How many inspection deficiencies does A GRACE SUB ACUTE & SKILLED CARE have?

A GRACE SUB ACUTE & SKILLED CARE has 48 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at A GRACE SUB ACUTE & SKILLED CARE?

A GRACE SUB ACUTE & SKILLED CARE has a four-star staffing rating from CMS with 1.10 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 A GRACE SUB ACUTE & SKILLED CARE located?

A GRACE SUB ACUTE & SKILLED CARE is located in SAN JOSE, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does A GRACE SUB ACUTE & SKILLED CARE have?

A GRACE SUB ACUTE & SKILLED CARE has 166 certified beds.

Who owns A GRACE SUB ACUTE & SKILLED CARE?

A GRACE SUB ACUTE & SKILLED CARE is a for profit - corporation facility and operates independently (not part of a chain).

How does A GRACE SUB ACUTE & SKILLED CARE compare to other nursing homes?

A GRACE SUB ACUTE & SKILLED CARE has a 4-star overall rating, placing it above average compared to other nursing homes in CA. Higher-rated facilities typically have better inspection results and staffing levels.

A GRACE SUB ACUTE & SKILLED CARE

Q: What is A GRACE SUB ACUTE & SKILLED CARE's CMS rating?

A GRACE SUB ACUTE & SKILLED CARE has a four-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Is A GRACE SUB ACUTE & SKILLED CARE safe?

A GRACE SUB ACUTE & SKILLED CARE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Q: Do nurses at A GRACE SUB ACUTE & SKILLED CARE stick around?

A GRACE SUB ACUTE & SKILLED CARE has low staff turnover at 14%, which means caregivers stay longer and know residents better.

Q: Was A GRACE SUB ACUTE & SKILLED CARE ever fined?

No, A GRACE SUB ACUTE & SKILLED CARE has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Q: Is A GRACE SUB ACUTE & SKILLED CARE on any federal watch list?

No, A GRACE SUB ACUTE & SKILLED CARE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

1250 S. WINCHESTER BOULEVARD, SAN JOSE, CA 95128 · (408) 241-3844

For profit - Corporation 166 Beds Independent Data: November 2025

Trust Grade

75/100

#275 of 1155 in CA

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A GRACE SUB ACUTE & SKILLED CARE nursing home in SAN JOSE, CA

Last Inspection: October 2024

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

Overview

A Grace Sub Acute & Skilled Care in San Jose, California has a Trust Grade of B, indicating it is a good choice among nursing homes. It ranks #275 out of 1,155 facilities in California, placing it in the top half, and #20 out of 50 in Santa Clara County, meaning there are only 19 local options that are better. The facility is improving, having reduced issues from 15 in 2024 to just 1 in 2025. Staffing is a strong point with a 4 out of 5-star rating and a low turnover rate of 14%, significantly below the state average. Notably, there have been no fines, indicating compliance with regulations, and the facility has more RN coverage than 86% of California nursing homes, which is crucial for catching potential problems. However, there are areas of concern. The facility had 48 documented issues, including failing to monitor a resident's dialysis access appropriately and not providing alternatives before using bed rails for many residents, which could risk entrapment. Additionally, there were lapses in proper tracking of controlled medications, raising the potential for medication errors. While there are strengths to consider, families should be aware of these weaknesses when making their decision.

Trust Score: B
In California: #275/1155
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 14% annual turnover. Excellent stability, 34 points below California's 48% average. Staff who stay learn residents' needs.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets 65 minutes of Registered Nurse (RN) attention daily — more than 97% of California nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations: 48 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 15 issues

2025: 1 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
5-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (14%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (14%)
34 points below California average of 48%

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

The Bad

No Significant Concerns Identified

This facility shows no red flags. Among California's 100 nursing homes, only 1% achieve this.

The Ugly 48 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

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** Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of one of three sampled residents (Resident 1) when medications were not available to be administered as ordered. This failure had the potential to compromise the resident's health and safety.Findings:Review of Resident 1's medical record indicated he was readmitted to the facility on [DATE] and had diagnoses including traumatic brain injury and epilepsy (a brain disorder that causes seizures [bursts of electrical activity in the brain that can cause changes in behavior, movements, and levels of consciousness]).Review of Resident 1's physician's orders indicated he had the following medication orders, dated 7/1/25: 1.) Clobazam (medication used to treat seizures) oral suspension 2.5 milligrams per milliliter (mg/ml, unit of dose measurement) give 8 ml via gastrostomy tube (GT, a tube inserted through the abdomen and into the stomach) two times a day; and 2.) Lacosamide (medication used to treat seizures) oral solution 100 mg/ml give 20 ml via GT two times a day. Resident 1 also had an order, dated 7/2/25, for Zonisamide (medication used to treat seizures) oral suspension 100 mg/5 ml give 15 ml via GT one time a day.Review of Resident 1's medication administration record (MAR), dated 7/2025, indicated Clobazam and Lacosamide were not documented as administered on 7/1/25, 7/2/25, and 7/3/25. Further review of the MAR indicated Zonisamide was not documented as administered on 7/2/25 and 7/3/25.Review of Resident 1's progress notes, dated 7/1/25 to 7/3/25, indicated the above medications were not available and that the facility was waiting for the medications to be delivered from the pharmacy.During an interview with licensed nurse A (LN A) on 7/10/25, at 3:21 p.m., LN A verified the above medications were not administered to Resident 1 because they had not been delivered to the facility from the pharmacy.During an interview with the consultant pharmacist (CP) on 8/14/25, at 1:20 p.m., the CP explained there was a delay in the delivery of the above medications because Clobazam and Lacosamide were controlled medications (medications regulated by the government due to their potential for abuse and addiction) and the pharmacy was waiting for the required triplicates (signed prescriptions from the physician or other valid prescriber). The CP further explained that Lacosamide was a high-cost medication for which the pharmacy requested delivery authorization from the facility, but the facility had not replied.An email from the CP, dated 8/15/25, was reviewed. The email contained documentation that the pharmacy faxed a request for triplicates for Clobazam and Lacosamide to Resident 1's physician on 7/2/25 at 12:31 p.m., but did not receive these triplicates until after 7/3/25. The email also contained documentation that the pharmacy faxed a high-cost medication delivery authorization request for Zonisamide to the facility on 7/2/25 at 2:54 a.m., but did not receive authorization from the facility until after 7/3/25.The facility's policy titled Pharmacy Services Overview, revised 4/2019, indicated, Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner.The facility's policy titled Medication Ordering and Receiving from Pharmacy Provider, dated 1/2025, indicated, Medications and related products are received from the provider pharmacy on a timely basis. The policy further indicated, The Drug Enforcement Agency (DEA) requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances.

Oct 2024 13 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide accommodation of needs for one of 22 residents (Resident 81) when Resident 81 did not have the appropriate staff call device (call button) that she would be able to use if she needed to call for assistance. This failure had the potential to result in the resident not getting assistance timely and delay necessary care and services. Findings: Review of Resident 81's clinical record indicated she was admitted to the facility with diagnoses including respiratory failure and quadriplegia (complete or partial paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). Review of Resident 81's Nursing admission Screening/History, dated 9/16/24 indicated the resident was alert x 4 (alert to person, place, time and event). Review of Resident 81's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 10/2/24 indicated her Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (cognitively intact). Review of Resident 81's physician order, dated 5/30/24 indicated she had an order for bilateral resting hand splints at all times except ADL's (activities of daily living) for contracture prevention. During an observation on 10/15/24 at 9:23 a.m., Resident 81 was in bed. Resident 81 had hand splints on her hands and arms. Resident 81's call button was on the bed next to her. During a concurrent interview with Registered Nurse K (RN K), he stated Resident 81 yells out when she needs help. During an interview on 10/16/24 at 1:59 p.m. the maintenance director (MD) stated the facility has other call devices available. He stated if a resident was not able to push on the call button using their fingers and the nusring staff could put a special call device if the resident needs it. During an interview with Resident 81 and an interpreter on 10/15/24 at 10:31 a.m., Resident 81 stated she calls out when she needs help. During an interview on 10/16/24 at 2:14 p.m., nurse supervisor M (NS M) stated Resident 81 has not been assessed for an appropriate call device. She stated there are other call devices available. NS M stated she thinks a call device that could be turned on by pressing it with her head would be good for Resident 81. During an observation on 10/17/24 at 11:10 a.m., Resident 81 was in bed. Resident 81 had hand splints on her hands and arms. Resident 81's call button was on the bed next to her. During a concurrent observation and interview on 10/17/24 at 2:03 p.m., when the Director of Nursing (DON) was asked if Resident 81's call button was appropriate for the resident and the DON asked if Resident 81 whether could move her thumbs. Resident 81 moved her arms slowly up and down and stated that she was not able to. The DON stated we have other call devices, including a padded call device or a call device that could be placed by her head. Review of the facility's policy, Assistive Devices and Equipment, revised 1/2020 indicated, Certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include . Call light devices. The policy also indicated appropriateness for resident condition is one of the factors that are addressed.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for two of 22 sampled Residents (Resident 66 and Resident 25). This failure had the potential for the residents and/or responsible party (RP) to be unaware of the plan of care. Findings: During a review of Resident 66's Baseline Care Plan (BCP), dated 10/04/2024, the BCP indicated Resident 66 was admitted on [DATE]. It also indicated the following were left blank: Therapy Services, BCP Completion Date, Date Reviewed With Resident/Representative, Staff Name and Signature, Resident signature, Representative Name and Signature. During a review of Resident 25's BCP, dated 10/10/2024, the BCP indicated Resident 25 was admitted on [DATE]. It also indicated the following were left blank: Safety, BCP Completion date, Date Reviewed With Resident/Representative, Resident signature, Representative Name and Signature. During an interview with Nurse Supervisor M (NS M) on 10/18/24 at 11:20 a.m., NS M stated the admission nurse would start the BCP upon admission and should have been completed within 72 hours. During a concurrent interview and record review with MDS Coordinator G (MDS G) on 10/18/24 at 11:58 a.m., MDS G confirmed the above findings and stated baseline care plans would be completed within 72 hours upon admission. During a concurrent interview and record review with Director of Nursing (DON) on 10/18/24 at 2:13 p.m., the DON confirmed the above findings. The DON stated all areas of the BCP should have been completed within 72 hours of admission for Resident 66 and Resident 25. During a review of the facility's policy and procedure titled (P&P), Care Plans - Baseline, dated December 2016, the P&P indicated, 1. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within Seventy-Two (72) hours of the resident's admission. 2. The interdisciplinary team will review the healthcare practitioner's order (e.g., dietary needs, medication, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care and needs including, but not limited to the following: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services . 4. The resident and their representative will be provided a summary of the baseline care plan .

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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Based on interview and record review, the consultant pharmacist (CP) failed to identify and report irregularities to the facility during the monthly regimen review (MRR) for two out of 20 sampled residents (Residents 5 and 93). The failure resulted in an unsafe order without being clarified for Resident 93, and Resident 5 not receiving the medication in accordance with the manufacturer's specifications to optimize drug therapy. Findings: 1. A review of Resident 93's clinical record indicated an order for Admelog [insulin lispro, a short-acting insulin to lower blood sugar] Injection Solution 100 UNIT/ML [milliliter] . Inject 3 ml [milliliters] subcutaneously [injection under the skin] as needed for DM [diabetes mellitus], dated 7/19/2024. The order had a dose of 3 ml which would be equal to 300 units of insulin; and did not have a frequency and parameters, such as blood sugar (BS} above certain readings, when to give it. During a concurrent interview and record review with Registered Nurse B (RN B) on 10/15/24 at 10:29 a.m., he reviewed Resident 93's Admelog order and stated he would give it if the BS was above 130 milligrams/deciLiter (mg/dL) as that would be considered high. RN B stated the 3 ml is a questionable dose and confirmed the order had no dosing frequency nor parameters when to give it. During a concurrent interview and record review with the Director of Nursing (DON) on 10/15/24 at 12:14 p.m., she reviewed Resident 93's Admelog order and stated, It is totally unclear, and the dose is wrong as 3 ml (or 300 units) would be very high. When asked whether the CP identified this as an irregularity during the monthly MRR since July 2024, the DON stated she could not find any recommendation related to this. During a telephone interview with the CP on 10/17/24 at 3:35 p.m., when asked whether she had identified and reported to the facility the irregular Admelog order for Resident 93, the CP responded she did not. She stated, Looks like I did not see it. 2. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including chronic kidney disease (CKD, long-term condition where the kidneys are damaged and can not filter blood properly). Resident 5's physician's orders included an order for: - Calcium Acetate (Phoslo; a phosphate binder, medication to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease) 667 mg, give 2 tablets by mouth three times a day for CKD, dated 6/3/2024. It was scheduled to be administered at 9 a.m., 1 p.m., and 5 p.m. According to the Prescribing Information from the manufacturer for calcium acetate, dated 3/2011, it indicated, Calcium acetate . when taken with meals, combines with dietary phosphate to form an insoluble calcium phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration. It indicated to take the medication with each meal. The facility scheduled breakfast at 7 a.m.; lunch at 12 noon; and dinner at 5 p.m. Thus, the calcium acetate administration time was not scheduled at the same time with breakfast and lunch. During an interview and record review with RN B on 10/16/24 at 11:37 a.m., he stated the facility meal scheduled breakfast around 7:30 a.m., lunch at noon, and dinner is at 5 p.m. He stated Resident 5 had breakfast around 7 to 7:30 a.m. that morning, and he administered the calcium acetate to Resident 5 at 8:35 a.m. (about one hour after breakfast). On 10/16/24 at 11:18 a.m., an interview was conducted with Resident 5, who had a Brief Interview for Mental Status (BIMS, a scale to determine a patient's cognitive understanding) of 15, conducted on 8/23/24, indicating she had intact cognition. When asked whether she took her Phoslo with food or whenever the nursing staff gave it to her, she stated, Whenever they give it to me. She said she did not know it has to be given with food. During a concurrent interview and record review with the DON on 10/16/24 at 12:09 p.m., she acknowledged the calcium acetate should be given with meals. She reviewed Resident 5's calcium acetate administration schedule and confirmed they were not consistent with meal times. A review of the Resident Details (a document showing the actual medication administration time) with the DON showed Resident 5's calcium acetate doses were not given during meal times 35 times out of 39 administrations from 10/3/24 to 10/15/24. A review of Resident 5's laboratory test, dated 3/6/24, indicated her phosphorous level was at 5.8 (high; the normal range is 2.5 - 5.0). During a telephone interview with the CP on 10/17/24 at 3:59 p.m., when asked whether she made a recommendation for Phoslo to be administered with meals, she stated, There was no recommendations after June this year for the Phoslo to be taken with meals. A review of the facility policy and procedures titled Medication Regimen Reviews, dated 5/2019, indicated, The consultant pharmacist performs a medication regimen review (MRR) for every resident . The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example . medications ordered in excessive doses . incorrect medications, administration times .

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure two out of 22 sampled residents (Residents 35 and 98) were free from unnecessary medications when Resident 35 received warfarin (a blood thinner to prevent blood clots) for a wrong indication; and Resident 98's lidocaine patch (a topical medication applied to the skin for pain) was not administered in accordance with the manufacturer's specifications. This deficient practice resulted inadequate indication for medication use; and the potential for adverse effects of medication. Findings: 1. A review of Resident 35's clinical record indicated he was admitted to the facility with diagnoses including chronic embolism and thrombosis of other specified veins (conditions that involve blood clots and can lead to serious complications) and saddle embolus of pulmonary artery with acute cor pulmonale (condition occurs when a large blood clot becomes lodged at the intersection where the main pulmonary artery divides and branches off into the left and right lungs). A review of Resident 35's physician's orders indicated the resident has been receiving warfarin, a blood thinner that required frequent blood testing and dosage adjustment based on the test results. He had the following orders: - Warfarin 1 mg, give 1.5 tablets by mouth at bedtime for pulmonary edema (condition where too much fluid builds up in the lungs, making it difficult to breathe), dated 9/13/24; - Warfarin 1 mg, give 1.5 tablets by mouth at bedtime for pulmonary edema, dated 9/20/24; - Warfarin 1 mg, give 1.5 tablets by mouth at bedtime for pulmonary edema, dated 9/25/24; During an interview with Resident 35 on 10/16/24 at 4:09 p.m., he stated he had been receiving warfarin for a massive saddle PE (saddle pulmonary embolism, a rare, life-threatening condition that occurs when a large blood clot gets lodged in the pulmonary artery, blocking blood flow to both lungs) that required very long hospitalization. During a concurrent interview and record review with the Director of Nursing (DON) on 10/17/24 at 11:45 a.m., she reviewed Resident 35's warfarin orders and confirmed the diagnosis for warfarin should be pulmonary embolism, not pulmonary edema. 2. A review of Resident 98's clinical record indicated she was admitted to the facility with diagnoses including back pain. A review of her physician's orders indicated an order for lidocaine patch 4%, apply to back topically one time a day for pain management, dated 9/21/24. On 10/17/24 at 11:19 a.m., Licensed Vocational Nurse C (LVN C) was asked to show the lidocaine patch that was administered to Resident 98 earlier that morning. LVN C provided a lidocaine 4% patch box labeled Lidocaine Pain Relief Patch. The manufacturer's directions in the back of the box indicated to not use longer than a 12-hour period. A review of Resident 98's medication administration record (MAR) with LVN C indicated a new patch was scheduled to be administered at 9 a.m., and the removal of the used patch was scheduled at 0859 a.m. (same time as the new patch application). LVN C stated he applied a new patch this morning at around 9 a.m. and removed the previous day's patch at the same time. During a concurrent interview and record review with the DON on 10/17/24 at 11:35 a.m., she stated the facility had a template for lidocaine patch application: it is supposed to be on at 9 a.m. and off at 9 p.m. (12-hour period). She reviewed Resident 98's lidocaine order and stated, It wasn't used for this patient, and confirmed it should have been used. During a telephone interview with the Consultant Pharmacist (CP) on 10/17/24 at 3:35 p.m., she stated, Lidocaine is supposed to be 12 hours on, 12 hours off. A review of the facility's policy and procedures titled, Medication Therapy, revised 4/2007, indicated, Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . Medication use shall be consistent with an individual's condition . All medication orders will be supported by appropriate care and practices . All decisions related to medications shall include appropriate elements of the care process, such as . The frequency of administration and duration of use are appropriate .

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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Based on observation, interview, and record review, the facility had a medication error rate of 5.56% when two medication errors occurred out of 36 opportunities during the medication administration for 2 out of 6 residents (Residents 67 and 93). The failures resulted in the nursing staff not following the facility's policy and procedures (P&P) and had the potential for the residents not receiving full therapeutic effects or complications of medications. Findings: 1. During the medication administration observation on 10/14/24 at 9:15 a.m., Licensed Vocational Nurse (LVN) A was observed preparing and administering 15 medications to Resident 67. Included in the medications was an oral inhaler called Alvesco (medication for asthma). After shaking the Alvesco inhaler, LVN A gave it to the resident and asked her to press on the inhaler and inhale deeply. After she finished, LVN A asked Resident 67 to repeat by giving herself another puff without allowing some time in between the inhalations. There was about 4 or 5-second time lapse between the 2 puffs. During an interview shortly after the observation, on 10/14/24 at 9:37 a.m., LVN A was asked whether he should have allowed time between the 2 puffs of inhaled medication, he stated, Not typically. He also stated he was not familiar with spacing out inhaled medications. A review of Resident 67's clinical record indicated a physician's order, dated 10/10/24, for Alvesco Inhalation 160 micrograms/actuation (unit of measurement), inhale 2 puffs orally two times a day for asthma prevention and control. During an interview with the Director of Nursing (DON) on 10/14/24 at 3:07 p.m., she stated, For patients with multiple inhalations, they [the nurses] should allow 1-2 minutes between inhalations. A review of the facility's P&P titled Administering Medications through a Metered Dose Inhaler, dated 10/2010, indicated, Repeat inhalation, if ordered. Allow at least (1) minute between inhalations of the same medication . 2. During the medication administration observation on 10/14/24 at 10:09 a.m., Registered Nurse (RN) B was observed preparing 10 medications, 1 liquid and 9 solid medications, for Resident 93. The resident was receiving medications via the gastrostomy tube (or G-tube, tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). RN B crushed each solid medication separately and diluted each with about 10 milliliters (mL, unit of measurement) of water. He also added some water to the liquid medication to dilute it. On 10/14/24 at 11 a.m., after attaching a 60-mL syringe to the resident's G-tube, RN B was observed flushing the G-tube with about 50 mL of water. Then he poured each of the medication in the syringe, one by one, without flushing with water between the 10 medications. He flushed the tubing with about 60 mL of water after the last medication. Shortly after the observation, on 10/14/24 at 11:19 a.m., RN B confirmed he did not rinse or flush the tubing with water between the medications. He said he was supposed to. During an interview with the DON on 10/14/24 at 3:07 p.m., she stated the nursing staff was to flush the resident's enteral tube with about 50 mL of water before medication administration, 10 mL after each medication, and do a final flush with 50 mL of water. A review of the facility's P&P titled Administering Medications through an Enteral Tube, revised 11/2018, indicated at the beginning of administration, Stop feeding and flush tubing with at least 50 mL warm water . If administering more than one medication, flush with at least 10 mL warm water . between medications . When the last of the medication begins to drain from the tubing, flush the tubing with 50 mL of warm water .

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide meals with food items according to preferences and dislikes for two of 44 residents (55 and 67). This failure had the potential to result in meal dissatisfaction, decreased intake, and leading to compromised nutritional and medical status for the residents. Findings: Review of Resident 55's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 67's admission Record indicated she was admitted to the facility on [DATE]. During a tray line observation with the dietary supervisor (DS) on 10/15/24, at 12:35 p.m., Resident 55's lunch ticket indicated he preferred to have a cheeseburger every day, but a cheeseburger was not served for him. Resident 67's lunch ticket indicated she disliked rice, but rice was served for her. During a concurrent interview with the DS, she confirmed that Resident 55's lunch ticket indicated he preferred to have a cheeseburger every day, but a cheeseburger was not served for him. Resident 67's lunch ticket indicated she disliked rice, but rice was served for her. The DS stated meals should have been served according to the residents' preferences and dislikes. Review of the facility's 2023 policy, Food preferences, indicated, Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of 27 initial pool residents (Resident 1) had access to a staff call device (call button), in case of needing help or for an emergency. This failure had the potential of Resident 1 becoming seriously harmed or even lead to death. Findings: During an observation in Room R3 on 10/14/24 at 8:40 a.m., the call button for bed A was observed hanging on the wall above the head of the bed, not within reach of Resident 1. Resident 1 stated she can not reach the call button, and would want to call. During an observation in Room R3 on 10/14/24 at 12:28 p.m., the call button was still hanging on the wall. During an observation in Room R3 on 10/14/24 3:17 p.m., the call button was still on the wall, out of reach of Resident 1. During an observation and subsequent interview with registered B (RN B) on 10/14/24 at 3:19 p.m., RN B took the call button off of the wall and handed it to Resident 1. RN B stated Resident 1 should have had the call button within reach. During a review of the facility's policy & procedure (P&P) titled Assistive Devices and Equipment, revised 01/2020, the P&P indicated, 1. Certain devices and equipment that assist with resident mobility, safety, and independence are provided for residents. These may include (but are not limited to): . d. Call light devices.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe, functional, and sanitary environment for one of 22 sampled residents (Resident 28) due to cracked walls near Resident 28's bathroom door and at the bottom left side of the toilet in the bathroom. This deficient practice had the potential to adversely affect the health and safety of residents in the facility. Findings: During an observation and interview with Resident 28 on 10/14/24 at 3:30 p.m., in Resident 28's room, Resident 28 stated about the cracked walls near her bathroom door and at the bottom, left side of the toilet in the bathroom. Resident 28 also stated that the walls were damaged and needed to be repaired. Resident 28 further stated that the facility was aware of the cracked walls near the bathroom door and the bottom left side of the toilet since last year. During a concurrent interview and record review with the maintenance director (MD) on 10/16/24 at 2:00 p.m., upon review of the maintenance log with the MD, the maintenance log indicated it was reported to maintenance. The MD confirmed that maintenance staff had started the repairs but missed the areas near the bathroom door and the bottom of the toilet. The MD stated he would inform the maintenance staff to complete the repairs. Resident 28's quarterly minimum data set (MDS, a federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 28's brief interview for mental status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 (a score of 0 to 7 indicates severe cognition impairment; 8 to 12 moderate impairment; 13 to 15 patient is cognitively intact). Review of facility's policy, Maintenance Service, revised 12/2009, indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the building in good repair and free from hazards .

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 75's face sheet (summary page of a patient's important information), printed 10/16/24 indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (treatment that helps body to remove extra fluid and waste products from blood). During a review of Resident 75's Physician order dated, 7/5/24 indicated monitor dialysis access AV (arteriovenous) fistula (connection made between an artery and a vein for dialysis access) left forearm for s/sx (signs and symptoms) of infection, swelling, redness, bleeding, or any drainage QS (every shift). Notify MD (medical doctor) as needed. During a review of Resident 75's Care Plan indicated an intervention, Do not draw blood or take B/P (blood pressure) on left arm shunt/fistula. During a Review of Resident 75's Blood Pressure Summary for 10/2024 indicated, Resident 75's BP was taken on the left arm from 10/1/14 to 10/15/24. During a concurrent interview and record review with Licensed Vocational Nurse D (LVN D) on 10/16/24 at 3:50 p.m., LVN D confirmed Resident 75's BP summary indicated the resident's blood pressures were taken on her left arm. LVN D stated Resident 75 has an AV shunt/fistula on the left arm and she cannot get her blood pressure taken on her left arm. LVN D stated taking blood pressures on the arm with AV fistula can cause injury to Resident 75. During a concurrent interview and record review with LVN E on 10/17/24 at 1:15 p.m., LVN E confirmed Resident 75's BP summary indicated his blood pressures were taken on the left arm. She stated licensed nurses are responsible for taking and recording the blood pressure. LVN E stated taking blood pressure on the arm with an AV fistula might cause bleeding. During a concurrent interview and record review with Director of Nursing (DON) on 10/17/24 at 4:43 p.m., the DON confirmed Resident 75's BP summary indicated the resident's blood pressure was taken on her left arm from 10/1/24 to 10/15/24. DON stated Resident 75 has an AV fistula on her left arm. She stated taking blood pressures to the left arm could put the resident at risk for bleeding. During a concurrent interview and record review with LVN L on 10/18/24 at 10:37 a.m., LVN L confirmed Resident 75's BP summary is correct and accurate. LVN L stated he worked with Resident 75 and when Resident 75 was eating using her right hand, he checked the blood pressure on her left arm. LVN L stated Resident 75 had AV fistula, but he cannot remember which arm. LVN L stated taking blood pressure to arm with AV fistula might cause bleeding. During a review of Resident 75's Physician order dated, 5/24/24 indicated, 1000 cc (cubic centimeter, unit of volume)/(per) day Fluid restriction AM (morning) = 180 cc, PM (evening) = 90 cc, NOC (night) = 0 cc, BF (breakfast) = 240 cc, L (lunch) = 240 cc, D (dinner) = 240 cc. During a concurrent interview and record review with Licensed Vocational Nurse D (LVN D) on 10/16/24 at 3:50 p.m., LVN D confirmed Resident 75 was on a fluid restriction, but there was no monitoring for Resident 75's fluid intake and output. LVN D stated there was no intake and output in Resident 75's records. During a concurrent interview and record review with LVN E on 10/17/24 at 1:15 p.m., LVN E confirmed there was no monitoring for intake and output for Resident 75. LVN E stated dialysis residents should have monitoring for intake and output. During a concurrent interview and record review with the Director of Nursing (DON) on 10/17/24 4:43 p.m., the DON confirmed there was no order to monitor intake and output for Resident 75. During a review of the facility's undated policy and procedures titled, Dialysis, Coordination of Care & Assessment, indicated do not perform blood pressures on arm with shunt. The policy also indicated to monitor fluid balance through recording and assessment of intake and output. Based on observation, interviews, and record review, the facility failed to ensure professional standards of practice were followed for five out of 22 sampled residents (Residents 25, 35, 75, 93, and 98) when: For Residents 25, 35, 93, and 98, there were incomplete physicians orders, which had the potential for unsafe implementation of the orders and untimely treatment or intervention residents' medical conditions. For Resident 75, the staff took the blood pressure (BP) on the same arm where the resident has the AV fistula (arteriovenous fistula, connection that's made between an artery and a vein for dialysis access), did not monitor her intake and output (the measurement of the fluids that enter the body and the fluids that leave the body). The failures had the potential to cause injury and unmonitored medical condition. Findings: 1. A review of Resident 93's clinical record indicated an order for Admelog [insulin lispro, a short-acting insulin to lower blood sugar] Injection Solution 100 UNIT/ML [milliliter] . Inject 3 ml [milliliters] subcutaneously [injection under the skin] as needed for DM [diabetes mellitus], dated 7/19/2024. The order had a dose of 3 ml which would be equal to 300 units of insulin; and did not have a frequency and parameters, such as blood sugar (BS) above certain readings, when to give it. During a concurrent interview and record review with Registered Nurse B (RN B) on 10/15/24 at 10:29 a.m., he reviewed Resident 93's Admelog order and stated he would give it if the BS was above 130 milligrams/deciliter (mg/dL) as BS above 130 mg/dL would be considered high. RN B stated the 3 ml is a questionable dose and confirmed the order had no dosing frequency nor parameters for when to give it. During a concurrent interview and record review with the Director of Nursing (DON) on 10/15/24 at 12:14 p.m., she reviewed Resident 93's Admelog order and stated, It is totally unclear, and the dose is wrong as 3 ml (or 300 units) would be too high. 2. A review of Resident 35's clinical record indicated he had the following orders for lorazepam (medication for agitation or anxiety): - Lorazepam 1 mg, Give 1 tablet by mouth as needed for Anxiety for 90 days, dated 4/20/24; it was discontinued on 5/17/24; - Lorazepam 1 mg, Give 1 tablet by mouth as needed for Anxiety for 90 days, dated 5/17/24; it was discontinued on 7/16/24. The above orders did not include the dosing frequency (how often to give it). A review of Resident 35's medication administration records (MARs) and the Controlled Drug Record for lorazepam indicated the nursing staff administered 28 lorazepam doses from 4/30/24 to 7/16/24 while the orders did not include a dosing frequency. There was no documented evidence the nursing staff clarified the order with the physician. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 10/15/24 at 4:16 p.m., she confirmed the above finding and acknowledged the nursing staff carried out the order and administered the medication while the order did not have the frequency. 3. A review of Resident 98's physician orders included the following insulin orders: - Insulin glargine (long-acting insulin), inject 17 units subcutaneously every 12 hours for DM, dated 9/19/2024 - Insulin lispro, inject as per sliding scale (a set of instructions for administering insulin dosages based on specific BS readings) . If BS < 60 follow hypoglycemic [low blood sugar] protocol, dated 9/20/2024. There was no written hypoglycemic protocol in Resident 98's clinical record. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) C on 10/17/24 at 11:19 a.m., when asked what he would do if the resident had a BS reading below 60, he stated he would call the doctor and give the resident some juice if she could drink; and if not, he would given Glucagon (an injectable medication to treat low BS). When asked if there were prescribed orders for hypoglycemic protocol, LVN C stated he could not find any. During a concurrent interview and record review with the DON on 10/17/24 at 11:35 a.m., she reviewed Resident 98's clinical record and confirmed there were no prescribed or an established hypoglycemia protocol. She stated, There should be an order for the protocol for staff to carry out. 4. A review of Resident 25's physician's orders included the following: - Insulin Glargine, inject 5 unit subcutaneously at bedtime for DM, dated 10/11/2024 - Insulin Lispro, inject per sliding scale . FSBS [finger-stick BS] <70 Refer to hypoglycemia orders, dated 10/11/2024 There was no prescribed hypoglycemia orders in Resident 25's medical record. During a concurrent interview and record review with the MDSC on 10/17/24 at 3:20 p.m., she confirmed despite having 2 insulin orders, there were no prescribed or an established hypoglycemia protocol in place for the nursing staff to follow in case the resident had BS readings below 70. She stated she just had the order clarified with the doctor about an hour before this interview. A review of the facility's policy and procedures (P&P) titled, Medication Therapy, revised 4/2007, indicated, Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks . All medication orders will be supported by appropriate care and practices . All decisions related to medications shall include appropriate elements of the care process, such as . Consideration of the clinical relevance of symptoms and abnormal diagnostic test results . Upon or shortly after admission, and periodically thereafter, the staff and practitioner . will review an individual's current medication regimen, to identify whether . b. The dosage is appropriate; c. The frequency of administration and duration of use are appropriate . A review of the facility's P&P titled Medication and Treatment Orders, revised 7/2016, indicated in part, Orders for medications must include . Dosage and frequency of administration . Clinical condition or symptoms for which the medication is prescribed . If clarification is necessary, the nurse shall contact the prescriber.

CONCERN (E)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to offer and/or attempt alternatives prior to the use of side rails (or bed rails, adjustable rigid bars attached to the side of a bed [examples include safety rails, grab bars, and assist bars]) for 18 of 22 sampled residents (Residents 66, 38, 75, 77, 13, 4, 9, 5, 73, 57, 29, 54, 98, 6, 99, 28, 82, and 16) and 77 nonsampled residents. This failure had the potential to place the residents at risk of entrapment and serious injury. Findings: 1. During an observation in Resident 66's room on 10/14/24 at 8:41 a.m., Resident 66 was sitting in bed. Resident 66's bed had both upper half side rails. Review of Resident 66's physician order, dated 10/04/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 66's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 66's Side Rail Assessment, dated 10/07/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 66's Informed Consent for the Use of Bed Rails, dated 10/04/24 indicated alternatives were not attempted. 2. During an observation in Resident 38's room on 10/14/24 at 8:48 a.m., Resident 38 was in bed. Resident 38's bed had both upper half side rails. Review of Resident 38's physician order, dated 4/21/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 38's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 38's Side Rail Assessment, dated 9/11/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 38's Informed Consent for the Use of Bed Rails, dated 4/21/22 indicated alternatives were not attempted. 3. During an observation in Resident 75's room on 10/14/24 at 8:55 a.m., Resident 75 was in bed. Resident 75's bed had both upper half side rails. Review of Resident 75's physician order, dated 1/27/23 indicated she had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 75's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 75's Side Rail Assessment, dated 9/16/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 75's Informed Consent for the Use of Bed Rails, dated 1/27/23 indicated alternatives were not attempted. 4. During an observation in Resident 77's room on 10/14/24 at 9:24 a.m., Resident 77 was in bed. Resident 77's bed had both upper half side rails. Review of Resident 77's physician order, dated 11/23/23 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 77's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 77's Side Rail Assessment, dated 8/20/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 77's Informed Consent for the Use of Bed Rails, dated 2/23/23 indicated alternatives were not attempted. 5. During an observation in Resident 13's room on 10/14/24 at 9:47 a.m., Resident 13 was in bed. Resident 13's bed had both upper half side rails. Review of Resident 13's physician order, dated 2/15/24 indicated he had an order for (1/2) Both Upper Side Rail up for postural support every shift. Review of Resident 13's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 13's Side Rail Assessment, dated 8/12/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 13's Informed Consent for the Use of Bed Rails, dated 3/21/21 indicated alternatives were not attempted. 6. During an observation in Resident 4's room on 10/14/24 at 10:00 a.m., Resident 4 was in bed. Resident 4's bed had both upper half side rails. Review of Resident 4's physician order, dated 9/27/21 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 4's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 4's Side Rail Assessment, dated 9/16/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 4's Informed Consent for the Use of Bed Rails, dated 9/27/21 indicated alternatives were not attempted. 7. During an observation in Resident 9's room on 10/14/24 at 10:04 a.m., Resident 9 was in bed. Resident 9's bed had both upper grab bars. Review of Resident 9's physician order, dated 10/11/23 indicated he had an order for grab bars/Side Rails up for positioning and easy bed mobility. Review of Resident 9's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 9's Side Rail Assessment, dated 7/26/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 9's Informed Consent for the Use of Bed Rails, dated 10/11/23 indicated alternatives were not attempted. 8. During an observation in Resident 5's room on 10/14/24 at 10:04 a.m., Resident 5 was in bed. Resident 5's bed had both upper grab bars. Review of Resident 5's physician order, dated 6/05/24 indicated he had an order for both upper grab bar/Rail up for positioning and easy bed mobility. Review of Resident 5's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 5's Side Rail Assessment, dated 8/23/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 5's Informed Consent for the Use of Bed Rails, dated 6/01/24 indicated alternatives were not attempted. 9. During an observation in Resident 73's room on 10/14/24 at 10:45 a.m., Resident 73 was lying in bed. Resident 73's bed had both upper half side rails. Review of Resident 73's physician order, dated 5/23/24 indicated he had an order for (1/2) Both Upper Side Rail up for postural support every shift. Review of Resident 73's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 73's Side Rail Assessment, dated 8/27/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 73's Informed Consent for the Use of Bed Rails, dated 5/22/24 indicated alternatives were not appropriate due to use of LAL [low air loss mattress]. 10. During an observation in Resident 57's room on 10/14/24 at 12:42 p.m., Resident 57 was lying in bed. Resident 57's bed had both upper half side rails. Review of Resident 57's physician order, dated 11/04/23 indicated he had an order for (1/2) Both Upper Side Rail up for postural support every shift. Review of Resident 57's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 57's Side Rail Assessment, dated 8/05/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 57's Informed Consent for the Use of Bed Rails, dated 11/02/23 indicated, Alternatives not appropriate due to use of LAL [low air loss mattress]. 11. During an observation in Resident 29's room on 10/14/24 at 1:55 p.m., Resident 29 was in bed. Resident 29's bed had bilateral half side rails. Review of Resident 29's physician order, dated 12/13/23 indicated she had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 29's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 29's Side Rail Assessment, dated 4/17/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 29's Informed Consent for the Use of Bed Rails, dated 11/13/23 indicated alternatives were not attempted. 12. During an observation in Resident 54's room on 10/14/24 at 1:55 p.m., Resident 54 was in bed. Resident 54's bed had bilateral half side rails. Review of Resident 54's physician order, dated 1/13/24 indicated he had an order for (1/2) Both Upper Side Rail up for postural support. Review of Resident 54's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 54's Side Rail Assessment, dated 8/20/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 54's Informed Consent for the Use of Bed Rails, dated 1/20/24 indicated alternatives were not appropriate. 13. During an observation in Resident 98's room on 10/14/24 1:55 p.m., Resident 98 was in bed. Resident 98's bed had bilateral half side rails. Review of Resident 98's physician order, dated 10/8/24 indicated she had an order for (1/2) Both Upper Side Rail up for postural support. Review of Resident 98's Side Rail Assessment, dated 9/18/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 98's Informed Consent for the Use of Bed Rails, dated 9/18/24 indicated alternatives were not attempted. 14. During an observation in Resident 6's room on 10/15/24 at 9:42 a.m., Resident 6 was in bed. Resident 6's bed had both upper (1/4) side rails. Review of Resident 6's physician order, dated 8/06/24 indicated he had an order for (1/4) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 6's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 6's Side Rail Assessment, dated 8/30/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 6's Informed Consent for the Use of Bed Rails, dated 8/06/24 indicated alternatives were not attempted. 15. During initial facility observations on 10/14/24, between 9:00 a.m. and 3:30 p.m., it was noted that Residents 99, 28, 82, and 16 each had bilateral half side rails raised. Review of Resident 99's physician order, dated 9/27/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 99's Side Rails care plan indicated an intervention, Identify and use appropriate alternatives prior to installing side rails. Review of Resident 99's Side Rail Assessment, dated 8/14/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 99's Informed Consent for the Use of Bed Rails, dated 9/27/24 indicated alternatives were not attempted. 16. Review of Resident 28's physician order, dated 3/5/22 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 28's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 28's Side Rail Assessment, dated 8/26/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 28's Informed Consent for the Use of Bed Rails, dated 3/5/22 indicated alternatives were not attempted. 17. Review of Resident 82's physician order, dated 2/5/24 indicated he had an order for (1/2) Both Upper Side Rail up for positioning and easy bed mobility. Review of Resident 82's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 82's Side Rail Assessment, dated 9/3/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 82's Informed Consent for the Use of Bed Rails, dated 2/5/24 indicated alternatives were not attempted. 18. Review of Resident 16's physician order, dated 1/11/20 indicated he had an order for May have both 1/2 Upper Side Rails up for repositioning and easy bed mobility. Review of Resident 16's Side Rails care plan indicated an intervention, Identify and use appropriate alternative prior to installing side rails. Review of Resident 16's Side Rail Assessment, dated 9/16/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails. Review of Resident 16's Informed Consent for the Use of Bed Rails, dated 4/7/19 indicated alternatives were not attempted. During an interview with the Director of Nursing (DON) on 10/16/24 at 2:00 p.m., the DON confirmed about the attempted alternatives prior to the use bed rails were findings. The DON stated that alternatives were not considered necessary, as the side rails were used for support, mobility, and positioning. The survey team expanded the sample and identified via observation and record review an additional 77 residents had side rails. Review of the Informed Consent for the Use of Bed Rails for the 77 residents indicated there was no documentation that the facility attempted alternatives prior to the use of side rails. During an interview on 10/18/24 at 11:55 a.m., the Director of Nursing (DON) confirmed most residents in the facility have side rails. She stated usually if they see that side rails will be beneficial for the resident, then they use the side rails. The DON stated if the facility determines alternatives are not appropriate for a resident, that is the reason why the facility did not attempt alternatives prior to the resident using side rails. Review of the facility's policy, Proper Use of Side Rails, revised 12/2016 indicated less restrictive interventions will be incorporated in care planning and documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration as in accordance with the facility policy and procedures (P&P) for 3 out of 5 residents (Residents 35, 39, and 85). The failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally). Findings: During an interview with the Director of Nursing (DON) on 10/15/24 at 3:40 p.m., she explained that each time a resident requested an as-needed controlled medication, the nurse assesses the resident, reviews the physician's order, signs it out of the CDR, administers the medication to the resident, documents the medication administration on the MAR, and re-assesses the resident for effectiveness of the medication within one hour. 1. A review of Resident 39's clinical record indicated a physician's order, dated 12/11/23, for diazepam (a controlled medication to treat anxiety or other medical conditions) 5 milligrams (mg, unit of measurement), give 1 tablet every 4 hours as needed for intermittent jerking. On 10/15/24 at 3:50 p.m., in the presence of the DON, an interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). A review of Resident 39's CDR for diazepam 5 mg and the June, August, and September 2024 medication administration records (MARs) indicated the nursing staff signed out of the CDR but did not document on the MAR to show the medication was administered to the resident, on 5 occasions, as follows: - 6/23/24 at 4 a.m. - 6/27/24 at 8 p.m. - 6/27/24 at illegible time - 8/7/24 at 8 p.m. - 9/12/24 at 8:30 p.m. During the interview and record review above, the MDSC confirmed this finding. She reviewed the nursing progress notes and stated there was documentation showing diazepam was given one time on 6/27/24 and on 9/12/24. However, both the DON and MDSC stated the nursing staff is expected to document the medication administration on the MAR so the computer system would prompt the re-assessment in one hour, and also to prevent the medication from being given again too soon. 2. A review of Resident 35's clinical record indicated a physician's order for lorazepam (medication for agitation and anxiety) 1 mg, give 1 tablet by mouth as needed for Anxiety for 90 days, dated 4/20/24. The order did not specify how frequent it should be administered. During a concurrent interview and record review with the MDSC on 10/15/24 at 4:16 p.m., a review of Resident 35's CDR for lorazepam 1 mg and the May and July MARs indicated, on 9 occasions, the nursing staff signed out one tablet on the CDR but did not document their administration on the MAR, as follows: - 5/1/24 at 2 p.m. - 5/2/24 at 2 p.m. - 5/7/24 at 3 p.m. - 5/11/24 at 3 p.m. - 5/13/24 at 3 p.m. - 5/17/24 at 3 p.m. - 5/25/24 at 3 p.m. - 7/15/23 at 3 p.m. - 7/30/24 at 8 a.m. During the interview and record review above, the MDSC verified the finding, and confirmed 9 lorazepam was not accounted for. 3. A review of Resident 85's clinical record indicated a physician's order, dated 11/26/2023, for oxycodone (a potent controlled medication for pain) 5 mg, 1 tablet every 6 hours as needed for moderate to severe pain. During a concurrent interview and record review with the MDSC on 10/15/24 at 4:29 p.m., a review of Resident 85's oxycodone 5 mg CDR and the July and August 2024 MARs indicated the nursing staff removed one tablet on the following dates and times without documenting in the respective administration on the MAR: - 7/22/24 at 4:30 a.m.; - 7/23/24 at 10:00 p.m.; - 7/24/24 at 6:00 a.m.; - 8/1/24 at 6:00 a.m. During a concurrent interview and record review on 10/15/24 at 4:35 p.m., the MDSC verified: three tablets of diazepam 5 mg for Resident 39; nine tablets of lorazepam 1 mg for Resident 35; and four tablets of oxycodone 5 mg for Resident 85, were unaccounted. She stated the nurses didn't document medication administration when they are supposed to. A review of facility's P&P titled Medication Administration Controlled Substances, dated 1/2023, indicated in part, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage . a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose . Administer the controlled medication and document dose administration on the MAR.

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 policy review, the facility failed to ensure food was stored, prepared, and served in accordance with professional standards for food safety when: 1. Undated food items, food past their used by date, bananas with black spots, partially soft and ruined tomatoes, dry green onion were found in the refrigerator and on the shelves in the kitchen; 2. A tube of Auto-Chlor test strips (used to test the chemical concentration of cleaning solutions to ensure that sanitizers are used appropriately in dishwashers, sinks, and buckets) was expired; and 3. Dietary supervisor (DS) did not sanitize the contaminated thermometer before checking the temperature of the lemonade. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 44 residents eating at the facility. Findings: 1. On 10/15/24, at 9:15 a.m., during an observation of the kitchen's storage shelves and in the walk-in refrigerator, with the registered dietician (RD) and the dietary supervisor (DS), the following were observed: a. A sugar container, but there was no use by date; b. Six tomatoes were partially soft and had signs of rotting; c. Four bunches of green onion were dry; d. One gallon of premium sweet pickle relish with a use by date of 7/6/24; e. Open bag of five pounds of raisins with no open date and no use by date; f. One brown rice container, one white rice container, and one barley container with no use by date; g. One imperial country style gravy mix received on 6/5/23; h. Eight ounces of ground cloves with use by date 10/2/24; i. Eighteen bananas with black spots; j. Open container of 20 ounces of whole sesame seed with no open date; k. Open container of 16 ounces of cayenne pepper with no open date; l. Open container of 16 ounces of whole Mediterranean oregano with no open date; m. Open container of five pounds of ground black pepper with no open date; n. Open container of five pounds of granulated onion with no open date; During a concurrent interview with the RD, the RD reviewed the facility's Dry Goods Storage Guidelines and confirmed that the sugar container should have a use by date on it. The RD stated the gravy mix was good for one year, and it was expired The RD also stated the above food should have open date and use by date. He stated the expired food should not be on the shelves and should have been discarded. Review of the facility's 2023 policy, Labeling and Dating of Foods, indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines . Review of the facility's 2023 policy, Storing Produce, indicated 1. Check boxes of fruit and vegetables for rotten, spoiled items . Throw away all spoiled items. 2. During an observation with the DS at the dishwasher in the kitchen on 10/15/24, at 11:15 a.m., a tube of Auto-Chlor test strips had an expiration date of 8/2024. During a concurrent interview with the DS, she confirmed that the tube of Auto-Chlor test strips was expired in 8/2024. The DS stated the tube should be discarded. 3. During a tray line observation on 10/15/24, at 12:05 p.m., the glasses of the drinks were placed in a bin with ice on top of their lids. The DS was checking the temperature of the lemonade. The DS held the thermometer in her hand; she tossed the ice on top of the lid of the lemonade glass with her index finger of the same hand, and the tip of the thermometer touched the bin several times, then the DS dipped the thermometer into the lemonade to check its temperature without sanitizing the thermometer. During a concurrent interview, the DS stated she should sanitize the contaminated thermometer before dipping it into the lemonade to check its temperature. Review of the facility's 2023 policy, Thermometer Use and Calibration, indicated . Cleaning and Sanitizing: . Wipe the clean thermometer with the sanitizing solution using a clean cloth or paper towel. Let the thermometer air dry before use.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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3. During an observation in Resident 73's room on 10/16/2024 at 11:28 a.m., Certified Nursing Assistant (CNA F) placed Resident 73's urinary drainage bag on his bed. The urine from the tube was observed flowing back toward the resident when turning Resident 73. During an interview with Treatment Nurse H (TN H) on 10/16/2024 at 12:11 p.m., TN H confirmed CNA F placed the urinary drainage bag on the bed of Resident 73 while he was doing the wound treatment. TN H stated Resident 73 would be at risk to have infection if the urine from the urinary drainage bag flows back into the bladder. During an interview with CNA F on 10/16/2024 at 12:40 p.m., CNA F confirmed the above observation and stated she put the urinary drainage bag on the bed when performing care with Resident 73. CNA F stated placing the drainage bag on the bed has the potential for infection. During an interview with infection preventionist (IP I) on 10/16/2024 at 4:14 p.m., IP I stated the urinary drainage bag should always be placed below the bladder. IP I stated urine that back flows has the potential to cause infection. During an interview with Director of Nursing (DON) on 10/17/2024 at 4:43 p.m., the DON stated urinary drainage bags should always be placed below the level of bladder to prevent infection. During a review of the facility's policy and procedure titled, Catheter Care, Urinary, date revised September 2014, indicated, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Based on observation, interview, and record review, the facility failed to ensure proper infection prevention techniques were followed when: 1. two oxygen concentrators had dirty filters, 2. a nurse did not wear appropriate personal protective equipment (PPE), two times during medications pass, for one of six residents who was on enhanced barrier precautions (a set of infection control measures that use gowns and gloves during high-contact care activities to reduce the spread of multidrug-resistant organisms), and 3. during personal care, the urine collection bag for one of 17 residents with a urinary catheter (a tube which is used to allow urine to drain if you have an obstruction in the tube that carries urine out of your bladder), was placed on the mattress of the bed. These failures had the potential of spreading facility acquired infections to vulnerable residents who are already immunocompromised. Findings: 1. During an observation on 10/14/24 at 9 a.m., the oxygen concentrator filter, in room R2, had a layer of greyish dust on it. During an observation and subsequent interview with the ADON on 10/16/24 at 10:14 a.m., when asked about the oxygen concentrator filter in room R2, the ADON stated I will clean it. During an observation on 10/15/24 at 9:42 a.m., the oxygen concentrator filter, in Room R1, had a layer of whitish dust on the filter. During an observation and subsequent interview with the assistant director of nursing (ADON) on 10/16/24 at 10:17 a.m., the ADON looked at the oxygen concentrator filter in room R1 and stated the filter needed to be cleaned. She stated she needs to check the facility's policy to see how often the filters should have been cleaned. During an interview with the administrator (ADM) 10/17/24 at 10:45 a.m., the ADM stated that they had cleaned the filters. During a review of the facility's policy & procedure (P&P) titled, Oxygen Equipment Maintenance - Oxygen Concentrator Filter, revised 10/2010, the P&P indicated General Guidelines | Assigned EVS staff is responsible for the scheduled, weekly cleaning and/or changing of the oxygen concentrators' filters. 2. During the medication administration observation with Registered Nurse (RN) J on 10/14/24 04:13 PM, RN J was observed donning on a pair of gloves at the medication cart and entering Resident 47's room to assess the resident's blood pressure (BP). She also wore a surgical mask, but did not wear a protective gown. Four large signs/posters were observed on Resident 47's room door. One of the large white posters read, PLEASE check-in with Charge Nurse before Entering Room. Wash hand BEFORE and AFTER Entering Room. The orange poster read, ENHANCE BARRIER PRECAUTIONS . PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities . Device care or use . feeding tube . Shortly after the BP assessment, on 10/14/24 at 4:17 p.m., RN J returned to the medication cart and started preparing four medications for the resident. On 10/14/24 at 4:32 p.m., RN J returned to the resident's room again without a gown. She changed into the new gloves and proceeded to administer the medications through the resident's gastrostomy tube (G-tube, tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). During the interview on 10/14/24 at 4:45 p.m., after being shown the posters on the resident's room, RN J stated she should have gowned up before entering the resident's room each time. A review of Resident 47's care plan, dated 2/6/24, for Enhanced Barrier/Standard Precautions indicated: [Patient 47] tested positive for CP-C.R.E (Carbapenemase-Producing Carbapenem-Resistant Enterobacterales, a type of bacteria that are resistant to antibiotics and can cause serious infections) - CDPH [California Department of Public Health] recommends the use of ESP [enhanced standard precautions], primarily the use of gowns and gloves for specific high contact care activities, based on the resident's characteristics that are associated with a high risk of MDRO [multi-drug resistant organism] colonization and transmission; - Perform hand hygiene and don PPE before beginning activity; - Gloves to protect hands; - Gown to protect body, clothes; - Mask/goggles/shield to protect face, eyes; - Place appropriate sign at room entry - Remove, discard PPE, and perform hand hygiene in room when activity complete. During an interview with the Director of Nursing (DON) and the Assistant DON (ADON) on 10/15/24 at 3:35 p.m., they stated, for residents on EBP, the staff providing care, such as BP measurement and medication administration, need to wear a mask, gown, and gloves before entering the room. A review of the facility's P&P titled Categories of Transmission-Based Precautions - EBP, dated 9/2024, indicated the following under Enhanced Standard Precautions/Enhanced Barrier Precautions: Wear gowns and gloves when performing high-contact tasks . This includes . Device care, for example . feeding tube.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Morse Fall Scale (an assessment used to determine a resident's risk for falls) after a fall for one of three sampled residents (Resident 1). This failure had the potential to compromise the facility's ability to identify fall risk factors and implement interventions accordingly. Findings: Review of Resident 1's medical record indicated he was admitted on [DATE] and had diagnoses including hemiplegia (one side of the body is paralyzed), disorientation (confusion), and muscle weakness. Review of Resident 1's Morse Fall Scale, dated 4/30/24, indicated Resident 1 was at moderate risk for falling. The instructions printed on the top of the Morse Fall Scale indicated, Complete on admission, quarterly, at change of condition, and after a fall. Review of Resident 1's situation, background, assessment, recommendation (SBAR, a communication tool), dated 5/10/24 and written by licensed nurse A (LN A), indicated Resident 1 was seen scooting out of bed. The SBAR indicated LN A tried to control Resident 1, but he got out in bed in sitting/lying position next to bed. The SBAR further indicated, Let resident lie down on floor safely with pillow on head and LN call for help. During an interview with LN A on 7/8/24, at 3:13 p.m., LN A explained what happened during the incident described in the above SBAR, dated 5/10/24. LN A stated she and another staff member saw Resident 1 sliding off his bed. LN A stated she tried to help Resident 1, but by the time she got to him, he had already slid onto the ground. LN A stated this incident was a witnessed fall. Further review of Resident 1's medical record indicated there was no documentation that the facility completed a Morse Fall Scale after Resident 1's witnessed fall on 5/10/24. During an interview and concurrent record review with LN B on 7/9/24, at 11:26 a.m., LN B confirmed the facility was supposed to complete a Morse Fall Scale after each time a resident fell. LN B reviewed Resident 1's medical record and confirmed there was no documentation that the facility completed a Morse Fall Scale after the resident fell on 5/10/24. The facility's policy titled Fall Risk Assessment, revised 3/2018, indicated the facility will seek to identify risk factors for falls and establish a falls prevention plan based on relevant assessment information. The facility's undated document titled FALL checklist was reviewed. The document listed the things that should be done if a resident fell. The third item listed on the document was, Morse assessment.

Mar 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Fall Morse Scale was completed accurately for one of two sampled residents (Resident 1). The failure to accurately assess residents ' fall risk has the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions for falls. Findings: Review of Resident 1 ' s medical record indicated he was readmitted to the facility on [DATE] with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain), epilepsy (a brain condition that causes recurring seizures [a sudden, uncontrolled burst of electrical activity in the brain]), and metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood that may lead to personality changes). Review of Resident 1 ' s Interdisciplinary Team Progress Notes (IDT), dated 9/14/23 , indicated Resident 1 had an unwitnessed fall on 9/13/23. Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool), dated 9/8/23, indicated his brief interview for mental status (BIMS, a tool used to screen and identify a resident ' s cognition [thinking ability]) was 15 (13-15 means intact cognition). Review of Resident 1 ' s morse fall scale assessment, dated 9/3/23, indicated Resident 1 had a history of falls; and that, his fall score was 40 (a score of 25 -44 means a moderate risk for falls). Review of Resident 1 ' s morse fall scale assessment, dated 9/29/23, indicated, no history of fall, and his fall score was 25. Review of Resident 1 ' s morse fall scale assessment, dated 11/15/23, indicated, no history of fall, and his fall score was 25. During a concurrent interview and record review with the director of nursing (DON) on 11/21/23 at 12:53 p.m., she verified the morse fall scale assessments were done for all residents every quarter, and post fall and as needed. The DON confirmed staff did not complete Resident 1 ' s morse fall scale assessments accurately on 9/29/2023 and 11/15/2023. The DON stated staff should have completed these assessments accurately to capture Resident 1 ' s history of falls. During a concurrent interview and record review with the Minimum Data Set (MDS, resident ' s clinical and functional assessment tool) Nurse (MDSN) on 12/11/23 at 11:00 a.m., the MDSN reviewed Resident 1's medical record and confirmed he had a fall on 9/13/23. The MDSN confirmed Resident 1 ' s morse fall scale assessments were not accurately completed on 9/29/2023 and 11/15/2023, which did not account for Resident 1 ' s fall on 9/13/2023. The MDSN stated staff should have accurately completed both assessments to derive accurate fall score(s) for Resident 1, which would then be used to develop a fall risk care plan for implementation. Review of the facility ' s policy and procedure titled, Falls-Clinical Protocol, dated 8/2012, it indicated, The staff will evaluate, and documents falls that occurs while the individual is in the facility. Review of the facility ' s policy and procedure titled, Charting and Documentation, dated 7/2017, indicated, All services provided for the resident towards the care plan goals or any changes in the resident ' s medical, physical, functional, or psychosocial shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary teams regarding the resident ' s condition and response to care.

Dec 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when: 1. A physician order for the wearing of a hand splint was not followed; 2. A physician order for the wearing of a knee brace was not followed; 3. RNA (Restorative Nursing Assistant) services were not provided as ordered; These failures resulted in Resident 1 not receiving proper treatment and had the potential to compromise Resident 1's health and well-being. Findings: 1. Review of Resident 1's clinical record indicated she was admitted on [DATE] with diagnoses including subarachnoid hemorrhage (bleeding into the fluid space surrounding the brain), aneurysm of carotid artery (bulging in one of the arteries supplying blood to the brain, head, face, and neck), and obstructive hydrocephalus (fluid build-up in the brain). Review of Resident 1's Minimum Data Set (MDS, assessment tool), dated 8/21/23, indicated Resident 1 had severely impaired cognitive skills for daily decision making and required extensive assistance for activities of daily living (ADL). Review of Resident 1 ' s physician order, dated 11/8/23, indicated, may wear left resting hand splint at all times, except ADLs, to prevent contractures. Check for signs and symptoms of redness and edema and notify MD accordingly. Review of Resident 1 ' s medication administration record (MAR) indicated the order to wear the left hand splint was listed on the MAR but the daily entries had an X marked in each box for the month of November and December. There were no licensed nurse ' s initials on the MAR to document Resident 1 ' s wearing of the left hand splint or checking for redness and edema by the licensed nurses. During an interview with Licensed Vocational Nurse A (LVN A) on 12/19/23 at 12:15 p.m., he stated Resident 1 should always wear the left hand splint as tolerated. During a concurrent record review, LVN A acknowledged Resident 1 had a physician order to wear a left hand splint and to monitor for redness and edema. LVN A confirmed the nurses were not documenting anything on the MAR for this physician order and stated the order was transcribed incorrectly. LVN A further stated when the order is transcribed correctly the nurses would initial every shift that the splint was applied and would document a Y or a N ' indicating yes or no for the presence of redness or edema. LVN stated nurses should follow the physician order and document the application and monitoring of the left hand brace. 2. Review of Resident 1 ' s physician order, dated 11/8/23, indicated RNA services order: Donning and Doffing (practice of putting on and removing) of knee brace on the right starting at 7am to 3pm for 7 times a week. A review of Resident 1 ' s MAR, TAR (treatment administration record), and RNA Treatment records was conducted. There was no evidence of licensed nurses or RNA staff carrying out the physician order and documenting the application of Resident 1 ' s right knee brace. During an interview and concurrent record review with Licensed Vocational Nurse A (LVN A) on 12/19/23 at 12:15 p.m., he stated the physician order for donning and doffing of the right knee brace was transcribed incorrectly. LVN A stated the physician order did not appear in Resident 1 ' s administration record and he confirmed there was no documented evidence that facility staff was applying Resident 1 ' s right knee brace. He further stated if the physician order was transcribed correctly the facility staff would initial the application and removal of the right knee brace. LVN A stated nurses should follow the physician order and document the donning and doffing Resident 1 ' s right knee brace. 3. Review of Resident 1 ' s physician order, dated 10/26/23, indicated RNA services order: Passive range of motion to gentle passive stretching on (B)UE/LE (both upper and lower extremity) for 5 times per week. Focus on stretching the right knee towards extension and left ankle motions. Apply the PRAFO boot (Pressure Relief Ankle Foot Orthosis boot to prevent contractures and pressure ulcers) after stretching. A review of Resident 1 ' s RNA treatment records indicated missing entries for the performance of RNA services as ordered by Resident 1 ' s physician. The RNA treatment record for 11/1/23 through 11/30/23 indicated RNA services were documented as performed only 8 times. The RNA treatment record for 12/1/23 through 12/18/23 indicated RNA services were documented as performed only 3 times. During an interview and concurrent record review with RNA B, on 12/19/23 at 1:50 p.m., he confirmed he was providing RNA services to Resident 1. He reviewed the RNA treatment record for the month of November and December and acknowledged there were blank spaces on the monthly records. He confirmed the physician order was for Resident 1 to receive RNA services 5 times a week. When asked to explain the missing entries he stated the blanks were the days when Resident 1 did not receive RNA services and stated Resident 1 refuses the range of motion exercises frequently. RNA B stated Resident 1 will often scream and yell when RNA B attempts to do range of motion as prescribed, and he will not force Resident 1 to exercise. He further added I can usually only do it once or twice a week. When asked if he documents Resident 1 ' s refusals, RNA B stated he was not aware that he needed to document Resident 1 ' s refusals. During an observation on 12/19/23 at 10:50 a.m., Resident 1 was seated in her wheelchair in the main dining room of the facility. She was not wearing any hand splint on her left hand or a right knee brace. During a concurrent interview with the ADON on 12/19/23 at 10:50 a.m., she confirmed that Resident 1 was not wearing any left hand splint or right knee brace. The ADON stated she was unaware of why Resident 1 was not wearing these devices. During an interview and concurrent record review with the ADON, on 12/19/23 at 11:45 a.m., she confirmed Resident 1 had physician orders to wear a left hand splint and a right knee brace. Upon further review of these physician orders, the ADON stated both of these orders were not transcribed correctly, The ADON stated licensed nurses were not initialing the application of the left hand splint or documenting to check for redness and edema, and she confirmed they should be. The ADON further stated the order to apply the right knee brace did not appear on Resident 1 ' s administration record so staff were not documenting the donning and doffing of the right knee brace, and she confirmed they should be. The DON reviewed Resident 1 ' s physician order for RNA services 5 times a week. She reviewed Resident 1 ' s RNA treatment record for November and December and acknowledged there were blank spaces on the record. When asked about the missing entries she stated she was unaware of why the RNA did not document that services were provided 5 times a week as ordered. She confirmed if a resident refuses medications or treatments, the refusal should be documented. Review of the facility policy titled Charting and Documentation, revised July 2017, indicated all services provided to the resident shall be documented in the resident ' s medical record. Documentation of procedures and treatments will include care-specific details, including . e. Whether the resident refused the procedure/treatment . g. The signature and title of the individual documenting. Review of the facility ' s undated Job Description: RNA, indicated Duties and Responsibilities: . Adheres to department procedures regarding documentation of services.

Jun 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

Grievances (Tag F0585)

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 resolve the grievance for one of three residents (1) when Resident 1's complaint about missing her chips, sodas, and baby wipes was not acted on. This failure had the potential to cause frustration for the Resident 1. Findings: Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE]. During an interview with Resident 1 on 6/30/23 at 11:55 a.m., she stated her sodas were missing, and her baby wipes which were stored in the closet were also missing. Resident 1 stated she reported them to the staff. During a concurrent observation, Resident 1's soda pack was placed on the bed next to her bed, and her closet did not have a lock. Review of the facility's grievance binder indicated on 5/2/23 Resident 1 filed a grievance about her missing chips, sodas, and wipes with the recommendations to have Resident 1's items placed in a closet with a lock and Resident 1 had the key. However, the grievance did not indicate that the recommendations were acted on. During an interview with the business office clerk A (BOC A) on 6/30/23 at 2:25 p.m., he stated he worked in the social services office and just transferred to the business office on 6/20/23. The BOC A reviewed Resident 1's 5/2/23 grievance, and confirmed that nothing had been done for Resident 1's complaint on missing items. During an interview with Resident 1 on 6/30/23 at 3:45 p.m., she confirmed that her closet did not have a lock, and she did not have a key. Review of the facility's policy, Grievances/Complaints, Filing, dated 4/2017, indicated The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative . 7. The Administrator had delegated the responsibility of grievance and/or complaint investigation to the Grievance Officer who is Social Services and Designee . 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the action that will be taken to correct any identified problems: a. The Administrator, or his or her designee, will make such reports orally within 5 working days of the filing of the grievance or complaint with the facility. b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office.

May 2022 15 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) for an increased dose of an antipsychotic medication (a type of psychotropic medication to manage psychosis including delusions, hallucinations, paranoia, or disordered thought) for one of 23 sampled residents (Resident 48). This failure had the potential to compromise the right of the residents or responsible parties (RPs, persons designated to make decisions of behalf of the residents) to be fully informed regarding care and treatment to make health care decisions. Findings: A review of Resident 48's clinical record indicated she had been receiving Seroquel (an antipsychotic medication) 50 milligrams (mg, unit of measurement) twice daily for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) M/B (manifested by) angry outburst, hitting, kicking, biting staff causing impairment in functional capacity, starting on 3/21/22. On 4/19/22, there was a physician's order to add 50 mg dose at bedtime. The total dose was 50 mg three times daily as of 4/19/22. A review of Resident 48's medical record indicated it had the informed consent, dated 3/20/22, for Seroquel 50 mg twice daily. There was none for the additional 50 mg dose added on 4/19/22. During a phone interview on 5/12/22, at 10:00 AM, with Resident 48's RP, she stated she was not familiar with the resident's medications, such as what the medications were and what they were for. She also stated she had not been contacted by a physician regarding the resident's care since the resident was admitted to the facility. During a phone interview on 5/12/22, at 11:00 a.m., with the medical director (MD), he stated the charge nurses give the informed consent form to residents or RPs, and he signs it. He also stated usually he had a hard time getting hold of the RPs. During a concurrent interview and record review on 05/12/22, at 11:13 a.m., with director of Nursing (DON) and licensed vocational nurse (LVN L), they confirmed there was no informed consent document in Resident 48's medical record for Seroquel that was ordered on 4/19/22. They confirmed there should be a documented informed consent for newly prescribed or increased antipsychotic medications. They further explained the prescriber was responsible for obtaining the informed consent from the resident or RP, and the nursing staff's responsibility was to verify with resident or RP if the prescriber obtained the informed consent. A review of the facility's policy and procedures titled Psychotropic Medication Use (Antipsychotics), revised December 2016, indicated, Whenever an order is obtained for psychotropic medications, the Licensed Nurse shall verify with the Attending Physician that informed consent has been obtained. The Licensed Nurse documents this verification on the Resident's Consent for Use of Psychotropic Medications form.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to address resident's needs for one of three sampled residents (Resident 74) when Resident 74 was not able to reach for her call light. This failure had the potential for residents' needs not being met. Findings: During a concurrent observation and interview on 5/9/22, at 8:42 a.m., with licensed vocational nurse A (LVN A) in Resident 74's room, Resident 74 was hitting the right siderail of her bed with her right hand. LVN A took the call light hanging on top of a gastric tube feeding machine (a device used for direct feeding to the stomach) situated on the left side of Resident 74. LVN A stated that the call light must be within reach of Resident 74. During an interview on 5/12/22, at 10:27 a.m., with certified nursing assistant H (CNA H), she stated that Resident 74 uses her right hand to use the call light. During an interview on 5/12/22, at 10:32 a.m., with registered nurse C (RN C), she stated that Resident 74 uses the call light for help. During an interview on 5/12/22, at 1:32 p.m., with the director of nursing, she stated that call lights must be within reach of residents. During a review of Resident 74's clinical record dated 9/1/21, the admission diagnosis indicated Resident 74 had hemiplegia (paralysis of one side of the body), hypertension (condition in which the force of the blood is too high), dysphagia (difficulty swallowing foods). Her Minimum Data Set (MDS, an assessment tool), BIMS (Brief Interview for Mental Status) dated 10/25/2021, indicated a score of 13 (no cognitive impairment). During a review of the facility's policy and procedure titled 'Call Lights' dated 12/08, indicated The call light will be put within reach of the resident.

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 observation, interview, and record review, the facility failed to protect a residents' personal health information for one of three computer monitors. This failure had the potential for the public to see or access resident's personal medical and demographic information. Findings: During an observation of nursing staff administering medications to residents on 5/11/2022, at 10:35 a.m., one laptop was open with residents' personal health information on laptop screen unattended. During an interview on 5/11/2022, at 10:45 a.m., with registered nurse B (RN B), she stated that she got busy and forgot to log out before going into a resident room. During an interview on 5/13/22 at 10:05 a.m., with the director of nursing, she stated that after giving medications, the nurse must close the laptop screen. No personal health information should be left unattended. A review of the facility's policy titled, Protected Health Information (PHI), Management and Protection, dated April 2014, indicated that It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure during administering medications,Concern regarding resident health records in plain sight.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide services to prevent contracture (condition leading to deformity) for two of nine sampled residents (Resident 77 and Resident 28) when: 1. Resident 77's lower extremities (legs and feet) did not have heel protectors (device to prevent deformity) applied on bilateral feet. 2. Resident 28 did not have a splint (device used to protect deformity) applied on his left arm as ordered. These failures had the potential to cause or worsen bone deformities. Findings: 1. During an observation on 5/9/22 at 8:58 a.m., in Resident 77's room, Resident 77's lower extremities did not have heel protectors. During a concurrent observation and interview on 5/9/22 at 3:40 p.m., with licensed vocational nurse A (LVN A) in Resident 77's room. Resident 77's soft heel protectors were inside the cabinet. LVN A stated she would check on the order for soft heel protector application. During a concurrent interview and record review on 5/10/22 at 10:23 a.m. with LVN A, LVN A stated that physician order, dated,11/15/2021, indicated Wear bilateral heel protectors for positioning/contracture management daily. During a review of Resident 77's admission diagnosis dated 10/11/2016, it indicated that she had joint contracture, and muscle weakness. During a review of the facility's policy titled, Mobility and Range dated 2017, indicated that Residents with limited range of motion (ability of a body part to move) will receive treatment and services to prevent a further decrease in range of motion. 2. During an observation on 5/9/22 at 11:18 a.m. in Resident 28's room, the arm splint was inside Resident 28's cabinet. During a follow-up observation and interview on 5/10/22 at 9:10 a.m., with registered nurse B (RN B) and certified nursing assistant M (CNA M) in Resident 28's room, Resident 28 had no splint applied on the left arm. The splint was found inside Resident 28's cabinet. RN B stated the splint should be applied to prevent contracture. During a record review on 5/10/22 at 9:30 a.m. with RN B, Resident 28's physician order dated 5/26/2021, indicated Patient may wear left hand splint daily for positioning and contracture prevention. Resident 28's admission diagnosis indicated that he had hemiplegia (paralysis of one side of the body), cerebral infarction (disrupted blood flow to the brain) During an interview on 5/12/22 at 9:42 a.m. with the director of nursing, she stated that all orders regarding use of heel protectors/splints should be followed by nurses and therapists to prevent damage to the affected body parts. During a review of facility's policy titled, Splinting (undated), the policy indicated Splinting is used to protect joints at position of rest that contribute to contracture and/or deformity.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide timely assessment and intervention for pain for one of two sampled residents (Resident 68). This failure had the potential for increased pain and discomfort for Resident 68. Findings: During an observation on 5/9/22, at 10:20 a.m., in Resident 68's room, she was rubbing the left side of her face and grimacing. During an interview on 5/10/22, at 9:48 a.m., with certified nursing assistant F (CNA F), she informed the nurse of Resident 68's pain on the left side of her face about two weeks ago. During a review of Resident 68's clinical record dated 3/22/22, Resident 68 was admitted for cerebral vascular accident (disrupted blood flow to the brain), and trigeminal neuralgia (chronic pain condition affecting the trigeminal nerve, this nerve carries sensation from the face to the brain). During an observation on 5/11/22, at 9:52 a.m., in Resident 68's room, registered nurse B (RN B) assessed the resident for pain. During a follow-up interview on 5/11/22 at 9:58 a.m. with RN B, she stated that Resident 68 had pain on the entire left side of head, face, and neck. Resident 68 was still complaining of pain. During an interview on 5/11/22, 1:26 p.m., with the nursing supervisor G (NS G) she stated that she was only made aware of the resident's pain on 5/10/22. NS G further stated that resident's pain should be reported immediately to the nurse and notify the physician accordingly. During an interview on 5/13/22 at 10:05 a.m., with the director of nursing, she stated that the nurse was responsible for assessing residents' pain and intervention. They should check for improvement. If no improvement, the nurse should contact the physician as soon as possible. Review of the facility's policy titled, Pain Assessment and Management, dated March 2020, the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

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 residents receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one of one resident (Resident 23) when Resident 23's dialysis site dressing was not removed as ordered. This deficient practice had the potential for the resident to be inadequately assessed and be at risk for complications. Findings: Review of Resident 23's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys no longer functioning in permanent basis) and thrombosis (blood clot) due to vascular prosthetic devices, implants and grafts, subsequent encounter. Review of Resident 23's physician order dated 1/8/21 indicated Resident 23's dialysis days were Tuesdays and Thursdays from 6:15 a.m. to 9:15 a.m. Review of Resident 23's physician order dated 5/8/22 indicated remove dialysis dressing to left arm AV shunt (a connection of artery and vein) (at least 4 hours post dialysis). During an observation on 5/11/22 at 9:53 a.m., with the treatment nurse (TN), Resident 23's arm had a white cover (dressing). Resident 23 confirmed his left arm was his dialysis site. Review of Resident 23's hemodialysis report sheet dated 5/10/22 indicated Resident 23 went to dialysis. During an interview with licensed vocational nurse d (LVN D) on 5/11/22 at 10:24 a.m., LVN D confirmed Resident 23 goes to dialysis on Tuesdays and Thursdays. During an interview with LVN D on 5/11/22 at 10:31 a.m., he confirmed Resident 23's dressing was not removed. During an interview with the director of nursing (DON) on 5/11/22 at 4:25 p.m., the DON reviewed Resident 23's physician order and stated the nurses should follow the physician's order. Review of the facility's undated policy, Dialysis Care indicated . Dressing will be changed in accordance with Attending Physician's order.

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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Based on observation, interview and record review, the consultant pharmacist (CP) failed to identify and report the irregular medication orders for two of seven sampled residents (Residents 64 and 84) in the monthly Medication Regimen Review (MRR). This failure resulted in medications not given in accordance with accepted standards of practice and had the potential for not meeting the residents' therapeutic needs or excessive use of medications for the residents. Findings: 1. During a medication administration observation on 5/10/22, at 08:47 a.m., licensed vocational nurse (LVN) J administered 1 tablet of vitamin D 1,000 International Units (IU, unit of potency for vitamins) via Resident 64's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). During medications reconciliation, Resident 64's vitamin D order was: vitamin D tablet (cholecalciferol) give 1 tablet via G-tube two times a day for supplement. Start date 12/23/21. The order did not include a strength. During a concurrent interview and record review on 5/10/22, at 11:05 a.m., with director of nursing (DON), verified there was no strength for Vitamin D order, she stated the nursing staff should have clarified with the physician. A review of Lexi-comp, a nationally recognized drug information resource, it indicated vitamin D comes in different dosage forms, such as: 1,000 IU, 5,000 IU, 25,000 IU and 50,000 IU. A review of the MRR binder (consisted of the CP's recommendations) indicated no recommendations in January, February, March, and April 2022 for Resident 64's medications. 2. A review of Resident 84's physician orders, dated 3/5/22, indicated: lorazepam 0.5 mg give 1 tablet by mouth as needed for Anxiety or S.O.B (shortness of breath) for 90 Days M/B (manifested by) verbalization of anxiousness. The order did not include a dosing frequency, such as how often it should be given. During a concurrent interview and record review on 05/12/22, at 11:13 a.m. with DON and licensed vocational nurse (LVN) L, they verified there was no dosing frequency for as needed Lorazepam order, and they stated all medications should have dosing frequency. A review of the Medication Administration Records (MARs) indicated nursing staff administered 10 doses in March 2022, 14 doses in April 2022, and 2 doses in May 2022. A review of MRR binder indicated no CP's recommendations related to the lack of dosing frequency for Resident 84's lorazepam in March and April 2022. During a phone interview on 05/12/22, at 01:53 p.m. with the CP, she verified above two medication irregularities. She stated she did not see any recommendations from her regarding the irregularities, and she should have identified the issues and notified the facility. A review of the facility's policy and procedures titled Medication Regimen Review and Reporting, dated 9/18, indicated, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities .The findings are communicated to the director of nursing or designee and medical director.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 23 sampled residents (Residents 48 and 13) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. The facility increased Resident 48's Seroquel (an antipsychotic medication) for bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) without adequate indication and documentation, and did not monitor the resident's lipid panel (a test that measures the amount of certain fat molecules called lipids in the blood) annually while the resident was on two antipsychotic medications. 2. For Resident 13, there was no specific behavior for the use of Seroquel. These failures had the potential for increased risks associated with psychotropic medication use that include but are not limited to sedation, anxiety, agitation, and memory loss. Findings: 1a. A review of Resident 48's clinical record indicated she was admitted to the facility with generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and bipolar disorder. A review of Resident 48's physician's orders reflected she was currently receiving two antipsychotic medications: 1. Seroquel 50 milligrams (mg, unit of measurement) give 1 tablet via G-tube at bedtime for Bipolar Disorder M/B (manifested by) angry outburst hitting, kicking, biting staff causing impairment in functional capacity, dated 4/19/22. 2. Olanzapine tablet 10 mg give 1 tablet via G-tube one time a day for schizophrenia M/B hallucination AEB (as evidenced by) talking to herself, dated 3/24/22. A review of Resident 48's medical record indicated the resident was admitted to the facility in August 2020 with Seroquel 25 mg twice daily for bipolar disorder. It was increased to Seroquel 50 mg twice daily starting on 3/21/22 (this dose was discontinued on 5/2/22). On 4/19/22, there was a physician's order to add 50 mg dose at bedtime. The total dose was 50 mg three times daily as of 4/19/22. There was no documented indication or rationale, such as an increase in behaviors/symptoms, in the medical record supporting the reason why the dose was increased. During a phone interview on 5/12/22, at 11:01 a.m., with the medical director (MD), he stated he did not recall regarding the indication of added Seroquel because he was in the middle of patient care, and he needed to talk to the team. He also stated resident has schizophrenia, and she did not respond to the medications well. During a concurrent interview and record review on 5/12/22, 11:18 a.m., with the director of nursing (DON) and LVN L, they confirmed there was no indication documented for increased Seroquel dose at bedtime from a physician on 4/19/22; also, there was no informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention in order to obtain agreement or permission for care, treatment, or services) for its use. They stated there should be a documented rationale or indication for any increased psychotropic medication, and an informed consent. 1b. A review of Resident 48's medical record indicated she had been receiving both Seroquel and olanzepine, in various doses, since admission in August 2020. A review of Lexi-comp, a nationally recognized drug information resource, it indicated antipsychotic medications have the ability to cause metabolic changes including increase in blood sugar and lipids (such as cholesterol and triglycerides). Lexi-comp indicated to monitor lipid panel 12 weeks after initiation and dose change, then annually for Seroquel and olanzapine use. There was no documented evidence in Resident 48's medical record the facility monitored for lipid panel since the resident's admission. A review of the Medication Regimen Review (MMR) binder (consisted of the Consultant Pharmacist (CP)'s recommendations) indicated the CP recommended to get order from the physician for hemoglobin A1C (a blood test that measures your average blood sugar levels over the past 3 months) and lipid panel on 5/3/22. During a concurrent interview and record review with nursing supervisor (NS) N, on 5/11/22 at 4:30 PM, she confirmed there was no lipid panel monitoring in the resident's medical record. On 5/12/22, a review of Resident 48's nursing progress notes, dated 5/11/22, by NS N indicated, pharmacy MMR dated 4/1/22-4/30/22 with pharmacy recommendation to get order from physician A1C and Lipid panel lab work. Lab A1C was done but not Lipid panel for the use of Seroquel on 5/4/22. Facility contacted lab on 5/11/22, and lab stated they called facility to notify them that the blood collected was not enough for lipid panel but no documentation regarding who they talked to. Facility informed the medical director (MD) to explain above, and MD ordered to do stat lipid panel on 5/11/22. During an interview with LVN L on 5/12/22, at 2:55 p.m., she stated she looked through the medical record and could not find any lipid panel monitoring for Resident 48. She acknowledged the monitoring for lipids was required for residents receiving antipsychotic medications. A review of the facility's policy and procedures (P&P) titled Medication Monitoring Medication Management, dated 1/22, indicated, Antipsychotic medications: indication for use must be thoroughly documented in the medical record . Diagnoses alone do not necessarily warrant the use of an antipsychotic medication. The P&P indicated the following for monitoring: Potential adverse consequences: the facility assures that residents are being adequately monitored for adverse consequences such as: .Metabolic: increase in total cholesterol and triglycerides, unstable or poorly controlled blood sugar, weight gain . 2. Review of Resident 13's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including major depressive disorder (persistent feeling of sadness and loss of interest), bipolar disorder (mental illness which a person can experience mood swings [period of overly happy or periods of feeling sad]). During multiple observations on 5/9/22 at 9:47 a.m., 9:50 a.m., 10:12 a.m., 12:03 p.m., 2:02 p.m., Resident 13 was screaming. During an interview with certified nursing assistant K (CNA K) on 5/9/22 at 11:25 a.m., CNA K stated Resident 13 does scream even at night. Review of Resident 13's physician's order dated 2/23/22 indicated Quetiapine Fumarate (seroquel) 50 milligrams (mg, unit of measurement) give 1.5 tablet twice a day for bipolar disorder manifested by angry outburst. During a concurrent interview and record review with nursing supervisor G (NS G) on 5/13/22 at 1:16 p.m., NS G reviewed Resident 13's physician order and stated the behavior should be clarified. During an interview with the DON on 5/13/22 at 2:33 p.m., the DON reviewed Resident 13's clinical record and stated the behavior should be specific to Resident 13. Review of the facility's policy Psychotropic Medication Use (Antipsychotics) dated 12/2016 indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.

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 proper medication storage and labeling of medications when: 1. Temperature monitoring was not consistently documented twice daily on the temperature log sheet, in May 2022, for one of two medication refrigerators; 2. Two insulin (medication to treat high blood sugar) pens had the pharmacy label on the caps instead of the body of the pens; 3. One opened tuberculin purified protein derivative (PPD, a solution used for tuberculin skin test) multi dose vial, one insulin pen, and an opened insulin vial were without the open date or discard date, to make sure they were not used beyond the discard date; 4. Two residents' expired medications were not removed from stock; 5. One unopened insulin vial was not labeled after removing from the refrigerator; 6. One pharmacy dispensed levetiracetam (medication to treat seizures) bottle was without an expiration date on the pharmacy label; 7. Three diabetisource ac (a tube feeding formula) was unattended on top of a cart in the hallway. The deficient practices had a potential for residents to receive medications with reduced potency from expired medications, and/or medication errors due to medications not being labeled. Findings: 1. During a visit to the facility's medication room for skilled nursing unit (Stations 2, 3, and 4) on 5/9/22, at 10:52 a.m. with licensed vocational nurse D (LVN D), the medication refrigerator was observed to contain numerous refrigerated medications including insulin pens, insulin vials, and two flu vaccine syringes. A review of the (REF #1) temperature log for May 2022 indicated it was missing temperatures and signatures on 5/7/22 and 5/8/22 PM (night) shift, and 5/8/22 and 5/9/22 AM (morning) shift. LVN D stated the nursing staff was to monitor and document the temperature monitoring twice daily. He verified the missing temperature monitoring and signatures. A review of the May 2022 temperature log indicated, Refrigerator Temperature to be monitored and documented on DAY SHIFT AND NOC [nocturnal, meaning night) SHIFT. 2. On 5/9/22 at 10:52 a.m., the inspection of REF #1 with LVN D identified two insulin pens which had the pharmacy labels on the caps instead of on the body of the pens. During a telephone interview with the consultant pharmacist (CP) on 5/12/22 at 10:23 a.m., she stated that it was advisable to put the pharmacy label on the body of the pen, not on the cap, to prevent mix-up errors. A review of the 2017 Institute for Safe Medication Practices' (ISMP, a nonprofit patient safety organization with recognized national expertise in medication error prevention) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, it indicated, A patient-specific label is affixed on the body of the insulin pen (not on the removable cap), without obscuring important information on manufacturer labeling or the dose counter/dose window to prevent mix-up errors such as when the caps of two different pens were inadvertently switched. 3. During a visit to the facility's medication room for the subacute unit on 5/9/22, at 11:20 a.m. with the nursing supervisor G (NS G) and director of nursing (DON), one opened PPD multi dose vial was found in the medication refrigerator without an open date. They verified it should have the date of when it was opened. A review of Lexi-comp, a nationally recognized drug information resource, indicated store at 2° Celsius (C) to 8°C (36° Fahrenheit (F) to 46°F); opened vials should be discarded after 30 days. During an inspection of Station 4 Medication Cart #2 on 5/9/22, at 3:37 p.m., with LVN D, Resident 23's Lantus (long last insulin) pen was found in the medication cart without an open date, and Resident 62's opened Lantus multi-dose vial without an open date. LVN D verified these findings. A review of Lexi-comp indicated prefilled pens: once in use, store prefilled pens at room temperature <30°C (<86°F) and use within 28 days. Vials: once punctured (in use), store vials refrigerated or at room temperature <30°C (<86°F) and use within 28 days. 4. During an inspection of Station 4 Medication Cart #2 on 5/9/22, at 3:37 p.m., with LVN D, Resident 23's insulin aspart (a short-acting insulin) multi-dose vial was found in the medication cart with an open date of 4/10/22; the pharmacy label on the insulin indicated to discard 28 days after opening, which indicated the insulin was expired on 5/8/22. LVN D verified this finding. During an inspection of the subacute unit Medication Cart #4 on 5/10/22, at 10:21 a.m., with LVN A, Resident 28's latanoprost eyedrop (to treat glaucoma) was found in the medication cart with an open date of 3/27/22. The pharmacy label on the eyedrop indicated to discard 42 days after opening, which indicated the eyedrop was expired on 5/7/22. LVN A verified this finding. 5. During an inspection of the subacute unit Medication Cart #4 on 5/10/22 at 10:21 a.m., with LVN A, one unopened vial of insulin admelog (short-acting insulin) was identified in the medication cart that was left at room temperature and without the date removed from the refrigerator. The pharmacy label indicated to refrigerate until opened then store at room temperature. LVN A verified this finding. A review of Lexi-comp indicated unopened vials, cartridges, and prefilled pens may be stored under refrigeration between 2°C and 8°C (36°F to 46°F) until the expiration date or at room temperature <30°C (<86°F) for 28 days. 6. During an inspection of the subacute unit Medication Cart #4 on 5/10/22 at 10:21 a.m., with LVN A, one pharmacy-dispensed levetiracetam (medication to treat seizures) bottle was identified in medication cart without an expiration date on the pharmacy label. LVN A verified it did not contain an expiration date. During an interview on 5/10/22, at 11:05 a.m., with DON, she stated each medication product must have an expiration date so the nursing staff would know if the medication was still good to give to the residents. A review of the facility's Policy and Procedures (P&P), titled Administering Medications, revised April 2019, indicated, 12.when opening a multi-dose container, the date opened is reordered on the container. A review of the facility's P&P, titled Storage of medications, revised November 2020, indicated, 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are to be disposed by the licensed nurse in the pharmaceutical waste . 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location . A review of facility's P&P, titled Labeling of Medication Containers, revised April 2019, indicated, 3. Labels for individual resident medications include all necessary information, such as: .h. the expiration date when applicable . 7. During multiple observations on 5/9/22 at 9:45 a.m., 9:50 a.m., 9:55 a.m., there were three bags of diabeticource ac (a tube feeding formula) on top of a medication/treatment cart unattended in the hallway. Residents were wheeling themselves in the hallway. During an interview with LVN D on 5/9/22 at 9:55 a.m., LVN D confirmed the above observation and stated the diabetisource ac should be inside the medication cart. During an interview with the DON on 5/10/22 at 4:57 p.m., the DON stated the three bags of diabetisource ac should be inside the medication cart or in the medication room. The DON further added the diabetisource ac were stored in the medication room. Review of the facility's policy, Storage of Medications, dated 11/2020, indicated The facility stores all drugs and biologicals in a safe, secure, and orderly manner.

CONCERN (D)

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

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to assist and provide emergency dental care for one of two sampled residents (Resident 68). This failure had the potential for Resident 68 to suffer pain. Findings: During an observation on 5/09/22, at 10:20 a.m., in Resident 68's room, she was observed rubbing her left side of her face and grimacing. During an interview on 5/10/22, at 9:48 a.m., with certified nursing assistant F (CNA F), CNA F stated that she told the nurse and social services assistant (SSA) of Resident 68's dental pain two weeks ago. During a review of Resident 68's clinical record dated 3/22/22, Resident 68 was admitted for cerebral vascular accident (disrupted blood flow to the brain), and trigeminal neuralgia (chronic pain condition affecting the trigeminal nerve, this nerve carries sensation from the face to the brain). During a concurrent observation and interview on 5/11/22, at 9:52 a.m., with registered nurse B (RN B), in Resident 68's room, she assessed the resident for dental pain using a flashlight. She observed the inside of the resident's mouth and there was no signs of redness, tenderness or swelling. Resident 68 still complained of left lower jaw pain. During an interview on 5/11/22, at 1:26 p.m., with nursing supervisor G (NS G), NS G stated that she was only made aware of the resident's dental pain on 5/10/22. NS G stated that the nurse should follow-up with SSA as soon as possible. During an interview on 5/13/22 at 10:05 a.m. with the director of nursing (DON), she stated that the nurse was responsible for assessing residents' need for a dental referral and communicating that to the SSA as soon as possible. During a review of the facility's policy titled, Dental Services, dated December 2016, the policy indicated Routine and emergency dental services to meet the resident's oral health services in accordance with the resident's assessment and plan of care.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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2a. During a medication administration observation on 5/10/22, at 08:47 a.m., LVN J administered 1 tablet of vitamin D 1,000 International Units (IU, unit of potency for vitamins) via Resident 64's gastrostomy tube (G-tube, a tube inserted through the belly that brings nutrition directly to the stomach). During medications reconciliation, Resident 64's vitamin D order was: Vitamin D tablet (cholecalciferol) give 1 tablet via G-tube two times a day for supplement. Start date 12/23/21. The order did not include a strength. During a concurrent interview and record review on 5/10/22, at 11:05 a.m., with DON, she verified there was no strength for vitamin D order. She stated the nursing staff should have clarified with the physician. During another interview with the DON on 5/12/22 at 9:31 a.m., she stated the physician wanted to get the lab work for the vitamin D first before ordering the correct dose for the resident. A review of the medication administration record (MAR) indicated the nursing staff had been administering the vitamin D, without the ordered strength, since the ordered date. A review of Lexi-comp, a nationally recognized drug information resource, indicated vitamin D comes in different dosage forms, such as: 1,000 International Units (IU, unit of potency for vitamins), 5,000IU, 25,000 IU, and 50,000 IU. 2b. A review of Resident 84's physician orders, dated 3/5/22, indicated: lorazepam 0.5 milligram (mg) give 1 tablet by mouth as needed for anxiety or S.O.B (shortness of breath) for 90 Days M/B (manifested by) verbalization of anxiousness. The order did not include a dosing frequency, such as how often it should be given. During a concurrent interview and record review on 05/12/22, at 11:13 a.m. with DON and LVN L, they verified there was no dosing frequency for as needed lorazepam order, and they stated all medications should have a dosing frequency. A review of the Medication Administration Records (MARs) indicated nursing staff administered 10 doses in March 2022, 14 doses in April 2022, and 2 doses in May 2022. A review of the facility's policy and procedures titled Medication and Treatment Order, revised July 2016, indicated, .Orders for medications must include: a. Name and strength of the drug; b. Number of doses, start and stop date, and/or specific duration of therapy (if applicable); c. Dosage and frequency of administration; . Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards or practice when: 1. Licensed nurses (LN) did not check food trays for the correct diets before serving the residents in two of 4 stations (Station AA and Station BB); 2. Two of seven sampled residents' (Resident 64 and 84) medications were not clarified with the physician. Resident 64's vitamin D (to prevent osteoporosis or treat vitamin D insufficiency) order did not have a strength since 12/23/21. Resident 84's as-needed lorazepam (medication to treat anxiety disorder) order did not have a dosing frequency since 3/5/22. These failures had the potential to compromise the residents' health and well-being, and not meeting the residents' therapeutic needs or excessive use of medications for the residents Findings: 1. During an observation in the hallway of station BB on 5/12/22 at 7:41 a.m., two LNs were passing medications in the hallways of stations AA and BB. Certified nursing assistants (CNA) were passing trays in station BB. The LNs were not observed checking the food tray before the CNAs distributed the trays to the residents. During an observation on 5/9/22 at 12:44 p.m., CNAs were seen passing out the lunchtime meal trays to the residents. There were two food carts parked in the hallway of station three and station four which contained the lunch trays of the residents. Two LNs were seen in the hallways of station three and four, standing by their medication carts, and were not participating in the passing of the lunch trays to the residents. During an interview with licensed vocational nurse D (LVN D) on 5/9/22 at 12:44 p.m., he was asked if he checked the contents of the meal trays before the CNAs distributed lunch to the residents on station three and station four. LVN D stated No I did not, I do it if I have time. During an interview with the director of nursing (DON) on 05/12/22 at 8:50 a.m., she stated Our process is to have the licensed nurses check the meal trays and make sure the food matches the diet tray card before the CNAs start passing the trays. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 05/12/22 at 12:17 p.m., lunch trays were being passed to the residents. LVN E was reading the diet cards while inspecting the contents of the meal tray for each resident prior to giving it to the CNAs to deliver to the residents. LVN E stated she compares the type of diet listed on the diet slip with the actual food on the tray. LVN E stated licensed nurses do this at every meal and for every resident tray. Review of the facility policy Tray Identification, revised April 2007, indicated nursing staff shall check each food tray for the correct diet before serving the residents.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Random controlled medication use audit for three of four sampled residents' (Residents 23, 48, and 71) as-needed controlled medications did not reconcile. The medications were 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 they were given to the residents. 2. Three of five controlled drug sign-in/sign out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the incoming and outgoing nurse during a shift change) were missing signatures. These failures had the potential for misuse or diversion of controlled medications and inaccurate accountability of controlled medications. Findings: 1. The controlled medication Count Sheets for four random residents receiving as-needed controlled medications were requested for review during the survey. a. Resident 23 had a physician's order for Percocet tablet 5-325mg (oxycodone-acetaminophen, a controlled medication for pain) give 1 tablet by mouth every 6 hours as needed for severe pain, start date 8/4/21. During a concurrent interview and record review on 05/10/22, at 03:32 p.m., with licensed vocational nurse (LVN) L, a review of Resident 23's Count Sheet for Percocet and 4/2022 and 5/2022 MARs reflected the nursing staff removed 1 tablet on 4/2/22 at 10:30 a.m., on 5/5/22 at 10 a.m., and on 5/6/22 at 10 AM from the medication cart and documented on the Count Sheet without documenting in the respective administration on the MAR. LVN L verified this finding, and stated any medication given needed to be documented on MAR as well. She confirmed three Percocet tablets were unaccounted for. b. Resident 48 had a physician's order for alprazolam tablet 1mg give 1 tablet via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) every 12 hours as-needed for anxiety for 90 days m/b (manifested by) pulling out tubing and rolling herself out of bed that poses a danger to herself, start date 4/2/22. During a concurrent interview and record review on 05/10/22, at 03:32 p.m., with LVN L, a review of Resident 48's Count Sheet for alprazolam and 4/2022 MAR reflected the nursing staff removed 1 tablet on 4/21/22 at 10 a.m. from the medication cart and documented on the Count Sheet without documenting the administration on the MAR. LVN L verified this finding and confirmed one alprazolam tablet was unaccounted for. c. Resident 71 had a physician's order for tramadol tablet 50mg give 1 tablet by mouth every 6 hours as needed for mild to moderate pain, start date 2/15/22. During a concurrent interview and record review on 05/10/22, at 03:32 p.m., with LVN L, a review of Resident 71's Count Sheet for Tramadol and 3/2022 and 4/2022 MAR reflected the nursing staff removed following from the medication cart without documenting in the respective administration on the MAR: 1 tablet on 3/17/22 at 2:30 p.m., 3/26/22 at 2 p.m., 3/28/22 at 2 p.m., 3/31/22 at 2 p.m., 4/2/22 at 2 p.m., 4/5/22 at 2 p.m., 4/6/22 at 2:30 (did not indicate in a.m. or p.m.), 4/8/22 at 2 p.m., 4/11/22 at 11:45 a.m., 4/13/22 at 2 p.m., 4/14/22 at 2 p.m., 4/21/22 at 2:30 p.m., 4/22/22 at 2 p.m., and 4/24/22 at 2 p.m LVN L verified the findings, and stated any medication given needed to be documented on MAR. She confirmed 14 Tramadol tablets were unaccounted for. A review of facility's policy and procedures, titled Administering Medications, revised April 2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next dose. A review of facility's policy and procedure, titled Documentation of Medication Administration, revised April 2007, indicated, 1. A nurse .shall document all medication administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after .it is given. 2. Five controlled drug sign-in/sign out sheets from random medication carts were reviewed during the survey. a. On 5/9/22 at 2:15 p.m., a review of the May 2022 controlled drug sign-in/sign-out sheets for Sub-Acute Unit Medication Carts #1 and #2 was conducted with LVN J. The review identified 14 missing signatures: on 5/1/22 AM (morning) and NOC (midnight) shifts, and from 5/2/22-5/6/22 a.m. shift between nursing shift changes for Medication Cart #1. It also identified 18 missing signatures: on 5/1/22 AM and NOC shifts, from 5/2/22-5/4/22 AM shift, 5/5/22 AM and PM shift, and 5/7/22-5/8/22 AM shift between nursing shift changes for Medication Cart #2. LVN J acknowledged the sheets were incomplete. b. A review of the May 2022 controlled drug sign-in/sign-out sheet for Skilled Nursing Facility Unit Medication Cart #2 on 5/9/22, at 3:37 p.m., with LVN D, identified 8 missing signatures: on 5/5/22 AM shift, and 5/6/22 AM, PM, and NOC shift between nursing shift changes. LVN D verified the sign-in/sign-out sheet was incomplete. A review of facility's policy and procedure titled Controlled Substances, revised April 2019, indicated, At the end of each shift: controlled medications are counted at the end of each shift. The nursing coming on duty and the nurse going off duty determine the count together. A review of the controlled drug sign-in/sign-out sheet reminder, dated May 2022, indicated, 2. Both incoming and outgoing must check narcotics at the end of each shift. 3. If the count is incorrect, the medication nurse must remain on duty until the count is correct. 4. Your signature is your verification that the count is correct.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during medication administration for four of five sampled residents (Residents 42, 53, 64, and 72). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications and possible side effects for residents. Findings: 1. During a medication pass observation on 5/9/22, at 09:01 a.m., with licensed vocational nurse D(LVN D), he administered six medications to Resident 53, including a tablet of aspirin enteric coated (a pain reliever with a coating that creates a delayed release of the medication also prevents stroke) 81 milligrams (mg). A review of Resident 53's clinical record indicated a physician's order, dated 12/29/21, for aspirin low strength tablet chewable 81 mg give 1 tablet by mouth one time a day for stroke prevention. During a concurrent interview and record review on 5/9/22, at 1:46 p.m., with LVN D, he verified the order indicated aspirin chewable tablet, but he administered the enteric coated tablet. He stated he needed to call the physician to change the order to enteric coated because the resident was having stomach problems. During another interview with LVN D on 5/9/22 at 3:37 p.m., LVN D stated the physician wanted to keep the aspirin order as chewable 81 mg tablet. 2. During a medication pass observation on 5/9/22 at 9:17 a.m., with LVN A, she administered 6 medications to Resident 72, including an Artificial Tears eyedrop (used to lubricate dry eyes and help maintain moisture on the outer surface of the eyes). At the bedside, LVN A instilled 1 drop in each of the resident's eyes. A review of Resident 72's clinical record indicated a physician's order, dated 9/13/21, for Artificial Tears Solution 1.4% (polyvinyl alcohol) instill 1 drop in left eye three times a day for dry eyes. During a concurrent interview and record review on 5/9/22, at 02:07 PM, with LVN A, she verified the physician's order indicated Artificial Tears 1 drop only for left eye. 3. During a medication pass observation on 5/9/22, at 10:18 a.m., with LVN O, he prepared and administered seven medications to Resident 42, including 2 tablets of Senna-Plus (a combination of sennosides [laxative] and docusate [a stool softener] to treat constipation) 8.6-50 mg, and 1 tablet of docusate 100 mg. A review of Resident 42's clinical record indicated physician's orders: a. Senna tablet 8.6mg (sennosides) give 2 tablets by mouth two times a day for bowel regularity (2 tabs = 17.2mg), hold for loose stools. Dated 9/22/21. b. Docusate sodium tablet 100 mg give 1 tablet by mouth two times a day for bowel management (hold for loose stool). Dated 9/22/21. During a concurrent interview and record review on 5/9/22, at 01:51 p.m., with LVN O, he showed the bottle of medication he used which was Senna-Plus, then verified the physician's order indicated to give Senna, not Senna-Plus. 4. During a medication pass observation on 5/10/22, at 08:47 a.m., with LVN J, she administered nine medications to Resident 64, including: a. A tablet of multivitamin with mineral (a dietary supplement contains a combination of vitamins and minerals). b. About two thirds of a capful of polyethylene glycol 3350 powder (Brand name Miralax, a laxative to treat constipation) mixed with about 6 ounces (oz) of water. During a concurrent interview and record review on 5/10/22 at 9:21 a.m., with LVN J, she stated the Miralax order was for 17 grams. She confirmed she did not measure the Miralax powder to the rim of the cap, but only about two-thirds full. A review of the manufacturer's directions on the polyethylene glycol 3350 powder bottle with LVN J at this time indicated the bottle cap is a measuring cup designed to contain 17 grams of powder when filled to the top rim. It indicated, Fill to the top of the bottle cap which will provide the correct dose (17g). A review of Resident 64's clinical record indicated physician's orders: Multivitamin tablet (multiple vitamin), give 1 tablet via G-tube (a tube inserted through the belly that brings nutrition directly to the stomach) one time a day for supplement. Dated 11/10/21. Polyethylene glycol 3350 powder, give 17 grams (g) via G-tube one time a day for bowel regularity (give with 4-8 oz fluid of water or juice), hold for loose stools. Dated 1/23/20. During a concurrent interview and record review on 5/10/22, at 10:18 a.m., with LVN J, she showed the bottle of multivitamin with mineral with orange label she used. LVN J verified the physician's order indicated multivitamin only, not multivitamin with minerals. A review of the facility's policy and procedure title Administering Medication, revised April 2019, indicated, Medications are administered in accordance with prescriber orders and The individual administering the medications checks .to verify . the right medication, right dosage . before giving the medication.

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 document review, the facility failed to follow proper sanitation and food handling practices when: 1. There were uncovered food items in the facility's kitchen freezer; 2. There was one unlabeled and undated pitcher of pink liquid in the reach-in refrigerator; and 3. Food service equipment was stored wet. These failures had the potential to cause food contamination and food-borne illness to 47 of 47 residents who received their food from the kitchen. Findings: 1. During the initial kitchen tour on 5/9/22 at 9:10 a.m., with the registered dietician (RD) inside the walk-in-freezer, a large bin containing a plastic bag of dinner rolls was observed. The bag of dinner rolls was open and exposed to the air. Another bin containing a plastic bag of corn dogs was observed to be open and exposed to the air. A third bin containing a plastic bag of bacon was observed to be open and exposed to the air. During a concurrent interview with the RD, he confirmed the plastic bags containing the dinner rolls, corn dogs, and bacon were open and exposed to the air in the freezer. The RD stated the bags should be closed. Review of facility's policy Procedure for Freezer Storage, dated 2018, indicate to store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn. Review of the U.S. Food & Drug Administration 2017 Food Code indicated food shall be protected from cross-contamination by storing the food in packages, covered containers, or wrappings. 2. During the initial kitchen tour on 5/9/22 at 9:10 a.m., with the registered dietician (RD), there was one unlabeled and undated pitcher of pink liquid in the reach-in refrigerator. The RD stated, That is diet juice, it should be labeled and dated. I will discard it now. 3. During the initial kitchen tour on 5/9/22 at 9:10 a.m., with the registered dietician (RD), two blender containers were observed on a wire rack. The two blender containers were stored right side up with their lids on top of each container. One container had visible water pooling inside at the base of the container and the second container had visible water drops inside the container. During a concurrent interview with the RD, he confirmed the blender containers were wet. The RD stated the blender containers should not be stored wet and should be air-dried. Review of facility's policy Electrical Food Machines, dated 2018, indicated to wash after each use, and wash in the dishwasher and allow to air dry. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. During a concurrent observation and interview on 5/12/22 at 8:40 a.m., with Registered Nurse C (RN C) in Resident 64's room, an irrigation syringe (tube for sucking in and injecting fluid), used for foley catheter (a rubber tube inserted into the bladder to drain urine), was hanging on the gastric tube (GT) machine (device used to give direct feeding to a stomach). It was attached to an intravenous pole (medical device used to hold bags of fluids or feeding machine). RN C stated that the irrigation syringe should not be on the GT machine for possible cross-contamination. During a concurrent observation and interview on 5/12/22 at 8:47 a.m., with the director of nursing (DON), in Resident 64's room, DON validated that foley syringes must be away from the GT machine to prevent infection. During an interview on 5/12/22 at 9:27 a.m., with DSD/IP, she stated that foley syringes should be placed away from GT machines to prevent infection. During a review of the facility's policy and procedure (P&P) titled, Catheter Irrigation, dated October 2010, the P&P number 20 indicated, Label and store irrigation syringe below an Intravenous pole. 6. During a medication pass observation on 05/09/22, at 09:28 a.m., with LVN A, after entering Resident 72's room, she applied gloves, then pulled the privacy curtain with gloved hands. She stopped the resident's ongoing tube feeding (a therapy where a feeding tube supplies nutrients to people who cannot get enough nutrition through eating) by pressing the pump. Resident 72's ventilator (supplies oxygen to assist with breathing to increase the flow of oxygen to the lungs) started beeping. LVN A performed suction through the resident's tracheostomy (an opening surgically created through the neck into the windpipe to allow direct access to the breathing tube) and mouth. She then removed the old gloves, put on new ones without sanitizing her hands, and proceeded to do the medication administration. During an interview on 5/09/22, at 09:38 a.m., with LVN A, she stated she should have done hand hygiene by sanitizing her hands before putting on new gloves. During an interview on 5/12/22, at 01:23 p.m., with IP/DSD, she stated nurses must do hand hygiene after taking off gloves and before putting on new gloves such as washing hands with soap and water or using hand sanitizer. A review of the facility's policy and procedure titled Handwashing/Hand Hygiene, revised August 2019, indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .J. after contact with blood or bodily fluids; k. after handling used dressings, contaminated equipment, etc.; l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. after removing gloves . Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Licensed vocational nurse D (LVN D) did not perform hand hygiene in between tasks; 2. Face shield unattended on top of a cart parked in the hallway; 3. Certified nursing assistant K (CNA K) did not tie her isolation gown before entering an isolation room; 4. The restorative nursing assistant (RNA) did not follow the sequence in donning personal protective equipment (PPE). 5. Resident 25 did not have a daily Covid-19 screening monitoring; 6. LVN A did not perform hand hygiene in between changing gloves; 7. Irrigation syringe was hanging on the gastric tube (GT) machine. These failures could result in the spread of infection and cross-contamination that could affect the 87 residents who reside in the facility. Findings: 1. During an observation on 5/9/22 at 9:56 a.m., LVN D went to attend Resident 35, touched the resident's arm, left the room and went to his medication cart and touched computer mouse without doing hand hygiene in between. During an interview with LVN D on 5/9/22 at 9:57 a.m., LVN D confirmed the above observation. During an interview with the director of staff development/infection preventionist (DSD/IP) on 5/13/22 at 1:51 p.m., the DSD/IP stated staff should perform hand hygiene in between tasks. Review of the facility's policy, Handwashing/Hand Hygiene dated 08/2019 indicated, perform hand hygiene before and after direct contact with residents. 2. During an observation on 5/9/22 at 10:01 a.m., there was a face shield on top of the maintenance cart parked in the hallway and unattended. During a concurrent observation and interview with the minimum data set coordinator (MDSC) on 5/9/22 at 10:06 a.m., the MDSC confirmed the above observation and stated the face shield should be properly stored. During a concurrent observation and interview with the DSD/IP on 5/9/22 at 10: 11 a.m., the DSD/IP confirmed the above observation and stated the face shield should be stored properly. On 5/9/22 at 10:25 a.m., the administrator (ADM) stated the facility was converting three stations into yellow zone (term use to indicate isolation units). 3. During a dining observation on 5/9/22 at 12:24 p.m., CNA K wore an isolation gown and did not fasten the waist tie before entering an isolation room. CNA K entered the isolation room with an untied isolation gown and distributed the meal trays. The waist tie of the gown was touching the floor. During an interview with CNA K on 5/9/22 at 12:28 p.m., she confirmed the above observation. During an interview with the DSD/IP on 5/13/22 at 1:51 p.m., the DSD/IP acknowledged the staff should tie the isolation gown when entering an isolation room. Review of the Centers for Disease Control and Prevention (CDC) website ppe-sequence.pdf (cdc.gov), indicated when donning a gown, fasten in back of neck and waist. 4. During an observation 5/12/22 at 8:05 a.m., the RNA put on gloves, donned an isolation gown, proceeded to an isolation room, and sat down and talked to a resident in the room. During an interview with the RNA on 5/12/22 at 8:10 a.m., the RNA explained the sequence of donning (putting on) a PPE by donning the gloves followed by the gown. At 9:07 a.m., the RNA stated the sequence was to don the gown first followed by the gloves. During an interview with the DSD/IP on 5/13/22 at 1:51 p.m., the DSD/IP stated staff should don the gown first, perform hand hygiene and don the gloves. Review of the CDC's website, ppe-sequence.pdf (cdc.gov) indicated to don the gown first. 5. Review of Resident 25's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including acute respiratory hypoxia (a condition when the lungs were not properly working and blood oxygen levels are low). Review of Resident 25's physician order did not indicate an order for daily screening for Covid-19 (a highly contagious respiratory disease) symptoms. During a concurrent interview and record review with the DSD/IP on 5/13/22 at 11:27 a.m., the DSD/IP reviewed Resident 25's medication administration record (MAR) and acknowledged there was no Covid 19 symptom monitoring. According to the CDC's website, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes | CDC, updated February 2, 2022 indicated, evaluate residents at least daily for fever and symptoms consisted with Covid-19.

Jun 2019 15 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's privacy for two of 25 sampled residents (Residents 382 and 76) when their body was exposed from the waist down and could be viewed outside from the hallway. This failure had the potential to affect Residents 382 and 76's self-esteem and self-worth. Findings: 1. Review of Resident 382's clinical record indicated he had diagnosis of traumatic subarachnoid hemorrhage (bleeding into the space between the surface of the brain) with loss of consciousness, epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures), tracheostomy (incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea), gastrostomy (surgery that makes a small opening through the skin into the stomach or intestine) and type 2 diabetes (condition that affects the way the body processes blood sugar (glucose). Resident 382's minimum data set (MDS, an assessment tool) dated 5/30/19, indicated his cognition (ability to remember, judge and use reason) was severely impaired. During multiple observations on 6/3/19 at 9:00 a.m., 9:11 a.m., 9:15 a.m. and 10:00 a.m., Resident 382 was lying in bed with no blankets covering his lower body from waist down and exposed to public view in the hallway. During a concurrent observation and interview with admission director H (AD H) on 6/3/19 at 9:15 a.m., AD H confirmed the above observations. She stated that the privacy curtain should have been pulled all the way to avoid Resident 382's lower body exposure. During a concurrent observation and interview with the director of staff development (DSD) on 6/3/19 at 10:02 a.m., the DSD confirmed the above observation. The DSD stated the staff should have used a privacy curtain to protect Resident 382's privacy. 2. Review of Resident 76's clinical record indicated he had diagnosis of traumatic brain injury, seizure (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity), and diabetes (high blood sugar). Review of Resident 76's MDS dated [DATE] indicated his cognition was severely impaired. During an observation on 6/3/19 at 12:22 p.m., Resident 76 was lying in bed with no blankets covering his lower body from waist down and exposed to public view in the hallway. During a concurrent observation and interview with certified nursing assistant I (CNA I) on 6/3/19 at 12:23 p.m., CNA I confirmed the above observation. CNA I stated the staff should have used a privacy curtain during activities of daily living (ADLs, a basic task for dressing, personal hygiene, toilet, and etc.) care to protect Resident 76's privacy. Review of the facility's revised policy, Resident Rights Guidelines for all Nursing Procedures, dated 10/2010, indicated Facility Staff must have appropriate training on resident rights, including resident's dignity and respect For any procedure that involves direct resident care, staff will provide resident's privacy and including bodily privacy.

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent for psychotropic medication (medication capable of affecting the mind, emotions, and behavior) for one of five sampled residents (Resident 36). This failure resulted in Resident 36 not being aware of the risks and benefits of taking psychotropic medications. Findings: Review of Resident 36's clinical record indicated she was re-admitted on [DATE] with diagnoses to include major depressive disorder( depression, a persistent feeling of sadness, and loss of interest). Review of Resident 36's physician orders' included Cymbalta (an antidepressant) delayed release 60 milligram (mg., a unit of measure on capsule by mouth one time a day for chronic pain management. Review of Resident 36's clinical record, Resident's Consent for use of Psychotropic Medications, dated 4/15/19, indicated there was no informed consent obtained from the Responsible Party. Resident 36 did not have the capacity to give informed consent. During an interview and record review with nurse supervisor K (NS K) on 6/6/19 at 1:24 p.m., she confirmed there was no informed consent for Cymbalta. She stated the informed consent should have been obtained by the physician and should have been verified by the nurse. Review of the facility's undated policy, Behavior/Psychotropic Drug Management Policy and Procedure, indicated .Whenever an order is obtained for psychotropic medications, the Licensed Nurse verifies with the Attending Physician that informed consent has been obtained. The Licensed Nurse documents this verification on the Resident's Consent for Use of Psychotropic Medication Form.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to notify all pertinent officials, in a timely manner, following an allegation of abuse for one of two residents (Resident 103) when Resident 103 had notified a staff member of her allegation. This failure had the potential to delay identification and implementation of appropriate corrective action and put the residents at risk for abuse. Findings: During an interview with Resident 103 on 6/3/19 at 9:02 a.m., she stated a certified nursing assistant (CNA) hurt her and put her in a cold shower, because she had a bowel movement and needed to be cleaned up and changed. During an interview with CNA A on 6/3/19 at 9:16 a.m., she stated Resident 103 had told her approximately three months prior about the alleged abuse, but she did not tell anyone. Review of the facility's policy, Abuse Prevention Policy dated 2/23/17, indicated employees and all health practitioners of the facility were mandated reporters. An employee who had knowleged or has been told by an elder or dependent adult that he/sshe experienced behavior contituting abuse shall make report to the local ombudsman or to the local law enforecement agency and the Department of Health Services Licensing & Certification not later than 24 hours of the incident .

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on interview, and record review, the facility failed to ensure the Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing of a transfer for four of four residents (Residents 43, 78, 95 and 106). This failure had the potential of not providing the resident and/or their responsible party (RP, a person who is accountable in making decision in behalf of the resident) with access to an advocate who could inform them of their rights and from being inappropriately transferred. Findings: 1. Review of Resident 43's situation background assessment recommendation (SBAR, a form of communication used in healthcare settings) dated 4/23/19 indicated he was transferred to an acute care hospital. 2. Review of Resident 78's SBAR dated 3/30/19 indicated he was transferred to an acute care hospital. 3. During concurrent interview and record review with licensed vocational nurse F (LVN F) on 6/5/19 at 9:28 a.m., she reviewed respiratory therapist (RT, specialized healthcare practitioner for patients who have trouble in breathing) notes and stated Resident 106 was sent to an acute care hospital on 5/9/19. During an interview with social services director G (SSD G) on 6/6/19 at 4:23 p.m., she stated she did not notify the ombudsman regarding hospital transfers. 4.Review of Resident 95's SBAR dated 4/28/19, indicated Resident 95 was transferred to an acute care hospital. During an interview with SSD G on 6/5/19 at 3:12 p.m., she confirmed the facility did not notify the Ombudsman regarding Resident 95's transfer to an acute care hospital.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

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 accurately code the minimum data set (MDS, an assessment tool) for seven of 25 residents (Residents 8, 61, 104,35,45,125 and 108) when their MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention. Findings: 1. During an initial tour on 6/3/19 at 8:56 a.m., Resident 8 stated she did not have dentures and showed her teeth. Resident 8 had upper and lower broken teeth. Review of Resident 8's MDS section L (Oral/Dental Status) dated 5/22/19 did not indicate a broken teeth assessment. During concurrent observation and interview with minimum data set coordinator M (MDSC M) on 6/4/19 at 3:42 p.m., MDSC M confirmed the above observation and stated the assessment was inaccurate. He stated the assessment should have reflected Resident 8's broken teeth. Review of Centers for Medicare and Medicaid Services (CMS, a federal agency) Resident Assessment Instrument (RAI, a standardized assessment tool for resident) RAI 3.0 Version 1.16 Manual Section L, indicated to code broken natural teeth if seen. 2. Review of Resident 61's MDS dated [DATE] indicated diagnosis of active tuberculosis (a serious infection that affects the lungs). During an interview with the director of nursing (DON), MDSC M, MDSC N, MDSC O on 6/3/19 at 11:50 a.m., they all confirmed Resident 61 did not have an active TB and they acknowledged the assessment was inaccurate. 3. Review of Resident 104's MDS dated [DATE], 2/2/19 and 11/2/18 indicated active diagnosis of viral hepatitis (an infection that causes liver inflammation and damage). 4. Review of Resident 35's MDS dated [DATE], 12/13/18 and 9/13/18 indicated active diagnosis of viral hepatitis. 5. Review of Resident 45's MDS dated [DATE], 12/19/18 and 9/19/18 indicated active diagnosis of viral hepatitis. 6. Review of Resident 125's MDS dated [DATE] and 2/14/19 indicated active diagnosis of viral hepatitis. 7. Review of Resident 108's MDS dated [DATE] indicated active diagnosis of viral hepatitis. During a group interview with the DON, MDSC M, MDSC N, MDSC O on 6/3/19 at 9:35 a.m., they all confirmed Resident 104, 108, 125, 45 and 35 did not have an active viral hepatitis and they acknowledged the assessment was inaccurate. A review of CMS RAI 3.0 Version 1.16 Manual Section I, indicated Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring or risk if death during the 7-day look back period .

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** 2. Review of Resident 43's care plan dated 5/17/19 indicated he was on restorative nursing assistant (RNA, nursing interventions that promote the residents' ability to live as independently and safely as possible) program active range of motion exercises three times a week. Review of Resident 43's May 2019 physician order did not indicate an order for RNA program. During an interview with the minimum data set coordinator N (MDSC N) on 6/6/19 at 12:58 p.m., he stated Resident 43 was not on the RNA program. During an interview with the director of nursing (DON) on 6/7/19 at 10:12 a.m., the DON stated the care plan was not revised and should have been revised quarterly and as needed. Based on interview and record review, the facility failed to develop and implement an individualized person-centered comprehensive care plan for four of 25 residents (Residents 35, 43, 32 and 94) when: 1. Resident 35's hand roll intervention was not implemented; 2. Resident 43's care plan was not revised; 3. Resident 32's care plan was not developed for enoxaparin sodium (anticoagulant medication); and 4. Resident 94's care plan was not developed for zolpidem tartrate (sedative-hypnotic medication) and enoxaparin sodium. These deficient practices had the potential for the resident's needs not being met. Findings: 1. During an observation on 6/3/19 at 8:49 a.m., Resident 35's both hands had contractures (a deformity that caused of stiffness or constriction of connective tissues). There was a rolled towel on her left hand but nothing on the her right hand. During concurrent interview and record review with nursing supervisor L (NS L) on 6/7/19 at 11:06 a.m., she reviewed Resident 35's care plan and confirmed the rolled towel should be on both hands to prevent a further decline. She further stated Resident 35's care plan was not followed. 3. Review of Resident 32's face sheet indicated he had diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis and cerebral infarction ((an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), and diabetes (increase in blood sugar). Review of Resident 32's minimum data set (MDS, an assessment tool) dated 3/8/19, indicated he was cognitively impaired required assistance for bed mobility, dressing, toileting, personal hygiene, bathing, and impairment of functional limitation in range of motion. Review of Resident 32's physician order dated 1/16/19, indicated enoxaparin sodium 40 milligrams (mg, unit of measurement) inject subcutaneously (under the skin) for deep vein thrombosis (DVT, a blood clot ). During an interview with licensed vocational nurse F (LVN F) on 6/6/19 at 3:02 p.m., she stated she was unable to find the care plan for enoxaparin soduim. LVN F stated Resident 32 should have a care plan for enoxaparin sodium. 4. Review of Resident 94's clinical record indicated, he had diagnoses of insomnia (inability to sleep) and tracheostomy (a tube is inserted through a cut in the neck below the vocal cords) status. Review of Resident 94's MDS dated [DATE], indicated he was cognitively intact, required assistance for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. Review of Resident 94's physician order dated 6/2/19 zolpidem tartrate tablet 10 mg as needed for insomnia. Review of Resident 94's physician order dated 1/18/19 enoxaparin sodium 40 mg inject subcutaneously for DVT. During an interview with NS L on 6/5/19 at 8:24 a.m., she stated there was no care plan developed for zolpidem tartrate medication and enoxaparin sodium medication. NS L also stated the licensed nurses were responsible for developing care plans and it should have been in place. Review of the facility's 2016 policy, Care Plans, Comprehensive Person-Centered, indicated person centered care plan should include measurable objectives, timetables to meet the residents physical, psychosocial, functional needs was developed, implemented for each resident.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate treatment and services were provided for three of seven residents (Residents 35, 36, 43, and 107) when the restorative nursing assistant (RNA, program that helps residents to gain an improved quality of life by increasing their level of strength and mobility) program was not implemented. This deficient practice had the potential to result in residents' decline in range of motion. Findings: 1. Review of Resident 43's June 2019 physician orders did not indicate a RNA program order. During a concurrent interview and record review with licensed vocational F (LVN F) on 6/7/19 at 8:31 a.m., LVN F reviewed Resident 43's situation background assessment recommendation (SBAR, a form of communication used in health care settings) dated 4/23/19. LVN F confirmed Resident 43 was transferred to an acute hospital and returned to the facility on 5/16/19. During an interview with minimum data set coordinator N (MDSC N) on 6/6/19 at 12:58 a.m., he stated Resident 43's RNA program was discontinued when he was transferred to an acute hospital. MDSC N confirmed the RNA program should have been reinstated when Resident 43 returned to the facility. He further stated, Resident 43 should have been in the RNA program. During an interview with the director of nursing (DON) on 6/7/19 at 10:12 a.m., the DON stated Resident 43 should have been in the RNA program. 3. During an observation on 6/3/19 at 8:49 a.m., Resident 35's both hands had contractures (a deformity that caused of stiffness or constriction of connective tissues). Review of Resident 35's physician order dated 2/21/18 indicated passive range of motion exercises three times a week. During concurrent interview and record review with nursing supervisor L (NS L) on 6/7/19 at 11:24 a.m., NS L reviewed the RNA documentation for May 2019 and stated there were episodes the RNA program was given only two times a week. The order for three times a week was not followed. 4. Review of Resident 36's clinical record indicated she was re- admitted on [DATE] with diagnoses including hemiplegia and hemeparesis (weakness on one side of the body)following unspecified cerebrovascular disease(stroke) affecting the right dominant side, generalized muscle weakness and contracture (essentially muscles or tendons that have remained too tight for too long, thus becoming shorter) of the right hand. Review of Resident 36's minimum data set (MDS, an assessment tool), dated 3/15/19, indicated she was moderately impaired in cognitive (thinking process) status. Except for eating, Resident 36 required extensive assistance in her activities of daily living (ADLS). She also had functional limitation in her range of motion (ROM) of the right arm, contracture of the right hand, and impairment on both sides of the lower extremities. During an observation on 6/6/19 at 10 a.m., Resident 36 was in bed doing a partial bath. She said she could wash her front with her left hand but the staff would wash her back and her private parts. She also stated the staff used to come and do exercises on her right arm but the staff did not do it lately. Her right hand was contracted. Doing an interview with MDSC O (Minimum Data Set Coordinator O) on 6/6/19 at 2:15 p.m., she stated the RNA program was discontinued on 3/2019 because the resident was able to do exercises during the activities. During an interview with activity director (AD) on 6/6/19 at 2:30 p.m., she stated Resident 36 would attend activities three to four times per week. Activity calendar indicated Exercise, Chair Exercise, and Exercise with music. When asked how the exercises would help with increasing strength and mobility for the affected arm and hand, she stated Resident 36 rarely used her right arm. The AD also confirmed they did not assess progress of resident's range of motion based on the activity exercises. 2. Review of Resident 107's face sheet indicated he was diagnosed with diabetes (increase blood sugar) and respirator (a device worn over the mouth and nose to protect the respiratory tract by filtering out dangerous substances (such as dusts or fumes) from inhaled air) status. Review of Resident 107's minimum data set (MDS, an assessment tool) dated 5/7/19, indicated Resident 107 was cognitively intact, required assistance with activities of daily living such as bed mobility, transfer, toileting, personal hygiene, dressing, and impaired functional limitation in range of motion. During an interview with the minimum data set coordinator O (MDS O) and concurrent record review on 6/5/19 at 2:55 p.m., she stated Resident 107 had functional limitation in range of motion on both upper and lower extremities. She stated Resident 107 should have been in the RNA program to prevent him from declining. During an interview with nursing supervisor L (NS L) on 6/6/19 at 2:36 p.m., she stated Resident 107 was transferred to the hospital on February 2019 and was not put back to the RNA program. NS L also stated Resident 107 would have benefitted within the RNA program to prevent contractures and declining. Review of the facility's undated policy, Restorative Nursing Services, indicated resident would receive restorative nursing as needed to help promote optimal safety and independence. Resident could start restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and management of a gastrostomy tube (G-tube, a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) was implemented for one of four sampled residents with G-tube (Resident 73). The facility failed to ensure a physician order was followed when the gastrostomy tube was not available for replacement when obstructed. This failure had the potential to delay the nutritional needs and compromise the health of the residents. Findings: Review of Resident 73's face sheet indicated he had diagnoses gastrostomy (a surgical operation for making an opening in the stomach), persistent vegetative state (a disorder of consciousness in which patients with severe brain damage), and diabetes (increase in blood sugar). Review of Resident 73's minimum data set (MDS, an assessment tool) dated 4/12/19, indicated persistent vegetative state, required assistance with bed mobility, dressing, toileting, personal hygiene and bathing. During an observation and concurrent interview with registered nurse J (RN J) on 6/6/19 at 9:18 a.m., an indwelling catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) was in the left side of Resident 73's abdomen. RN J stated Resident 73 G-tube was obstructed and was replaced with an indwelling catheter on 5/25/19. RN J also stated it had been 13 days since the indwelling catheter was inserted for Resident 73. Review of Resident 73's physician order dated 5/5/19, indicated to replace the G-tube as needed when obstructed. Review of Resident 73's progress note dated 5/25/19, indicated the gastrostomy was obstructed and G-tube was not available. Resident 73 could use indwelling catheter until gastrostomy was available as ordered. Review of Resident 73's physician order dated 5/25/19, indicated may use indwelling catheter until G-tube was available. During an interview with the central supply manager (CSM) on 6/6/19 at 9:25 a.m., he stated he was not aware the G-tube for Resident 73 was not available, he was not informed by the licensed nurses. During an interview with the medical director (MD) on 6/6/19 on 10:49 a.m., he stated the indwelling catheter was temporary until the G-tube was available. The MD stated the G-tube should have been ordered to replace the indwelling catheter for Resident 73. During an interview with the nurse supervisor L (NS L) on 6/6/19 at 1:42 p.m., she stated the indwelling catheter was inserted temporary until G-tube was available. NS L stated the licensed nurses should have ordered the G-tube to replace the inserted indwelling catheter of Resident 73. Review of the facility's 2014 policy, Changing a Feeding Tube, indicated to replace the feeding tube as ordered or as directed.

CONCERN (D)

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

Deficiency F0740 (Tag F0740)

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 two of five residents (56 and 125) with behavior problems were adequately monitored. For Residents 56 and 125, the facility did not follow-up on psychiatric services (referral). This failure could potentially affect the residents' highest physical, mental and psychosocial well- being. Findings: 1. Review of Resident 56's clinical record on 6/7/19, indicated he was admitted on [DATE], with diagnoses to include anxiety disorders (feelings of intense, excessive and persistent worry and fear about everyday situations). Review of Resident 56's minimum data set (MDS, an assessment tool) dated 3/29/19 indicated he was cognitively intact and he had verbal behavioral symptoms (i.e. angry outbursts) directed at staff. Review of Resident 56's physician orders' indicated he was on Depakote for mood instability manifested by angry outburst; Duloxetine for depression ( persistent feeling of sadness and loss of interest) manifested by multiple health concerns; and Trazadone for insomnia (inability to sleep). Review of Resident 56's care plan indicated he had behavior of falsely accusing staff and other people when he did not get what he wants; behavior problem of angry outburst manifested by yelling and cursing at staff and at other residents; and non-compliance with care and other treatment (i.e. keeping alcohol at the bedside). Review of Resident 56's miscellaneous record on 6/7/19, indicated the social service staff notified the physician on 7/12/18, via a facsimile (fax), regarding a psychological review of Resident 56, for a new diagnosis of depression. It also indicated the resident had verbally expressed at least one item in the past, feelings of desiring self-harm. During an interview with the social service director skilled nursing facility (SSD SNF) on 6/7/19 at 8:41 a.m., she stated the social service staff who notified the physician, was no longer employed in the facility. She acknowledged there was no referral for a psychiatry evaluation (medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders) or follow-up for Resident 56. The SSD SNF stated the medical physician ordered the psychotropic (drugs that affect a person's mental state) medications for the resident, During an interview with social service director G (SSD G) on 6/7/19 at 11: 27 a.m., she stated there was a challenge on psychiatric referrals especially on county services. She stated they used to do face time with a psychiatric service in Los Angeles but it stopped when there was a change in administration. SSD G confirmed and acknowledged there was no documentation on any referral or follow-up for psychiatric services. She stated residents who were cognitively intact have the right to refuse care and the treatment plan. However, she confirmed there was no documentation of refusal by Resident 56 of any recommended treatment plan. She also acknowledged the facility did not look into other options for referral to ensure the residents received appropriate psychiatric services. 2. Review of Resident 125's clinical record indicated he was admitted on [DATE] with diagnoses to include major depressive disorder (feelings of persistent sadness, and loss of inerests), insomnia, chronic pain, and insomnia (inability to sleep) among others. Review of Resident 125's annual minimum data set (MDS, an assessment tool) dated 2/14/19, indicated he was cognitively intact and fairly independent in his activities of daily living (ADLS). Review of Resident physician orders included orders for Cymbalta (antidepressant) manifested by continuous verbalization of health concerns, and Trazadone for depression manifested by angry outburst. During an interview and record review with the director of nursing (DON) on 6/6/19 at 1:37 p.m., she stated Resident 125 was followed by psychiatric (psych) services once a month. She stated according to social service, Resident 125 sometimes refused to go to psych follow-up visits. The DON confirmed there is no documentation of the resident's refusal to go to psych visits and was not specifically indicated in the care plan. The DON also acknowledged there was no follow-up by the facility on Resident 125's visits because there was documentation of the visits. During an interview with the SSD SNF on 6/7/19 at 8:45 a.m., she stated Resident 125 would sometimes go to psych follow-up visits while out on pass. She acknowledged there was no system of tracking resident's visits as he is independent. Review of the facility's undated policy, Behavior/Psychotropic Drug Management Policy and Procedure, indicated it is the facility's policy to ensure that when a resident displays mental to psychosocial adjustment difficulties, he/she receives appropriate treatment and services in order to obtain or maintain the highest practicable physical, mental, and psychosocial well-being .Interventions include .consider psychiatric/psychological consultation 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 an accurate accounting of controlled substance (CS) medications (medications with a high risk for abuse and addiction) when random CS medication audits did not reconcile for seven of 19 residents (Residents 36, 37, 41, 59, 60, 88 and 382). This failure had the potential to result in the abuse or the misuse of controlled medications. Findings: 1. During an interview and record review with the director of nursing (DON) on 6/5/19 at 1:50 p.m., she compared the Medication Administration Record (MAR) and the corresponding Controlled Drug Record (CDR) of Residents 36, 37, 41, 59, 60, 88 and 382 for the month of April, May and June 2019. The DON further stated the narcotic medications were not properly accounted for and confirmed the following discrepancies: Resident 36's MAR did not reflect hydrocodone-acetaminophen (pain medication) 5-325 milligram (mg- unit of measure) being administered on 6/3/19 as it was recorded in her CDR. Resident 60's MAR did not reflect lorazepam (anxiety medication) 0.5 mg being administered on 4/16/19 and 4/29/19 as it was recorded in his CDR. Resident 382's MAR did not reflect hydrocodone-acetaminophen (pain medication) 7.5-325 mg being administered on 5/29/19 as it was recorded in his CDR. Resident 37's MAR did not reflect hydrocodone-acetaminophen (pain medication) 5-325 mg being administered on 5/3/19, 5/4/19, 5/8/19, 5/9/19, and two times on 5/12/19 as it was recorded in his CDR. Resident 88's MAR did not reflect oxycodone (pain medication) 5 mg being administered on 4/26/19, 4/29/19, 5/12/19, 5/19/19, two times on 5/21/19 and 5/22/19 as it was recorded in her CDR. Resident 41's MAR did not reflect hydrocodone-acetaminophen (pain medication) 10-325 mg being administered on 5/30/19, 5/31/19, and 6/2/19 as it was recorded in her CDR. Resident 59's MAR did not reflect morphine sulfate (pain medication) 15 mg being administered on 5/27/19, 5/28/19, 5/29, 5/30/19, 5/31/19, 6/1/19, 6/2/19, and 6/4/19 as it was recorded in her CDR. Review of the facility's policy Medication Administration - Controlled Substances dated 2007, indicated When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing from controlled storage: date and time of administration, amount administered and signature of the nurse administering the dose. Administer the controlled medication and document dose administration on the MAR.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 43's clinical record indicated he was re-admitted to the facility on [DATE] with diagnoses including schizophrenia (severe mental disorder affecting how a person's think, feel and behaves). Review of Resident 43's physician order dated 5/17/19, indicated Risperidone (an antipsychotic medication used to treat schizophrenia, bipolar disorder) one milligram (mg, unit of measurement) via gastrostomy tube (G-Tube, a tube that is inserted through the abdomen to deliver nutrition directly to the stomach) at bed time for schizophrenia manifested by visual hallucination. Review of Resident 43's physician order dated 5/16/19 indicated monitor side effect of risperidone every shift. Review of Resident 43's medication administration record (MAR) for the month May and June 2019 indicated a check marked on the monitoring of side effect of risperidone. The MAR did not indicate if there were side effects of the medication. During an interview with licensed vocational F (LVN F) on 6/6/19 at 12:58 p.m., she stated the licensed nurses should put 0 if there were no side effect episode. She further acknowledged the monitoring of Risperidone side effects were not in the progress notes. During an interview with the director of nursing (DON) on 6/7/19 at 10:12 a.m., the DON stated from January to June 6, 2019 MAR indicated X for Risperidone side effect monitoring. The monitoring should indicate the number of side effect episode. 2. Review of Resident 59's physician order dated 5/27/19 indicated Lurasidone (Latuda) 120 milligram (mg, unit of measurement) daily for paranoid schizophrenia (a mental illness characterized by delusions and hallucinations). Review of Resident 59's physician order dated 4/6/18 indicated monitor side effect of Latuda everyshift. During concurrent interview and record review with nursing supevisor L (NS L) on 6/7/19 at 10:21 a.m., NS L confirmed the monitoring of Latuda every shift indicated X instead of 0 if there was no episode. NS L stated she should put a 0 for no side effects instead of X mark which did not clearly indicate the specific side-effects of Latuda. 4. Review of Resident 36's clinical record indicated she was re-admitted on [DATE] with diagnoses to include major depressive disorder (depression, persistent feeling of sadness, loss of interest) and chronic pain. Review of Resident 36's physician orders' included Cymbalta (an antidepressant) delayed release 60 milligram (mg., a unit of measure on capsule by mouth one time a day for chronic pain management. Review of Resident 36's medication administration record (MAR) for the month of April 2019, indicated to give Cymbalta delayed release, one capsule a day for depression manifested by continuous verbalization of multiple concerns. Review of Resident 36's medication administration record (MAR) for the months of April, May, and June 2019, indicated to monitor side effects of Cymbalta (i.e. dry mouth, sleepiness, fatigue , constipation, loss of appetite, sweating ) every shift. There was a check marked every shift. During an interview with the director of nursing (DON) on 6/6/19 at 9:42 a.m., she stated Cymbalta was not only indicated for pain but for depression. She also acknowledged which she just added depression as indication for Cymbalta use. For monitoring side-effects, the DON stated the staff should put a 0 for no side effects instead of a check mark which did not clearly indicate the specific side-effects of Cymabalta. Review of the facility's policy, Depression-Clinical Protocol, revised 9/12, indicated under Monitoring and Follow-Up . The staff and physician will monitor the resident's response to treatment for depression and will document The staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and other classes of medications. Based on interview and record review, the facility failed to ensure the residents were free from unnecessary drugs for four of four sampled residents (Residents 128, 59, 36, and 43). Resident 128 who received lorazepam (antianxiety medication) ordered as needed (mg, unit of measurement) had no evidence of documentation the prescribing physician evaluated Resident 128 for the appropriateness of the medication. Resident 59 who received Lurasidone (Latuda) 120 milligram (mg, unit of measurement) daily for paranoid schizophrenia (a mental illness characterized by delusions and hallucinations); Resident 43 who received Risperdone (antipsychotic medication); and Resident 36 who received Cymbalta (antidepressant medication) had no monitoring for side effects every shift as prescribed by the physician. This failure had the potential for the residents to receive unnecessary medication. Findings: 1. Review of Resident 128's face sheet indicated she had diagnoses dementia (memory problem) and hypertension (increase in blood pressure). Review of Resident 128's Minimum Data Set (MDS, an assessment tool) dated 5/18/19, indicated she was cognitively impaired, required assistance for bed mobility, transfer, dressing, toileting, eating, and personal hygiene. Review of Resident 128's physician order dated 5/10/19, indicated lorazepam 0.5 milligrams (mg, a unit of measurement) to give by gastrostomy tube (G-Tube, a tube inserted through abdomen that delivers nutrition and hydration directly to the stomach) as needed for anxiety for 90 days. During an interview with nursing supervisor K (NS K) on 6/5/19 at 3:50 p.m., she stated she was unable to find a evidence of documentation the prescribing physician evaluated Resident 128 regarding the appropriateness of lorazepam as needed for 90 days. During an interview with the pharmacy consultant on 6/5/19 at 4:15 p.m., she stated Resident 128 should have an evidence of documentation regarding lorazepam as needed for 90 days. Review of the facility's 12/2016 policy, Antipsychotic Medications Use, indicated the need to continue as needed orders for psychotropic medications beyond 14 days required the prescribing physician document the rationale for the extended order.

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 5.56% medication error rate when two medication errors out of 36 opportunities were observed during medication administration for one resident (Resident 60). This failure had the potential to compromise the resident's medical health. Findings: Review of Resident 60's physician orders dated 3/5/19, indicated Budesonide Suspension (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma) 0.5 milligrams/2milliliters (mg, ml units of measure). 2 ml inhale orally via nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) two times a day for COPD (chronic obstructive pulmonary disease, a lung disease in which airflow is obstructed and interferes with normal breathing). Resident 60's physician order dated 5/27/19 indicated Ipratopium-Albuterol Solution (help control the symptoms of lung diseases) 0.5-2.5(3)mg/3ml. 3 ml inhale orally via nebulizer every 4 hours as needed for COPD. During an observation on 6/3/19 at 4:24 p.m., licensed vocational nurse Q (LVN Q) administered the scheduled medications to Resident 60. She opened a plastic vial containing liquid labeled Budesonide Inhalation Suspension and poured it into the nebulizer compartment. LVN Q opened a second plastic vial containing a liquid labeled Iprat-albuterol and added it to the liquid already in the nebulizer. She turned on the nebulizer machine and handed the device to Resident 60 who proceeded with his inhalation treatment. During a concurrent interview with LVN Q on 6/3/19 at 4:24 p.m., she stated the Budesonide was a routine medication and the Iprat-albuterol is a prn (pro re nata as needed) medication. LVN Q stated, Resident 60 .always asks for the prn medication when I give his routine 5 p.m. medications, he requests the Iprat-albuterol for shortness of breath. I always give the 2 two medications together in the nebulizer, I was told to do that when I was trained. During an interview with the director of nursing (DON) on 6/5/19 at 1:50 p.m., she stated the nebulizer medications should been administered separately, not combined into one treatment. According to Lexicomp ([NAME].com, an online nationwide source for drug information) regarding Budesonide, (Oral Inhalation) for administration: Use with jet nebulizer connected to an air compressor; administer with mouthpiece or facemask. Do not mix with other medications in nebulizer.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were appropriately stored and labeled during an inspection of two medication rooms and randomly selected medication carts when the following was found: 1. An emergency kit (e-kit, a box containing medication needed for immediate administration) containing injectable (put into the body using a needle and syringe) medications contained expired medications. 2. Medications that required refrigeration were stored inside the medication carts. 3. An injectable medication pen was opened and used with no date. 4. Liquid nutritional supplement was expired. These failures had the potential for the administration of expired or deteriorated medications or biologicals. Findings: 1. During an observation and concurrent interview with licensed vocational nurse B (LVN B) on 6/03/19 at 2:57 p.m., an e-kit containing injectable medications were examined in the medication room shared by Stations 3 and 4. On the outside of the e-kit was an inventory list of medications contained in the e-kit and their corresponding expiration dates. The inventory list identified: Lasix (water pill) 20mg/ml, 3 vials (2ml) with an expiration date of 6/1/19. LVN B opened the e-kit and removed three (2ml) vials of Lasix 20mg/ml, each vial had an expiration date of 6/1/19 printed on the vial. LVN B stated the Lasix was expired and should have been removed from the e-kit. 2. During a random inspection of medication cart SUB-ACUTE #7 with LVN D on 6/4/19 at 11:15 a.m., a house supply bottle of Acidophillus (a probiotic, living organisms that when ingested provide numerous health benefits) was noted with an open date written on the top of the bottle. Directions on the bottle read refrigerate after opening. LVN D verified the directions and confirmed the bottle was opened and in use and should have been refrigerated. During a random inspection of medication cart SNF #3 with LVN C on 6/4/19 at 11:35 a.m., a house supply bottle of Acidophillus was noted with an open date written on the top of the bottle. Directions on the bottle read, refrigerate after opening. LVN C verified the directions and confirmed the bottle was opened and in use and should have been refrigerated. A review of the facility's policy, Storage of Medications revised April 2007, indicated medications requiring refrigeration must be stored in a refrigerator locked in the drug room at the nurses' station or other secured locations. 3. During a random inspection of medication cart SUB-ACUTE #7 with LVN D on 6/4/19 at 11:15 a.m., an opened and undated multi-use Victoza (drug for the treatment of a chronic condition that affects how the body processes blood sugar) pen was observed. LVN D confirmed there was no date on the pen indicating when the medication was opened and stated there should be an open date. Review of Lexicomp online (www.[NAME]-comp.com, a nationally recognized drug information resource) regarding Victoza, indicated pen should be discarded 30 days after initial use. 4. During a random inspection of medication cart SUB-ACUTE #7 with LVN D on 6/4/19 at 11:15 a.m., one 8 ounce can of Suplena (liquid therapeutic nutritional supplement) was observed in the bottom drawer of the medication cart. The Suplena had an expiration date of May 2019. LVN D stated the supplement was expired and should have been discarded. A review of the facility's policy Storage of Medications revised April 2007, indicated the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. During an interview with the director of nursing (DON) on 6/5/19 at 1:50 p.m, the facility's policy for storage of medications was reviewed. She confirmed that the e-kits should not contain any expired medications. She stated that the pharmacists visits monthly to check the contents of all the facility e-kits. The DON stated medications requiring refrigeration should not be kept in the medication carts after opening if the directions indicate to refrigerate. The DON stated all vials and pens should be dated when opened and discarded per manufacturers recommendations. She further stated that expired medications and nutritional supplements should be discarded by the expiration dates on the products.

CONCERN (D)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to store and ensure food under sanitary conditions for one of two sampled residents (Resident 94) when resident food brought by a family member (FM) was not properly stored, labeled and dated. This failure had the potential for food borne illness and food contamination. Findings: Review of Resident 94's clinical record indicated, he had diagnoses of morbid (unhealthy state) obesity due to excess calories and tracheostomy (a tube is inserted through a cut in the neck below the vocal cords) status. During an observation on 6/3/19 at 8:33 a.m., Resident 94 was lying on bed with three opened bags of biscuits on the bedside table and an opened bag of a loaf of bread. During an observation and interview with registered nurse J (RN J) on 6/4/19 at 4 p.m., she stated Resident 94 had opened bags of biscuits on the table and an opened bag of loaf bread. RN J stated the food was not properly stored, labeled and dated. During an interview with registered dietitian (RD) on 6/6/19 at 1:19 p.m., he stated the staff should have covered, sealed, and dated the food brought by the family member. Review of the facility's 2016, Food Brought by Family/Visitors, indicated the food brought by family/visitors that was left with resident to consume later will labeled and stored in a manner that was clearly distinguishable from facility-prepared food. Non-perishable foods will be stored in a resealable containers. with tight-fitting lids. Containers would be labeled with the resident name, item and the use by date

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to assure proper infection control practices was followed when: 1. Resident 382's undated used gastrostomy (GT, a surgical opening into the stomach for administration of nutrition and medications) syringe, opened unlabeled one gallon of distilled water were in the resident's room. 2. Resident 90 outdated nebulizer tubing was left on top of the machine. 3. Resident 131's suction machine (a device act or process of sucking) tubing was hanging and touching the floor. Findings: 1. During an observation on 6/4/19 at 9:47 a.m., undated GT syringe was at the bedside of Resident 382. During a concurrent observation and interview with licensed vocational nurse R (LVN R) on 6/4/19 at 9:53 a.m. She confirmed the above observation. LVN R further stated that it should have been dated. During an observation on 6/4/19 at 9:54 a.m., one gallon of opened unlabeled distilled water was in Resident 382's room. During a concurrent observation and interview with the LVN D on 6/4/19 at 9:57 a.m. She confirmed the above observation. LVN D further stated that it should have been labeled. Review of the facility's policy and procedure, Medication Administration Enteral Tubes revised 9/2018, indicated clean feeding syringe and return to plastic container of bedside stand or hang it on feeding pole Syringes are replaced after 24 hours or as required by state regulation. 2. During an initial tour observation on 6/3/19 at 8:56 a.m., nebulizer tubing dated 5/3/19 was left on top of the machine of Resident 90's bedside table. During a concurrent observation and interview with the LVN D on 6/3/19 at 8:58 a.m, she confirmed the above observation. LVN D further stated that the tubing was outdated and it should have been changed. Review of the facility's policy and procedure, Administering Medications through a Small Volume (Handheld) Nebulizer revised 10/2010, indicated rinse and disinfect the nebulizer equipment according to facility protocol Store in a plastic bag with the resident's name and the date on it. Change equipment and tubing every seven days. 3. Review of Resident 131's face sheet indicated he had diagnoses of respiratory failure (condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) and tracheostomy (a tube is inserted through a cut in the neck below the vocal cords) status. Review of Resident 131's minimum data set (MDS, an assessment tool) dated 5/2319, indicated Resident 131's he was cognitively impaired, required assistance for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. During an observation on 6/3/19 at 8:01 a.m., observed suction (the act or process of sucking) tubing was hanging and touching the floor. During an observation and interview with licensed vocational nurse P (LVN P) on 6/3/19 at 8:02 a.m., she stated the suction machine tubing should not be touching the floor. During an interview with nursing supervisor L (NS L) on 6/6/19 at 2:30 p.m., she stated the suction machine tubing should have been placed inside the bag to prevent contamination. Review of the facility's undated policy, Suctioning The Lower Airway, indicated to remove secretion and to prevent infection of the the lower respiratory tract.

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.
• 14% annual turnover. Excellent stability, 34 points below California's 48% average. Staff who stay learn residents' needs.

Concerns

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

Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

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About This Facility

What is A Grace Sub Acute & Skilled Care's CMS Rating?

CMS assigns A GRACE SUB ACUTE & SKILLED CARE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is A Grace Sub Acute & Skilled Care Staffed?

CMS rates A GRACE SUB ACUTE & SKILLED CARE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 14%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at A Grace Sub Acute & Skilled Care?

State health inspectors documented 48 deficiencies at A GRACE SUB ACUTE & SKILLED CARE during 2019 to 2025. These included: 48 with potential for harm.

Who Owns and Operates A Grace Sub Acute & Skilled Care?

A GRACE SUB ACUTE & SKILLED CARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 166 certified beds and approximately 102 residents (about 61% occupancy), it is a mid-sized facility located in SAN JOSE, California.

How Does A Grace Sub Acute & Skilled Care Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, A GRACE SUB ACUTE & SKILLED CARE's overall rating (4 stars) is above the state average of 3.2, staff turnover (14%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting A Grace Sub Acute & Skilled Care?

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 A Grace Sub Acute & Skilled Care Safe?

Based on CMS inspection data, A GRACE SUB ACUTE & SKILLED CARE 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 4-star overall rating and ranks #1 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 A Grace Sub Acute & Skilled Care Stick Around?

Staff at A GRACE SUB ACUTE & SKILLED CARE tend to stick around. With a turnover rate of 14%, the facility is 31 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 11%, meaning experienced RNs are available to handle complex medical needs.

Was A Grace Sub Acute & Skilled Care Ever Fined?

A GRACE SUB ACUTE & SKILLED CARE 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 A Grace Sub Acute & Skilled Care on Any Federal Watch List?

A GRACE SUB ACUTE & SKILLED CARE 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: 166
Avg. Residents: 102
Occupancy: 61.6%
Ownership: For profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
Low Turnover: +5
48 Deficiencies: -10
Final Score: 75/100

Nearby Alternatives

IDYLWOOD CARE CENTER 5-star WOODLANDS HEALTHCARE CENTER 5-star MISSION SKILLED NURSING & SUBA... 5-star

View all in SAN JOSE →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056376