; not given on 1/14/24, and given as ordered on 1/16/24 and the pulse recorded was 118 – normal pulse is between 60 - 80. Resident #6 went three days without this medication. According to the manufacturer, if a dose is missed, take it as soon as possible, or skip the dose if the next dose is due within 12 hours. Resident 1 ' s physician order dated 1/8/24 for Empagliflozin (a medication to lower the risk of heart attack, stroke, or death from heart failure), give 10mg orally once daily – not given on 1/14/24 9:00 A.M. Per the manufacturer, if a dose is missed, take it as soon as you can, not if it is almost time for the next dose. Resident 1 ' s physician ' s order dated 1/8/24 for Bumex (a medication used to treat fluid retention in people with heart failure), give 4 mg orally, twice daily – not given 1/9/24 at 5:00 P.M. and not given 1/14/24 at 9:00 A.M. Resident 1 ' s physician ' s order dated 1/7/24 for Heparin Sodium (a medication to prevent or treat blood clots, depending on the dose given), give 5,000 units SQ (sub cutaneous, under the skin) twice daily – not given 1/9/24 at 5:00 P.M. and not given 1/14/24 at 9:00 A.M. Per the manufacturer, call the physician if a dose is missed. Resident 1 ' s physician ' s order dated 1/8/24, for Spironolactone ( a medication to decrease fluid retention in people with heart failure), give 25mg orally twice daily – not given 1/9/24 at 5:00 P.M. and not given 1/14/24 at 9:00 A.M. Resident 1 ' s physician ' s order dated 1/7/24 for Midodrine (a medication that treats low blood pressure by constricting/narrowing the blood vessels), give 5 mg three times a day, hold (do not give) if SBP (a measurement of blood pressure) is less than 140 – not given 1/14/24 at 11:00 A.M. On February 29, 2024 Resident 2 ' s medical record was reviewed. Resident 2 ' s admission Record indicated Resident 2 was admitted on [DATE] with health conditions that included: Orthostatic hypotension (a sudden drop in blood pressure with a change in position, that may cause dizziness, fainting); heart failure (a lifelong condition where the heart muscle cannot pump well enough to meet the body ' s needs for blood and oxygen – symptoms are fatigue, edema -swelling of legs, shortness of breath,); atrial fibrillation (the upper chambers of the heart are not beating in sync with the lower chambers, causing fatigue, shortness of breath, and risk for blood clots); aortic and mitral valve insufficiency (blood flows backwards into the heart, with symptoms of chest pain, fatigue, shortness of breath, and risk for blood clots). Resident 2 ' s physician ' s order dated 12/26/23 for Amiodarone (a medication to keep the heart beating regularly, prescribed for people with life-threatening heart rhythm disorders), give 200 mg tablet orally once daily – not given 1/14/24. Physician ' s order dated 12/26/23 for Pradaxa (a medication for heart rhythm disorders, to minimize the risk of clots) give 110mg orally twice daily – not given 1/9/24 at 5:00 P.M. and not given 1/14/24 at 9:00 A.M. According to the manufacturer ' s guidelines, if a dose is missed, it should be taken as soon as possible, unless it is within 6 hours of the next dose. Physician ' s order dated 12/28/23, for Midodrine HCl (a medication that treats low blood pressure by narrowing blood vessels), give 5 mg tablet, two tablets, orally, three times a day. Hold (do not give) if SBP (a blood pressure measurement) is less than 130 – not given on 1/14/24 11:00 A.M. dose. On February 29, 2024, Resident 3 ' s medical record was reviewed. Resident 3 ' s admission Record indicated Resident 3 was admitted on [DATE], with health conditions that included: typical atrial flutter (a short in the electrical system of the heart, causing the upper chambers to beat very rapidly); paroxysmal atrial fibrillation (the upper chambers of the heart are not beating in sync with the lower chambers, causing fatigue, shortness of breath, and risk for blood clots, leading to stroke or heart attack); aortic and mitral valve insufficiency (blood flows backwards into the heart, with symptoms including chest pain, fatigue, shortness of breath and risk for blood clots, leading to stroke or heart attack). Resident 3 ' s physician ' s order dated 4/21/23 for Apixaban (a medication used to lower the risk of stroke in people with atrial fibrillation), 2.5 mg orally twice daily. Not given on 1/9/24 5:00 P.M. dose, and not given on 1/14/24 9 A.M. dose. According to the manufacturer, if a dose is missed, take it on the same day it is remembered, and take the next dose at the regular time. Stay on the twice daily dose schedule. Resident 3 ' s physician ' s orders dated 12/28/23 for Isosorbide Mononitrate ER (a medication that dilates blood vessels, making it easier for the heart to pump, and reducing chest pain), give 30 mg orally daily – not given 1/14/24. Resident 3 ' s physician ' s orders dated 12/28/23 for Metoprolol Succinate ER (a medication to treat high blood pressure), 25 mg, give 50mg orally daily – not given 1/14/24. Resident 3 ' s physician ' s orders dated 2/28/23 for Cilostazol (a medication to relax the blood vessels, especially in the legs, and decrease blood clot formation) give 100mg orally twice daily – not given on 1/9/24 at 5:00 P.M. and not given on 1/14/24 at 9:00 A.M. A joint interview was held with the ADM and DON on 2/29/24 at 11:25 A.M. The ADM and DON both stated that the medication errors were addressed with nursing staff only, and not in stand up. The ADM and DON further state the issue will be brought to the next QAPI (quality control) meeting in April. A concurrent record review of January 2024 eMARs and interview was held with the DON on 2/29/24 at 12:20 P.M. The DON stated she was unaware of medications not given on the evening of 1/9/24 for Resident 1, Resident 2, and Resident 3. The DON stated that to prevent future occurrences of not administering medications as ordered by the physician, all nurses had been educated regarding the importance of medication administration as ordered by the physician. This education was informal at change of shift huddles, with no written record of education given. The DON stated that nothing was given to the Director of Staff Development (DSD) for new hire orientation of licensed staff. In a follow up interview on 2/29/24 at 4:30 P.M. the DON further stated her expectation the physician and responsible party would be notified right away of medications not given, but the nurses should have worked together to ensure all medications were given to all the residents as the DON directed. When the direction was given to staff, the DON stated the nurse on the floor did say that it was do-able. The DON stated that some medications - cardiac medications, insulin – would possibly have severe effects (on resident's health) if missed. The facility Policy and Procedure titled Administering Medications, dated April 2019, was reviewed. It reflects: the Policy Statement Medications are administered in a safe and timely manner, and as prescribed. .6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Jul 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Provide adequate supervision to a resident at risk for falls, and 2. Comply with a facility policy to thoroughly investigate a fall. As a result, Resident 1had an unwitnessed fall, fractured a rib, and the facility did not evaluate the reason for the fall. Findings: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses to include a hip fracture (broken hip) and dementia (the loss of the ability to think, remember and reason), per the admission Record. On 7/10/23, a record review was conducted. On 6/24/23, Resident 1's Fall Risk Assessment was completed by licensed nurse (LN) 1. LN 1 indicated Resident 1 was at high risk for falls due to her history of falling at home, and due to her forgetting her physical limitations. LN 1 obtained a physician's order for a bed alarm (an alarm placed on a bed which sounds when a resident leaves the bed). On 7/5/23, Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool for cognition) score was 10, indicating moderate impairment. Per a nurses' progress note, dated 6/30/23 at 3:30 P.M., LN 1 documented that on Resident 1 was found sitting on the floor outside of a room across the hallway and one room down from her own room. Per LN 1, Resident 1 was unable to explain how she had fallen. LN 1 documented Resident 1's bed alarm was, .activated and faintly heard from far . On 7/10/23 at 11:40 A.M., a concurrent interview and record review was conducted with LN 2. LN 2 stated when a resident was identified as high risk for falling, the facility obtained an order for a bed alarm, and mats for the sides of the bed, and frequent observation by staff. LN 2 stated since the fall, Resident 1 had been moved to a room near the nurses' station where staff could monitor her closely. LN 2 stated she did not know why Resident 1 was not placed in a room close to the nurses' station upon admission, despite the fall risk being assessed as high. LN 2 stated it was the responsibility of the nurses to assess whether the bed alarm was set correctly. On 7/10/23 at 12:15 P.M., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1 in Resident 1's room. A bed alarm was viewed near Resident 1's bedside. CNA 1 demonstrated how the alarm worked by sitting on Resident 1's bed, turning the alarm on, then standing up. An alarm sounded, a low volume beeping. CNA 1 stated the alarm was set on low volume. CNA 1 stated she believed the low volume was the correct setting for nighttime, and the volume should be set on high for daytime. CNA 1 stated she does not remember an inservice explaining when to use low or high volume on the alarm. CNA 1 stated she was not working the day Resident 1 fell but was told by coworkers she had been moved closer to the nurses' station to be closer to staff members. CNA 1 stated it was the both the CNAs' job and the nurses' job to ensure the bed alarm was set correctly, and could be heard. On 7/10/23 at 12:30 P.M., an observation of facility rooms was conducted. Resident 1's first assigned room was five rooms away from Nurses' Station 2, and not visible from either Nurses' Station 2 or Nurses' Station 1. On 7/10/23 at 12:40 P.M., an interview was conducted with Resident 1. Resident 1 was seated in a wheelchair at the nurses' station watching a video. Resident 1 stated she did not remember falling in the hallway. 2. Per a Fall Scene Investigation Report, dated 6/30/23 and authored by LN 1, an alarm was in use at the time of the fall. Box 13 of the Fall Scene Investigation Report queried whether an alarm was being used at the time of the fall. LN 1 checked Yes. Box 13's next question asked, if yes, was it working correctly? The answer was left blank. Per an Interdisciplinary Team (IDT) note, dated 7/3/23, the IDT determined their plan to keep Resident 1 safe from falls based on LN 1's documentation. The IDT did not document any concerns regarding missing information, reasons why the bed alarm was not heard by staff, or rationale for initial room placement five rooms away from Nurses Station 2. LN 1 was not available for an interview. On 7/10/23 at 11:40 A.M., a concurrent interview and record review was conducted with LN 2. LN 2 reviewed the Fall Scene Investigation Report, and stated it was important to complete the Report thoroughly to make improvements and keep the residents safe from injury. On 7/10/23 at 12:05 P.M., a concurrent interview and record review was conducted with the Administrator (Admin). The Admin reviewed the documents and stated the purpose of the IDT meeting was to ensure policies had been followed, to get input from the team about what might have happened, and to determine how to resolve the issue. The Admin stated the forms were not complete and the IDT should have followed up with LN 1. On 7/10/23 at 1:45 P.M., a concurrent interview and record review was conducted with LN 3. LN 3 stated she was working on 6/30/23 when Resident 1 fell, but she was not assigned to her. LN 3 stated on 6/30/23 she was walking behind LN 1, when they both saw Resident 1 on the floor. LN 3 stated they checked Resident 1 for injury while they waited for the paramedics to arrive. LN 3 reviewed the Fall Scene Investigation Report and LN 1's nurses note and stated she would have documented the assessment. LN 3 stated she did not recall hearing an alarm, or discussing the bed alarm with LN 1. LN 3 stated, We need to be more clear. We should have documented the alarm and the assessment. Per a facility policy, revised June 2023 and titled Fall Prevention and Management, .6. Residents who are identified as high risk will .individualized precautions will be noted to avoid falls .Steps following a fall: .4. Documentation will include incident report/event report completion, the nurse's notes, a fall investigation .6. Review and update causative factors .and fall assessment will be completed 8. Nursing staff will make appropriate interventions upon the completion of the report to prevent reoccurrence of a fall or to minimize injury .10. IDT risk review of falls should occur .within twenty four (24) hours of the event .Staff Development: .2. Licensed staff will receive training in the use of the fall risk tool, documentation .3. Ongoing training will include .adaptive devices .Quality Assurance 1. A Risk Team will review falls at least weekly to prevent reoccurrence and/or prevent injury .3. Falls will be tracked and trended for .root cause analysis and system causes .

Jun 2023 8 deficiencies

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and ensure one of 13 sampled residents (Resident 2) who kept medications at bedside had a physician order, care plan, and an Interdisciplinary Team (IDT, a group of staff meeting and working together for the benefit of the resident) assessment to determine if safe and clinically appropriate for the resident to self-administer medications. These failures had the potential to result in unsafe medication administration and could have allowed other residents to access unlocked medications. Findings: A review of Resident 2's medical record indicated she was admitted to the facility on [DATE]. During a medication pass observation for Resident 2 on 6/5/23, at 9:15 A.M., Licensed Nurse (LN 24) was observed administering six medications including baclofen (used to treat muscle spasms) tablet, FeroSul (an iron supplement) tablet, amlodipine (used to treat high blood pressure) tablet, loratadine (used to treat allergies) tablet, vitamin B12 (used as a vitamin supplement) tablet, and oxycodone (used for pain) tablet. A review of Resident 2's medical record indicated the following physician's orders: - Artificial Tears Solution 0.4 %, Instill 1 drop in both eyes in the morning for dry eyes, dated 11/14/19; - Polyethylene Glycol 3350 Kit (generic for Miralax, used for constipation), Give 1 packet by mouth in the morning for constipation, dated 4/24/22. During an interview on 6/5/23, at 3:08 P.M., with LN 24, when asked if the Artificial Tears eye drops were administered to Resident 2 during the morning medication pass on 6/5/23, LN 24 stated, the resident wants to do it herself and the bottle stays at the beside. Then LN 24 retrieved a bottle of Systane Lubricant Eye Drops Ultra High Performance Dry Eye Relief from the resident's room, the bottle had a date 6/1/23 written with black marker. LN 24 stated, 6/1/23 is the date opened when the resident's family bought the eye drops from home. When asked how the self-administration of the Systane eye drops were documented in the medication administration record (MAR), LN 24 stated, [doctor] ordered under 'Artificial Tears', I chart under that order. When asked if the Miralax was administered to Resident 2 during the morning medication pass on 6/5/23, LN 24 stated, I give her the [Miralax] powder from the packet placed in a medicine cup, she will mix the powder into her orange [juice] . and take it with breakfast. When asked to describe the facility's process for resident self-administration of medications, LN 24 stated, I am not sure about the policy. I will ask. During an interview on 6/5/23, at 4:15 P.M., with Resident 2, she stated, I asked for the eye drops to keep at my bedside .They did not show me how to use [the eye drops], I know how to use them . Resident 2 had a BIMS of 13 (Brief Interview for Mental Status, is an assessment tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment), which indicated she was cognitively intact. During an interview on 6/5/23, at 4:21 P.M., with LN 27, when asked to describe the facility's process for resident self-administration of medications, LN 27 stated, first need an assessment to see if the resident is qualified, the Director of Nursing (DON) and Registered Nurse coordinate with the physician, then need a demonstration from the resident, a care plan, physician orders, and consent. When asked if aware of any residents in the facility that self-administer medications, LN 27 stated, I am not aware of any residents right now. During an interview on 6/6/23, at 8:53 A.M., with LN 25, when asked to describe the facility's process for resident self-administration of medications, LN 25 stated, there is a self-administration form and competency for the resident, then nurses educate the resident, the resident demonstrates competency, and nurses notify the doctor. When asked if aware of any residents that self-administer medications at the facility, LN 25 stated, Resident 2 does her own eye drops. I have not had [Resident 2], [assessment] form should be in her chart under assessment. During an interview on 6/6/23, at 9:05 A.M., with LN 22, when asked to describe the facility's process for resident self-administration of medications, LN 22 stated, [Resident 2] wanted to do it herself, eye drops and Miralax. When asked if a self-administration assessment was completed prior to the resident self-administration of eye drops and Miralax, LN 22 stated, She's been doing it for awhile .Sometimes she asked me to leave the powder so she can mix herself .I leave the powder with her and come back. When asked if nurses educated the resident how to take the Miralax, LN 22 stated, We showed her the 8 ounce cup and we showed her how to pour 8 ounces of water, how to stir and dissolve [Miralax powder]. When asked if resident education was documented, LN 22 stated, I am not sure. When asked again, if a self-administration assessment was completed, LN 22 stated, I am not sure. LN 22 confirmed, no documentation of a care plan or assessments related to the self-administration of medications were found in Resident 2's medical record. During a concurrent interview and record review on 6/6/23, at 9:36 A.M., with LN 22, Resident 2's Medication Self-Administration Evaluation dated 2/26/19, 11/13/19, and 12/19/19 were reviewed. LN 22 stated, the Medication Self-Administration Evaluation indicated: - On 2/26/19, Resident agreeable for the nurses to administer her meds.; - On 11/13/19, Unable [to self-administer] and does not say resident can self-administer medications.; - On 12/19/19, [Assessment] incomplete, does not state resident able to self-administer medications. When asked if medications should be left at the bedside for Resident 2 to self-administer, LN 22 stated, The right thing is we should not leave .any medications .at the bedside . During a follow-up interview with LN 22, on 6/6/23, at 11:43 A.M., LN 22 confirmed no documentation of an IDT assessment related to the self-administration was found in Resident 2's medical record. During an interview with the DON on 6/8/23, at 1:24 P.M., when asked to describe the facility's process for resident self-administration of medications, the DON stated, a self-assessment needs to be done, make sure there are (physician) orders, and the medication is stored in a locked container. When asked if the facility's IDT had determined that Resident 2 can safely self-administer medications, the DON stated, They [IDT] didn't determine but they should have. During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated January 2023, the P&P indicated, Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications . During a review of the facility's P&P titled, Self-Administration of Medications, dated February 2021, the P&P indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .If it is deemed safe and appropriate for a resident to self-administer mediations, this is documented in the medical record and the care plan .Self-administered medications are stored in a safe and secure place, which is not accessible by other residents .Nursing staff reviews the self-administered medication record for each nursing shift, and transfers pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician notification regarding a significant weight loss for 1 of 5 residents reviewed for weight loss (Resident 203). This failure had the potential for delayed treatment plan for the resident. Findings: Resident 203 was admitted to the facility on [DATE] with the diagnosis of Hemiplegia (severe or complete loss of strength) and Hemiparesis (weakness or the inability to move on one side of the body) following Cerebral Infarction (the disrupted blood flow to the brain, also known as a stroke), according to Resident 203's admission Record. During observation and interview with Resident 203 on 6/5/23, at 10:40 A.M., Resident 203 was in bed with food untouched on her breakfast tray. Resident 203 stated she disliked the food served at the facility. Resident 203 stated the food was always bland. Resident 203 stated her family brought in food from home and had to request for staff to bring it in. Resident 203 stated she had lost weight because of the bland food. During observation and interview on 6/5/23, at 12:17 P.M., Resident 203 was in bed with food on the lunch tray untouched. Resident 203 stated the food was horrible and was still waiting for the spaghetti brought in by her family member. An observation and interview were conducted on 6/5/23, at 4:46 P.M. Resident 203 was observed sitting up in bed with dinner tray on the overbed table and food was untouched. Resident 203 requested for a substitute tray from CNA 1. CNA 1 stated Resident 203 did not eat much and preferred only sweets. An interview and concurrent record review was conducted on 6/7/23, at 11:34 A.M. with LN 1. LN 1 reviewed Resident 203's weights. LN 1 stated Resident 203 weighed 130.6 lbs on 12/4/22, and 104.3 lbs on 6/4/23. LN 1 stated Resident 203 had a 10% significant weight loss. LN 1 checked Resident 203's record and stated the attending physician has not been notified. LN 1 stated it was important to inform the physician regarding Resident 203's weight loss to order new interventions, lab tests and referrals as needed. During an interview 6/07/23, at 12:04 P.M. with the Registered Dietician (RD), the RD stated she had interviewed Resident 203 regarding food likes and dislikes because Resident 203 did not like the food. The RD stated she was aware of the significant weight loss. An interview was conducted on 6/8/23, at 3:01 P.M. with the Director of Nursing (DON). The DON stated physicians must be notified regarding resident weight loss. The DON stated it was their policy to inform the physician and it was important for the physician to provide interventions and recommendations in order to prevent further weight loss. During a review of the facility's policy and procedure (P&P) titled, Physician Notification, dated 3/2014, the P&P indicated, It is the policy of Casa de las Campanas Health Center that the attending physician will be notified of any of the following . a change in weight of five pounds or more . When made aware of any of the above events, the licensed nurse informs the resident's attending physician and D.N.S. (Director of Nursing Services)/designee.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a resident's care plan related to weight monitoring for one of 13 residents reviewed for care plans. (Resident 203). This failure resulted in Resident's 203's weekly weights to not be monitored weekly as planned, which could result in a delayed identification of a weight change. Findings: Resident 203 was admitted to the facility on [DATE] with the diagnosis of Hemiplegia (severe or complete loss of strength) and Hemiparesis (weakness or the inability to move on one side of the body) following Cerebral Infarction (the disrupted blood flow to the brain, also known as a stroke), according to Resident 203's admission Record. During observation and interview with Resident 203 on 6/5/23, at 10:40 A.M., Resident 203 was in bed with food untouched on her breakfast tray. Resident 203 stated she disliked the food served at the facility. Resident 203 stated her family brought in food from home and had to request for staff to bring it in. Resident 203 stated she had lost weight because of the bland food. Resident 203 was observed and interviewed on 6/6/23, at 4:46 P.M. Resident 203 had the dinner tray in front of her and was not eating. Resident 203 stated she will eat meat, but not the meat served on her tray. During an interview on 6/6/23, at 4:46 P.M., with CNA 2. CNA 2 stated Resident 203 did not eat much and preferred only sweets. CNA 2 stated Resident 203 required one on one feeding assistance due to weight loss. During an interview 6/07/23, at 12:04 P.M., with the Registered Dietician (RD). The RD stated she had interviewed Resident 203 regarding food likes and dislikes because Resident 203 did not like the food. The RD stated she was aware of the significant weight loss. An interview was conducted on 6/8/23, at 12:20 P.M., with CNA 3. CNA 3 stated the CNAs or Restorative Nurse Aides (RNA-certified nursing assistants trained in specific skills to help patients maintain and/or restore physical function) had a schedule to weigh residents. CNA 3 stated a 5 lb (pounds) weight loss was reported to the charge nurse and RD. CNA 3 was not aware of Resident 203's weight schedule. An interview and concurrent record review was conducted on 6/7/23, at 3:58 P.M., with LN 2. LN 2 reviewed Resident 203's weight record. LN 2 stated the weight record in the electronic medical record indicated weights were completed on 3/19/23, 3/26/23, 4/2/23, 5/7/23 and 6/4/23. LN 2 reviewed Resident 203's nutrition care plan and stated the care plan indicated to weigh Resident 203 weekly. LN 2 stated Resident 203's weights were not completed weekly as indicated in Resident 203's care plan. LN 2 stated it was important to follow the care plan to monitor weight gain or loss and to assist in improving the care for the resident. During an interview on 6/8/23, at 3:01 P.M., with the DON. The DON stated Resident 203's care plan indicated weekly weights, but they were not done. The DON stated the weekly weights were important to monitor improvement or continued decline. 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, .The comprehensive, person-centered care plan .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide treatment in accordance with the facility's policy and procedure when physician's orders were not clarified for one of 13 sampled residents (Resident 23). During medication administration, five medications were administered by mouth when the physician's orders were written to be given via a G-Tube (gastrostomy tube, a tube inserted through the belly that brings nutrition or medications directly to the stomach). This failure had the potential for not meeting Resident 23's therapeutic needs and had the potential of causing aspiration (breathing in medication or fluid into the lungs), which could lead to serious lung problems such as pneumonia (lung infection). Findings: During a medication pass observation for Resident 23 on 6/6/23, at 7:54 A.M., Licensed Nurse (LN 21) was observed preparing 12 medications which included one aspirin (used to prevent blood clot) chewable tablet, two atenolol (used to treat high blood pressure) tablets, one-half losartan (used to treat high blood pressure) tablet, one metformin (used to treat diabetes) tablet, and two sennosides-docusate (generic for Senna S, used to treat constipation) tablets. LN 21 crushed the metformin tablet, mixed the metformin powder with applesauce, and stated, [Resident 23] doesn't swallow bigger tablets. LN 21 brought the medications to the resident's bedside where Resident 23 was sitting in a wheelchair while certified nurse assistant (CNA 26) assisted her with breakfast. LN 21 proceeded to administer the crushed metformin, aspirin tablet, atenolol tablets, and losartan half-tablet by mouth, on a spoon with applesauce. Then LN 21 attempted to administer the two sennoside-docusate tablets by mouth and Resident 23 was unable to swallow the tablets. LN 21 instructed the resident to spit the tablets back into the medicine cup. LN 21 obtained two new sennoside-docusate tablets from the medication cart, crushed the tablets, mixed the sennoside-docusate powder with applesauce, returned to the bedside, and administered the sennoside-docusate by mouth, on a spoon. During a concurrent interview and record review on 6/6/23, at 11:57 A.M., with LN 21, Resident 23's medical record was reviewed. The medical record indicated the following physician's orders: - Aspirin 81 milligrams (mg, unit of measurement) chewable tablet, Give 1 tablet via G-Tube one time a day, dated 5/6/23; - Atenolol 50 mg tablet, Give 1 tablet via G-Tube one time a day, dated 3/28/23; - Losartan 25 mg tablet, Give 0.5 (half) tablet via G-Tube one time a day, dated 3/29/23; - Metformin 1000 mg tablet, Give 1 tablet via G-Tube two times a day, dated 6/3/23; - Senna S 8.6 mg-50 mg tablet (Sennosides-Docusate), Give 2 tablet enterally (G-Tube) in the morning, dated 4/8/23. LN 21 confirmed, she administered the five medications listed above by mouth, and the orders were written by the physician to be given via the G-Tube. LN 21 acknowledged, she should have called the physician to clarify the orders to be given by mouth prior to administration. When asked why the medications were not given via the G-Tube as ordered by the physician, LN 21 stated, the resident's G-Tube was pulled out yesterday, but medications had previously been given by mouth, to progress off the G-tube, according to report by the previous nurse. LN 21 stated, This is the first time I have given [Resident 23] meds [medications] orally [by mouth]. During a concurrent interview and record review on 6/6/23, at 12:13 P.M., with LN 22, Resident 23's medical record was reviewed. LN 22 confirmed the physician's written orders for aspirin, atenolol, losartan, metformin, and sennosides-docusate were prescribed to be given via the G-tube and there were no physician's orders to change the route of administration to by mouth. LN 22 acknowledged, there should have been a physician's order to give the medications by mouth. During a concurrent interview and record review on 6/07/23, at 9:33 A.M., with LN 23, Resident 23's medical record was reviewed. LN 23 stated, I follow the orders .if orders say 'G-tube' I give it by G-tube. LN 23 acknowledged, if the route needed to be changed, the doctor should have been notified. LN 23 confirmed, there were no physician's orders in the resident's medical record to give medications by mouth instead of via the G-Tube. LN 23 stated, I would have gotten the order clarified and notified the [doctor] right away. During a telephone interview with the Nurse Practitioner (NP) on 6/07/23, at 10:02 A.M., the NP stated, If [medication] is ordered to give via G-Tube .to change to oral, they have [to] call me to clarify. The NP acknowledged she should have written the order. She stated, I said we can try [by mouth] but I didn't write the order. When asked what risks are associated with the administration of medications by mouth when ordered to be given by G-Tube, the NP stated, Aspiration. During an interview with the Director of Nursing (DON) on 6/8/23, at 1:28 P.M., when asked the expectations for order clarifications by staff, the DON stated, when the resident started to take on medications by mouth, the orders should have been changed, and nurses need to clarify with the doctor. During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated January 2023, the P&P indicated, Medications are administered in accordance with written orders of the prescriber. If a .medication order seems to be unrelated to the resident's current diagnosis or condition .the nurse contacts the prescriber for clarification .the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when a random controlled medication use audit for one of four sampled residents (Resident 8) did not reconcile. The medication was signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was given to the resident. This failure had the potential to result in misuse or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and inaccurate accountability of controlled medications. Finding: The controlled medication Count Sheets for four random residents receiving controlled medications were requested for review during the survey. Resident 8 had a physician's order for oxycodone (a controlled medication for pain) 7.5 milligrams (mg, unit of measurement) tablet, give 1 tablet by mouth every 3 hours as needed for moderate to severe pain, start date 3/31/23. During a concurrent interview and record review on 6/6/23, at 4:56 P.M., with the Director of Nursing (DON), a review of Resident 8's Count Sheet for oxycodone and the 5/2023 MAR indicated the nursing staff removed one tablet on 5/14/23 at 7:50 A.M. and 5/16/23 at 1:50 A.M., from the medication cart and documented on the Count Sheet without documenting the respective administration on the MAR to show they were administered to the resident. The DON confirmed two oxycodone tablets were not accounted for. During a follow-up interview with the DON on 6/7/23, at 5:34 P.M., the DON stated, she could not locate documentation for the missing documentation of the oxycodone tablets given to Resident 8 on 5/14/23 at 7:50 A.M. and 5/16/23 at 1:50 A.M. The DON acknowledged it is important to keep accurate account of controlled medications to make sure there is no diversion. During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated January 2023, the P&P indicated, The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MRRs for one out of two sampled residents (Resident 28). This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the resident. Findings: A review of the hospital History and Physical (H&P), dated 9/10/22, the H&P indicated, Resident 28 Fell at her memory care facility .and subsequently hit the back of her head. She presented to the emergency room .and was found to have a .subdural hematoma [a serious condition where blood collects between the skull and the surface of the brain] . A review of Resident 28's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including traumatic subdural hemorrhage (a serious condition where blood collects between the skull and the surface of the brain usually caused by a head injury), muscle weakness, abnormalities of gait and mobility, history of falling, difficulty in walking, unsteadiness on feet, dementia, and insomnia. A review of Resident 28's clinical record indicated she had been receiving Ramelteon (a hypnotic medication which has sedating effect, used to treat insomnia) 8 milligrams (mg, unit of measurement) at bedtime since 9/13/22. Resident 28's clinical record showed, on 10/7/22, the physician ordered a new medication, tramadol (an opioid medication used for pain, which has sedating effects) 25 mg every 6 hours as needed for moderate to severe pain. On 10/25/22, Resident 28 sustained a fall. A review of the change of condition progress notes, dated 10/25/22, at 10:59 P.M., indicated on 10/25/22, .[Resident 28] had an unwitness fall, was alert .[Resident 28] was lying on the Floor and stated she lost her balance and fall on her Buttocks. [Resident 28] does not have visible injuries .no complaints of head pain or any pain in the upper and lower extremity. Brought back to wheelchair with assistance .No noted change in mental status .No head injury, wounds, swelling noted in the Body .[Resident 28] stated that no pain or discomfort .and she refused to be sent to Hospital for further evaluation . A review of Resident 28's clinical record indicated she sustained four additional unwitnessed falls on 11/17/22, 12/27/22, 1/10/23, and 6/4/23. According to Lexi-comp, a nationally recognized drug information resource, the combined use of Ramelteon and tramadol results in a drug-drug interaction (interaction between a drug and another substance that prevents the drug from performing as expected). It indicated, CNS [Central Nervous System] Depressants [medications that slow brain activity, which causes drowsiness and muscle relaxation] may enhance CNS depressant effect of Opioids (powerful pain-reducing medications) .Avoid concomitant use of opioids and .other CNS depressants when possible. These agents should only be combined if alternative treatment options are inadequate. If combined, limit the dosages and duration of each drug. Risk Rating D [a major risk level]: Consider therapy modification. Lexi-comp indicates both Ramelteon and tramadol could cause drowsiness, sedation, and falls. During an interview on 6/8/23, at 11:49 A.M., with Licensed Nurse (LN 22), when asked whether the facility asked the pharmacist to review Resident 28's medication regimen to see if the falls could have been attributed to the medications, LN 22 stated, No, pharmacist was not called after the [fall] on 6/4/23, I do not know about the previous falls. LN 22 acknowledged that a pharmacist should have been called after each fall. During an interview with the Director of Nursing (DON) on 6/8/23, at 1:13 P.M., when asked whether the facility asked the pharmacist to review Resident 28's medication regimen to see if the falls could have been attributed by the medications, the DON stated, We always ask .it should have been done .in addition to monthly MRR. The DON was unable to locate documentation for request of MRR by pharmacist following the falls on 10/25/22, 11/17/22, 12/27/22, 1/10/23, and 6/4/23. During an interview with the CP, on 6/8/23, at 1:53 P.M., she stated, whenever a resident had change of condition such as a fall, the facility should request for an immediate MRR from the pharmacy to see if medications could be the contributing factor. The CP confirmed that no falls were reported to the pharmacy for Resident 28. She stated, For repeated falls [the facility] should have requested an [immediate] MRR and pharmacy would have done a review of the medications to see if any medications could have contributed to her falls. When asked whether she identified in the monthly MRR in 10/2022, 11/2022, 12/2022, 1/2023, or 5/2023, regarding the potential for Ramelteon and tramadol to contribute to the resident's falls and made recommendation for changes, the CP stated, No, I didn't know she had a fall. If I knew she had a fall I would have recommended to look out for those medications potentially causing a fall. A review of the CP's monthly MRRs for Resident 28, from 10/2022 to 5/2023, indicated there were no recommendations from the CP for consideration of changes to Ramelteon and/or tramadol, as they could have contributed to the resident's falls. During a review of the facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions . During a review of the facility's P&P titled, Medication Regimen Review and Reporting, dated January 2023, the P&P indicated, More frequent medication regimen reviews may be deemed necessary. This may include when the resident experiences an acute change of condition .

CONCERN (E)

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

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 203 was admitted to the facility on [DATE] with the diagnosis of Hemiplegia (severe or complete loss of strength) and Hemiparesis (weakness or the inability to move on one side of the body) following Cerebral Infarction (the disrupted blood flow to the brain, also known as a stroke), according to Resident 203's admission Record. During observation and interview with Resident 203 on 6/5/23, at 10:40 A.M., Resident 203 was in bed with food untouched on her breakfast tray. Resident 203 stated she disliked the food served at the facility. Resident 203 stated she had lost weight because of the bland food. Resident 203 was observed and interviewed on 6/6/23, at 4:46 P.M. Resident 203 had the dinner tray in front of her and was not eating. Resident 203 stated she will eat meat, but not the meat served on her tray. Resident 203 pressed her call light button and requested for a meal substitute from CNA 1. Resident 203 asked CNA 1 what else there was to eat. CNA 1 stated chips and crackers were the only substitute in the kitchen. Resident 203 ate the cake but declined the carrots. Resident 203 stated her food needed seasoning and requested seasoning from CNA 1. CNA 1 left Resident 203's room and returned with salt and pepper. Resident 203 stated the carrots tasted better with the salt and pepper. During an interview on 6/07/23, at 12:04 P.M. with the Registered Dietician (RD), the RD stated she had interviewed Resident 203 regarding food likes and dislikes because Resident 203 did not like the food. The RD stated Resident 203 complained of the food being bland. The RD stated an alternate menu at the nurse's station should be provided to residents who did not like the food served. During an interview on 6/8/23, at 3:01 P.M. with the DON, the DON stated food substitute should be offered to residents. The DON stated alternate menus were in resident's drawers and at the nursing station. The DON stated it was important to offer a meal substitute for Resident 203 to prevent further weight loss. The DON also stated bland food needed seasonings. The DON stated condiments should be available on resident's meal tray if they were allowed according to physician's orders. The DON stated a tasteful meal provided more meaning for the resident to eat, and for a resident not to lose weight. During a review of the facility's policy and procedure (P&P) titled, Resident Rights-Food and Nutrition Services Department, dated 8/31/18, the P&P indicated, .6. Substitutes of like calorie value should be offered to the resident if the planned menu is refused. If the resident refused the nutritional substitute, another item of like caloric value should be offered . Based on observation, interview and record review, the facility failed to address the nutritional needs for three (Resident 203, Resident 11, Resident 30) of five residents reviewed for nutritional services when: 1. Resident 11 and Resident 30 were not assessed for food preferences. 2. Resident 203 was not offered an alternate meal after the resident refused the meal served and was not offered condiments to enhance the food's palatability. These failures resulted in Resident 203's continued refusals to eat the meals served by the facility, which could negatively impact the resident's health. In addition, this failure had the potential for Resident 11 and Resident 30 to have decreased food intake, which could lead to weight loss. Findings: 1a. Resident 11 was admitted to the facility on [DATE] with diagnoses of an intertrochanteric fracture of left femur (thigh bone) and falls per the facility's admission record. Resident 11 was observed at Resident Council on 6/6/23 at 10 A.M., in her wheelchair and dressed and groomed neatly. Resident 11 stated, I have not eaten in 2 days; all I had was junk yesterday and the day before. A review of Resident 11's Brief Interview for Mental Status (BIMS: a cognitive assessment) indicated a score of 14 (cognitively intact). A review of Resident 11's progress notes was conducted on 6/7/23 at 11 A.M., and no food preference assessment was located since 2/27/23 and the subsequent change of Registered Dietician (RD). A concurrent record review and interview was conducted on 6/7/23 at 11:04 A.M., with the RD. The RD stated, There is no assessment of food preference and a quarterly nutrition assessment is due. An interview was conducted with the Director of Nursing (DON) on 6/8/23 at 12:14 P.M. The DON stated, It is important for the RD to assess the residents for food preferences so they have food they like to eat and not lose weight. A review of the facility's policy, dated 8/31/18, titled Resident Rights- Food and Nutrition Services Department, indicated: .Procedure 3. Reasonable accommodations should be made by the Food and Nutrition Services Department to those with food preferences. A food preference list should be obtained .by the qualified nutrition professional . 1b. Resident 30 was admitted to the facility on [DATE] with diagnoses that included syncope (fainting) and Parkinson's Disease (a disorder of the central nervous system that causes tremors). An observation of Resident 30 was conducted on 6/5/23 at 11:30 A.M. Resident 30 was reclining on the bed; there was a container of pineapple chunks on the overbid table. Resident 30 stated: They don't feed me and I hate pineapple. A review of Resident 11's progress notes was conducted on 6/7/23 at 11 A.M., and no food preference assessment was located. An interview was conducted with certified nurse assistant (CNA) 11 on 6/5/23 at 3:34 P.M. CNA 11 stated: He doesn't like the food, maybe he would like ethnic food, he won't eat our food. He will eat what his wife brings from home. A concurrent record review and interview was conducted on 6/7/23 at 11:04 A.M., with the RD. The RD stated, There is no assessment of food preferences since the resident was admitted . An interview was conducted with the Director of Nursing (DON) on 6/8/23 at 12:14 P.M. The DON stated, It is important for the RD to assess the residents for food preferences so they have food they like to eat and not start to lose weight. A review of the facility's policy, dated 8/31/18, titled Resident Rights- Food and Nutrition Services Department, indicated: .Procedure 3. Reasonable accommodations should be made by the Food and Nutrition Services Department to those with food preferences. A food preference list should be obtained .by the qualified nutrition professional .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure that all food items were labeled and dated. In addition, the facility did not ensure that there were no expired food items. This failure had the potential for residents to become ill due to increased bacteria growth in the food, and/or have decreased food intake leading to weight loss due to poor food palatability. Findings: An initial tour/observation of the facility's main kitchen was conducted on 6/5/23 at 9:00 A.M., with the facility's Executive Chef (EC). In the walk-in refrigerator, there was a container of pickled ginger with an expiration date of 6/4/23; and a 3 lb. bucket of blueberry muffin mix with an expiration date of 6/4/23; and a container of wilted celery with no use by date. In the dry storage area, there were five (5) 24 ounce cans of tomato soup with a use by date of 6/4/23; the following dry spices had an expiration date of 4/23: herbs de Provence; cream of tartar; whole cloves; ground turmeric; star anise; coriander; oregano; onion powder; chipotle; and lemon pepper. In addition, there was a cardboard box filled with russet potatoes that had no received on date; and a cardboard box filled with red-skinned potatoes that had no received on date. In the facility's satellite kitchen, there were 12 boxes of Ensure Plus with no received on date; and 30 cereal boxes with no received on date. An interview was conducted with the EC on 6/5/23 at 9:20 A.M. The EC stated, Items should all have received on dates and there should be no expired items. An interview was conducted with the Dietary Services Manager (DSM) on 6/5/23 at 9:30 A.M. The DSM stated.It is important for foods to be labeled and dated and expiration dates checked so residents are not at risk for food-borne illness. An interview was conducted with the Director of Nursing (DON) on 6/8/23 at 12:14 P.M. The DON stated, There should never have been any food that was expired or not dated; it can lead to food-borne illness. A review of the facility's policy, dated 3/6/20, titled, Labeling and Dating for Safe Storage of Food, indicated, . all products should be dated upon receipt . A review of the facility's policy, dated, 4/6/23, titled, Food Storage, indicated, Policy: .any expired or outdated food products should be discarded .and, .all products should be inspected for safety and quality and be dated upon receipt .

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Provide adequate supervision to a resident at risk for falls, and 2. Comply with a facility policy to thoroughly investigate a fall. As a result, Resident 1 had an unwitnessed fall, and the facility did not identify the cause of the fall. Findings: Resident 1 was admitted to the facility on [DATE], with diagnosis to include partial paralysis of the body following a stroke, per the admission Record and Progress Notes. 1. On 4/27/23 at 11:05 A.M., an interview was conducted with the Director of Nursing (DON). Per the DON, Resident 1 had a fall on 4/6/23, shortly after she was admitted . The DON stated Resident 1 was confused, so a chair alarm and a bed alarm (a loud alarm which alerted when the resident stood up) were ordered and implemented. The DON stated the Licensed Nurse (LN 1) wanted to keep Resident 1 near her, so LN 1 placed Resident 1 in a wheelchair near the nurse station. The DON stated Resident 1 stood up, walked forward a few steps, then fell and hit her head on the nurse station. The DON stated Resident 1 was unconscious for 30-60 seconds. On 4/27/23, a Record Review was conducted. Per a Fall Evaluation, completed on 4/6/23 by LN 1, Resident 1 was at high risk for falls due to previous falls, multiple diagnosis, and impaired ability to walk. Resident 1's fall risk score was 75, with high risk evaluated as 45 and higher. A Progress note, dated 4/6/23 and authored by LN 2, indicated Resident 1 was newly admitted , confused, and standing up unassisted. LN 2 documented a Certified Nursing Assistant (CNA) put Resident 1 in a wheelchair near the nurse station for safety. A Change of Condition (COC) form, dated 4/6/23 and authored by LN 1, indicated Resident 1 had fallen near the nurse station. LN 1 documented Resident 1 was confused, but she had no pain and was alert. On 5/4/23 at 1:30 P.M., an interview was conducted with LN 2. LN 2 stated she was the medication nurse assigned to Resident 1 on 4/6/23. LN 2 stated she had been working at the nurse station when the fall occurred. Per LN 2, no alarm sounded. LN 2 stated she heard Resident 1 fall, so she went around the nurse station to see what happened. LN 2 stated it was the nurses' responsibility to assess a resident when they fell, but she did not want to touch her or move her. LN 2 stated she had not yet given any medications to Resident 1, and she was not familiar with her. LN 2 stated Resident 1 was unconscious. On 5/4/23 at 2:15 P.M., an interview was conducted with LN 1. LN 1 stated she had admitted Resident 1 by completing her paperwork, including her fall assessment. LN 1 stated Resident 1 was able to speak, but she was confused. LN 1 stated she had obtained an order for an alarm on the bed, as Resident 1 was a high fall risk. LN 1 stated keeping the residents safe was the most important part of her job. Per LN 1, she asked CNA 1 to place the alarm on the bed for safety, then she started entering information into the computer. LN 1 stated she did not hear anything more about Resident 1 trying to get out of bed. The next call she received was when Resident 1 had fallen. LN 1 stated Resident 1 was still talking but confused. LN 1 stated she had not heard an alarm, and Resident 1 was alert and confused while they waited for paramedics to arrive. On 5/4/23 at 2:53 P.M., an interview was conducted with CNA 1. CNA 1 stated he was assigned to Resident 1 on 4/6/23. CNA 1 stated when Resident 1 arrived at the facility, he was responsible for getting her blood pressure and temperature, and for getting her comfortable in her room and bed. CNA 1 stated Resident 1 was confused but speaking to him. Per CNA 1, Resident 1 tried to get out of bed, so he placed an alarm on her bed. CNA 1 stated Resident 1 still tried to get up independently, so he placed her into a wheelchair and placed Resident 1 in front of the nurse station. CNA 1 stated he did not inform anyone he was placing Resident 1 there, and no chair alarm was attached to the wheelchair. CNA 1 stated, I guess I should have watched her at the nurse station. I was advised to put the alarm on her bed, so she must be a fall risk .I should have told someone we needed to watch her. Per a facility policy, revised July 2017 and titled Fall Prevention and Management, .4. All residents should be considered at risk for falls for 72 hours following admission due to change in environment .6. Residents who are identified as high risk will .individualized precautions will be noted to avoid falls .7. Change of shift reports will include communication to all nursing staff regarding fall risk for new residents .a. CNA's will be made aware of residents at high risk for falls . Per an undated facility document, titled Fall Intervention Cheat Sheet, .Interventions .sensor alarm to room .Last resort would be to add an alarm .frequent checks . 2. On 4/27/23 at 11:05 A.M., an interview was conducted with the DON. Per the DON, Resident 1 had a fall on 4/6/23, shortly after she was admitted . The DON stated Resident 1 was confused, so a chair alarm and a bed alarm (a loud alarm which alerted when the resident stood up) were ordered and implemented. The DON stated LN 1 wanted to keep Resident 1 near her, so LN 1 placed Resident 1 in a wheelchair near the nurse station. The DON stated Resident 1 stood up, walked forward a few steps, then fell and hit her head on the nurse station. The DON stated Resident 1 was unconscious for 30-60 seconds. On 4/27/23, a Record Review was conducted. A Progress note, dated 4/6/23 and authored by LN 2, indicated Resident 1 was newly admitted , confused, and standing up unassisted. LN 2 documented a CNA placed Resident 1 in a wheelchair near the nurse station for safety. A Change of Condition (COC) form, dated 4/6/23 and authored by LN 1, indicated Resident 1 had fallen near the nurse station. LN 1 documented Resident 1 was confused, but she had no pain and was alert. On 4/27/23 at 5:17 P.M., an interview was conducted with the DON. Per the DON, she should have done a investigation about why the fall occurred, and she should have interviewed all staff who had information about the fall. The DON stated, The purpose of conducting a thorough investigation is to get a complete picture of the situation, and to prevent future falls . On 5/4/23 at 1:30 P.M., an interview was conducted with LN 2. LN 2 stated she was the medication nurse assigned to Resident 1 on 4/6/23. LN 2 stated she had been working at the nurse station when the fall occurred. Per LN 2, no alarm sounded. LN 2 stated she heard Resident 1 fall, so she went around the nurse station to see what happened. LN 2 stated Resident 1 was unconscious, and not speaking. LN 2 stated it was the nurses' responsibility to assess a resident when they fell, but she did not want to touch her or move her. LN 2 stated she did not check Resident 1 for injuries, and she did not observe anyone else check her for injuries. LN 2 stated the DON had not interviewed her about the incident. On 5/4/23 at 2:15 P.M., an interview was conducted with LN 1. LN 1 stated she had admitted Resident 1 by completing her paperwork, including her fall assessment. LN 1 stated Resident 1 was able to speak, but she was confused. LN 1 stated she had obtained an order for an alarm on the bed, as Resident 1 was a high fall risk. LN 1 stated keeping the residents safe was the most important part of her job. Per LN 1, she asked CNA 1 to place the alarm on the bed for safety, then she started entering information into the computer. LN 1 stated she did not hear anything more about Resident 1 trying to get out of bed. The next call she received was when Resident 1 had fallen. Per LN 1, she did not assess Resident 1 for injuries as she was concerned about moving her before the paramedics arrived. LN 1 stated she had not heard an alarm, and Resident 1 was alert and confused while they waited for paramedics to arrive. Per LN 1, She was never unconscious. LN 1 stated she was not interviewed about the incident by anyone at the facility. On 5/4/23 at 2:53 P.M., an interview was conducted with CNA 1. CNA 1 stated he was assigned to Resident 1 on 4/6/23. CNA 1 stated when Resident 1 arrived at the facility, he was responsible for getting her blood pressure and temperature, and for getting her comfortable in her room and bed. CNA 1 stated Resident 1 was confused but speaking to him. Per CNA 1, Resident 1 tried to get out of bed, so he placed an alarm on her bed. CNA 1 stated Resident 1 still tried to get up independently, so he placed her into a wheelchair and placed Resident 1 in front of the nurse station. CNA 1 stated he did not inform anyone he was placing Resident 1 there, and no chair alarm was attached to the wheelchair. CNA 1 stated, I guess I should have watched her at the nurse station. I was advised to put the alarm on her bed, so she must be a fall risk .I should have told someone we needed to watch her. CNA 1 stated he had received education regarding fall prevention and intervention recently, but nobody had interviewed him about Resident 1's fall. Per a facility policy, revised July 2017 and titled Fall Prevention and Management, .Steps following a fall: 1. Head to toe assessment by a licensed nurse completed before the resident is moved .3. Documentation will include .a fall investigation .5. Review and update causative factors, interventions .7 upon the completion of the report to prevent reoccurrence of a fall or to minimize injury .Quality Assurance .3. Falls will be tracked and trended for .root cause analysis and system causes .

Feb 2020 6 deficiencies

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to maintain and protect confidential information for 15 confidential residents. As a result, the confidential information of 15 residents was exposed to the general public. Findings: During the facility observation on 2/24/20 at 6:53 A.M., a computer monitor screen mounted on the wall by the facility's exit door adjacent to the main dining room was on. The computer screen showed 15 resident pictures with their names and room numbers. There were four residents in the dining room, and two staff were walking within view of the computer screen. On 2/27/20 at 6:54 A.M., an interview was conducted with CNA 6. CNA 6 stated the computer screen should have been off. CNA 6 stated residents' information should not be exposed because of HIPAA (Health Insurance Portability and Accountability Act - privacy rule to protect individuals' medical and other personal health information). On 2/27/20 at 6:56 A.M., an interview was conducted with CNA 7. CNA 7 stated she had not logged out of the computer screen. CNA 7 stated someone could have seen and read the resident information which was a violation of the resident's privacy. On 2/27/20 at 7:05 A.M., an interview was conducted with LN 8. LN 8 stated staff must log off the computer screen completely to avoid exposing the residents' confidential information, and to avoid a HIPAA violation. On 2/27/20 at 7:45 A.M., an interview was conducted with the DSD. The DSD stated resident's personal information should not be visible to any unauthorized staff to protect their privacy. According to the facility's policy, dated 3/2014, titled Confidentiality of Information, . 1. The facility will make sufficient efforts to safeguard all resident records, whether medical, financial According to the facility's policy, dated 10/2010, titled Resident Rights Guidelines for All Nursing Procedures, . 1. staff must have appropriate in-service training on resident right, including: . e. Confidentiality of protected information

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a physician's order and evidence of consent for the use of a bed alarm (a device that emitted an audible signal when the resident moved in certain ways), for one of two residents (219) reviewed for the use of restraints. As a result, Resident 219 was not offered the opportunity to decline the use of a device that potentially restricted movement while in bed. Findings: Resident 219 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, per the facility's admission Record. On 2/28/20, Resident 219's medical record was reviewed. Resident 219's MDS (screening tool to assess cognitive and functional capability), dated 2/25/20, indicated little or no cognitive impairment. According to the nursing progress notes, dated 2/20/20, Resident 219 had a fall when she attempted to get out of bed without calling for assistance. The IDT recommended the use of a bed alarm. On 2/28/20 at 1:00 P.M., Resident 219 was interviewed. A clear wire connected to a metal box with a red light was observed hanging from the headboard of Resident 219's bed. Resident 219 stated the wire was connected to the pad on her bed that sounded an alarm when she moved. Resident 219 stated she did not know when alarm was placed on her bed. Resident 219 stated she was unaware if the facility had spoken with her daughter about the alarm. On 2/28/20 at 1:10 P.M., Resident 219's medical record was reviewed with LN 6. LN 6 was unable to find any evidence a physician's order was obtained for use of the bed alarm. LN 6 stated the facility should not have put an alarm on Resident 219's bed without a doctor's order. LN 6 was unable to find any evidence Resident 219 or any family members had been informed about the use of the bed alarm. LN 6 stated Resident 219 should have been informed of the risks and benefits, and the choice to accept or decline the use of the alarm. According to the facility's policy, titled Personal Alarm Use, revised December 2014, 1. e. a bed and/or chair alarm may put [sic] instituted with a physician's order.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure three medications were stored correctly. This failure had the potential to cause the medications to deteriorate and lose their effect. Findings: On 2/27/20 at 9:43 A.M., an observation of the split medication storage cart was conducted. The medication cart contained three boxes of single dose Ipratropium Bromide Solution (a medication to treat asthma, and shortness of breath), and one box of single dose Ipratropium Bromide and Albuterol Sulfate Solution (a medication that opened the airway making it easier to breathe). The foil containers in each box held multiple single dose vials (small glass or plastic bottles) of medication. The foil containers within each box were opened, and exposed to light. On 2/27/20 at 9:45 A.M., a joint record review and interview was conducted with LN 1. Per the manufacturer's instructions, both medications must be protected from light inside the foil containers. LN 1 stated she did not know the foil containers should have been closed, to protect the medications from light. On 2/27/20 at 9:55 A.M., an observation of medication storage cart two was conducted. The medication cart contained one box of single dose Albuterol Sulphate Solution (a medication to make breathing easier) and one box of single dose Ipratropium Bromide and Albuterol Sulfate Solution. The two boxes of medication had opened foil containers inside the boxes. The foil containers in each box held multiple single dose vials of medication. The foil containers within each box were opened, and exposed to light. On 2/27/20 at 9:57 A.M., a joint record review and interview was conducted with LN 2. Per the manufacturer's instructions, both medications must be protected from light inside the foil containers. LN 2 stated she did not know the foil containers should have been closed. LN 2 stated she thought if the box containing the foil container was closed, the medication was protected from light. On 2/28/20 at 1:15 P.M., an interview was conducted with the DON. The DON stated the LNs should have followed the manufacturer's guidelines in the correct storage of the medications. Per the facility's policy, titled Central Storage of Medications, dated November 2018, . It is the policy of the facility to ensure proper storage and labeling of drugs . F . no contaminated or deteriorated drugs shall be available for use

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate services with a hospice agency (comfort care) to provide a plan of care for one of five residents (12) reviewed for hospice services. As a result, Resident 12 was at risk for delays in services, and miscommunication regarding care and treatment. Findings: Resident 12 was admitted to the facility on [DATE] with diagnoses to include dementia (decline in memory and thinking affecting the ability to perform everyday activities), according to the facility's admission Record. Resident 12 was admitted to hospice care on 1/30/20. On 2/27/20, Resident 12's medical record was reviewed. The MDS (standardized assessment and care-screening tool), dated 2/5/20, indicated Resident 12 had severe cognitive impairment. Resident 12 required extensive assistance from staff with all activities of daily living. On 2/27/20 at 10:36 A.M., Resident 12's hospice binder (notebook) was reviewed with LN 7. There was no evidence of a plan of care from the hospice agency in the binder. LN 7 stated the purpose of the plan of care was to collaborate and communicate any information related to Resident 12's care and treatment. On 2/27/20 at 10:43 A.M., the SSD was interviewed. The SSD stated she was the liaison (contact person) between the facility and the hospice agencies. The SSD was unable to find evidence of a care plan in Resident 12's hospice binder or medical record. The SSD stated the hospice plan of care should have been available to the facility, and in Resident 12's hospice binder by the next hospice visit. On 2/27/20 at 11:26 A.M., the DON was interviewed. The DON stated the expectation was the hospice plan of care should have been available to facility staff by being placed in Resident 12's hospice binder. On 2/27/20 at 11:33 A.M., the HN from [name of hospice agency] was interviewed by telephone. The HN stated she did not provide the facility with Resident 12's plan of care when she did not put the plan in his hospice binder. According to the undated facility's policy, titled Hospice Program, . 1.6. The hospice agency . will develop a written interdisciplinary hospice plan of care as appropriate to be utilized by the hospital agency and [name of facility]. According to the contract signed by the facility and [name of hospice agency], dated 8/29/19, . 5.02. A Hospice Plan of Care will be initiated by Hospice and maintained at the facility.

CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI) committee failed to identify the lack of knowledge and skills training of the Licensed Nurses in the set up and care of tube feeding equipment. In addition, the facility failed to identify the lack of knowledge and responsibility of the Certified Nursing Assistants with tube feeding equipment. As a result, the facility did not ensure consistent quality care was provided to all residents with tube feedings. See F726. Findings: On 2/28/20 at 1:38 P.M., an interview was conducted with the ADM during the QAPI meeting. The ADM stated the QAPI committee met monthly, quarterly, and as needed. The ADM stated the committee included himself and the following members: 1. Medical Director 2. Medical Records Director 3. Rehabilitation Directors which included the Physical Therapist and Occupational Therapists 4. Director of Staff Development/Infection Control Nurse 5. Activities Director 6. Social Worker 7. Dietitian 8. Director of Food and Beverage 9. Minimum Data Set (MDS) Nurse 10. Clinical Care Manager/Assistant Director of Nursing 11. Pharmacist 12. Housekeeping Supervisor 13. Director of Nursing The ADM stated the meeting was open to all staff. The ADM stated the CNAs attended the meeting if the issues were CNA specific, and the LNs attended if the issues were LN specific. The ADM stated his expectation was for the tube feeding company to provide inservice training to the staff and the DON. The ADM stated he was not aware that the LNs and CNAs were not trained on how to use the tube feeding equipment. The ADM stated this had not been identified as an issue, and therefore not presented during QAPI meetings.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide staff training for tube feeding equipment for two of two residents (265, 8) reviewed for tube feeding when: A. The CNA turned the tube feeding equipment off and, B. Licensed Nurses had not received training in the use of tube feeding equipment. These failures had the potential for Residents 265 and 8 to receive inadequate nutrition, placing them at risk for further weight loss. Findings: Residents 265 and 8's clinical records were reviewed on 2/27/20. Resident 265 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing), per the facility's admission Record. According to the facility's Nutrition/Dietary Progress Notes, dated 1/10/20, Resident 265 had a PEG (Percutaneous Endoscopic Gastrostomy - a tube placed in the stomach as an access for nutrition) due to inadequate nutritional intake and weight loss. Resident 8 was readmitted to the facility on [DATE] with diagnoses that included dysphagia following cerebral infarction (blockage or narrowing in the arteries supplying blood and oxygen to the brain), per the facility's admission Record. A. On 2/27/20 at 6:41 A.M., a concurrent observation and interview was conducted with CNA 9. CNA 9 stated she turned off Resident 265's tube feeding pump because, It was beeping for a long time. CNA 9 stated she was not sure if CNAs were allowed to turn the feeding pump off. On 2/27/20 at 6:45 A.M., an interview was conducted with LN 10. LN 10 stated CNAs were not allowed to touch or turn the tube feeding machine off for safety reasons. LN 10 stated staff may forget to turn the machine back on and the resident would not be fed. On 2/27/20 at 6:52 A.M., an interview was conducted with CNA 11. CNA 11 stated CNAs were not allowed to touch or manipulate the feeding pump equipment. On 2/27/20 at 7:05 A.M., an interview was conducted with LN 8. LN 8 stated only LNs could touch the feeding pump equipment and CNAs were not allowed to turn them off. On 2/27/20 at 7:45 A.M., an interview was conducted with the DSD. The DSD stated CNAs were not allowed to turn off the feeding tube equipment because it was not in their scope of practice. B. On 2/27/20 at 7:05 A.M., an interview was conducted with LN 8. LN 8 further stated she had not received any training about the tube feeding machine that the facility used. On 2/27/20 at 7:45 A.M., a concurrent interview and record review was conducted with the DSD. The facility's form titled, Inservice/Continuing Education, for LN 10 did not include tube feeding equipment competency. The DSD stated the LN skills checklist did not include tube feeding competency, which would indicate they had received training. In addition, the DSD stated, I have not received training about the tube feeding equipment. On 2/27/20 at 9:17 A.M., an interview was conducted with LN 12. LN 12 stated the facility used two types of tube feeding equipment, and she had not received any training on either one. On 2/27/20 at 9:20 A.M., an interview was conducted with LN 2. LN 2 stated when she was hired at the facility, she did not receive any training about the tube feeding pumps. LN 2 stated, . it would help us to be more competent and proficient. On 2/28/20 at 8:21 A.M., an interview was conducted with the DSD. The DSD stated she had not provided any training about tube feeding equipment to the LNs and CNAs. The facility did not provide a policy and procedure for tube feeding equipment maintenance and troubleshooting, or a policy for staff competency.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most California facilities.

Concerns

• 35 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.

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About This Facility

What is Casa De Las Campanas's CMS Rating?

CMS assigns CASA DE LAS CAMPANAS an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Casa De Las Campanas Staffed?

CMS rates CASA DE LAS CAMPANAS's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 47%, compared to the California average of 46%. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Casa De Las Campanas?

State health inspectors documented 35 deficiencies at CASA DE LAS CAMPANAS during 2020 to 2025. These included: 35 with potential for harm.

Who Owns and Operates Casa De Las Campanas?

CASA DE LAS CAMPANAS is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 99 certified beds and approximately 52 residents (about 53% occupancy), it is a smaller facility located in SAN DIEGO, California.

How Does Casa De Las Campanas Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, CASA DE LAS CAMPANAS's overall rating (3 stars) is below the state average of 3.1, staff turnover (47%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Casa De Las Campanas?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Casa De Las Campanas Safe?

Based on CMS inspection data, CASA DE LAS CAMPANAS has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Casa De Las Campanas Stick Around?

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

Was Casa De Las Campanas Ever Fined?

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

Is Casa De Las Campanas on Any Federal Watch List?

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

Facility Details

Beds: 99
Avg. Residents: 52
Occupancy: 52.6%
Ownership: Non profit - Other
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
35 Deficiencies: -10
Final Score: 60/100

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555362