SKYLINE HEALTHCARE CENTER - SAN JOSE
For profit - Partnership
253 Beds
MARINER HEALTH CARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#1118 of 1155 in CA
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Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Skyline Healthcare Center in San Jose has received a Trust Grade of F, indicating significant concerns regarding the quality of care provided. Ranking #1118 out of 1155 facilities in California places it in the bottom half, and #49 out of 50 in Santa Clara County, showing very few local options are worse. Although the facility is improving-reducing issues from 37 in 2024 to 19 in 2025-there are serious problems, including a critical failure to maintain a sanitary environment that led to a cockroach infestation affecting nearly all residents. Staffing is rated average with a turnover of 40%, which is on par with state averages, but the RN coverage is concerning, being lower than 75% of facilities in California. Additionally, the facility has incurred fines totaling $105,089, which is higher than 78% of state facilities, indicating repeated compliance issues.
- Trust Score
- F
- In California
- #1118/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 40% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- $105,089 in fines. Lower than most California facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 100 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 4%
Review needed
37 → 19 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 37 issues
2025: 19 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below California average (3.1)
Significant quality concerns identified by CMS
Staff Turnover: 40%
Near California avg (46%)
Typical for the industry
Federal Fines: $105,089
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: MARINER HEALTH CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 100 deficiencies on record
2 life-threatening 1 actual harm
Jun 2025
18 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the call light button (a cord with a button use...
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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 the call light button (a cord with a button used by the resident to request assistance) for one of 238 residents (Resident 25) was within reach and appropriate for her condition. This failure had the potential to result in delays of care and treatment.
Findings:
Review of Resident 25's medical record indicated Resident 25 was initially admitted on [DATE] and had diagnoses including Epilepsy (a neurological disorder characterized by recurring seizures [sudden , uncontrolled surges of electrical activity in the brain]), unspecified, intractable, without status epilepticus, other lack of coordination, unspecified disorder of psychological development (a condition that affects a person's cognitive, emotional, and behavioral development, often originating in childhood), and delayed milestone in childhood.
During an observation on 6/23/25, at 9:36 a.m., Resident 25 was asleep, and the call light button was on the floor.
During a concurrent observation and interview on 6/23/25, at 11:16 a.m., with Licensed Vocational Nurse (LVN) L, LVN L confirmed Resident 25's call light button was on the floor and verified the resident should have another device appropriate for the resident.
During a review of the facility's undated policy and procedure (P&P) titled, Resident Call System, the P&P indicated, Residents are equipped with communication system, allowing them to request assistance by contacting either a staff member or a centralized workstation. 4. If a resident has a disability that prevents them from using the call system, an alternative means of communication that is usable for the residents is provided and documented in the care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liabili...
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Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability when a resident comes off Medicare Part A) for two of three residents (Residents 95 and 186). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended.
Findings:
Review of Resident 95's medical record indicated she was admitted under Medicare Part A on 4/30/25.
Review of the Beneficiary Notice section of the Entrance Conference Worksheet, filled out by the facility and presented to the survey team on 6/24/25, indicated Resident 95 was to be discharged from Medicare Part A services on 6/26/25 and continue living in the facility.
Review of Resident 95's SNF Beneficiary Protection Notification Review, filled out by the facility and presented to the survey team on 6/25/25, indicated the facility initiated Resident 95's discharge from Medicare Part A services when benefit days were not exhausted (the resident still had Medicare Part A days remaining). The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 95.
Review of Resident 186's medical record indicated he was admitted under Medicare Part A on 3/4/25. The medical record further indicated Resident 186 came off Medicare Part A on 5/20/25 and continued living in the facility.
Review of Resident 186's SNF Beneficiary Protection Notification Review, filled out by the facility and presented to the survey team on 6/25/25, indicated the facility initiated Resident 186's discharge from Medicare Part A services when benefit days were not exhausted. The SNF Beneficiary Protection Notification Review further indicated the facility did not provide a SNF ABN to Resident 186.
During an interview with the interim social services director (ISSD) on 6/25/25, at 10:41 a.m., the ISSD confirmed the facility did not provide a SNF ABN to Residents 95 and 186.
The Department of Health and Human Services and Centers for Medicare & Medicaid Services Form CMS-20052, dated 2/2022, indicated the facility must provide a SNF ABN when residents are discharged from Medicare Part A services, with skilled benefit days remaining, and continue to live in the facility.
According to the Centers for Medicare & Medicaid Services (CMS, https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN-), the facility must provide a SNF ABN prior to providing custodial care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete an annual Minimum Data Set (MDS, an assessment tool) for o...
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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 an annual Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 89). This failure had the potential to compromise the facility's ability to develop and implement care plan interventions.
Findings:
Review of Resident 89's medical record indicated she was admitted to the facility on [DATE]. The medical record indicated the facility completed an annual MDS assessment on 5/12/24. Further review of the medical record indicated the facility did not complete an annual MDS assessment for Resident 89 in May of 2025.
During an interview and concurrent record review with Minimum Data Set Coordinator B (MDSC B) on 6/26/25, at 1:17 p.m., MDSC B reviewed Resident 89's medical record and stated the facility should have completed an annual MDS assessment in May of 2025. MDSC B confirmed the facility did not complete this annual MDS assessment.
The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2024, indicated, The Annual assessment is a comprehensive assessment for a resident that must be complete on an annual basis (at least every 366 days). The RAI manual indicated the date of the annual MDS assessment must be set within 366 days of the previous annual assessment, and must be completed no later than 14 days after the set date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two of 36 sampled residents (Residents 164 and 192) when:
1. For Resident 164, multiple falls were not coded on the MDS; and
2. For Resident 192, tobacco use was not coded on the MDS.
Failure to accurately complete the MDS had the potential to compromise the facility's ability to develop and implement care plan interventions.
Findings:
1. Review of Resident 164's medical record indicated she was admitted on [DATE] and had a history of falling.
Review of Resident 164's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change in a resident's condition), dated 11/16/24, indicated Resident 1 had a witnessed fall in her room.
Review of Resident 164's Progress Notes, dated 11/21/24, indicated she slid down and was found on the floor in her room.
During an interview and concurrent record review with Minimum Data Set Coordinator B (MDSC B) on 6/25/25, at 10:50 a.m., MDSC B reviewed Resident 164's medical record and confirmed the resident fell on [DATE] and 11/21/24. MDSC B stated these falls should have been coded on Resident 164's MDS dated [DATE]. MDSC B reviewed Resident 164's MDS, dated [DATE], and confirmed section J1800 was coded No, indicating Resident 164 did not fall during the specified time frame. MDSC B confirmed section J1800 should have been coded Yes, to indicate Resident 164 fell during the specified time frame.
The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions), dated 10/2024, indicated for section J1800, Code 1, yes if the resident has fallen during the specified time frame.
2. Review of Resident 192's medical record indicated he was admitted on [DATE] with diagnoses including osteomyelitis (bone infection) of vertebra, sacral and sacrococcygeal region (bones in the spine), fracture (a break in a bone) of T7-T8 vertebra (the seventh and eight bones in the spine).
Review of Resident 192's Safe Smoking Assessment Evaluation (an assessment tool), dated 3/28/25, indicated Resident 192 smoked cigarettes.
During a concurrent interview and record review with MDSC A ,on 6/27/25 at 9:11 a.m., MDSC A reviewed Resident 192's medical record and confirmed the resident smoked cigarettes. MDSC A reviewed Resident 192's MDS, dated [DATE], and confirmed section J1300 Current Tobacco Use was coded No', indicating Resident 192 did not smoke cigarettes. MDSC A confirmed section J1300 should have been coded Yes, to indicated Resident 192 smoked cigarettes.
The RAI Manual, dated 10/2024, indicated for section J1300, Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident-centered baseline care plans were deve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident-centered baseline care plans were developed within 48 hours of admission for two of thirty-six sampled residents, (Residents 337 and 380), when:
1. For Resident 337, there was no communication problem care plan that was initiated and
2. For Resident 380, there was no baseline activity care plan that was created, and she had no activity care plan at all.
These deficient practices had the potential to cause delays in the continuity of care and communication which could negatively affect residents' health, safety and delivery of care.
Findings:
1. Resident 337 was admitted to the facility on [DATE] with diagnosis of Cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Aphasia (a disorder that makes it difficult to speak), abnormalities of gait and mobility, Dysphagia (difficulty swallowing).
During a concurrent interview and record review on 6/26/25 at 9:52 a.m., with the assistant Director of Nursing (ADON), the ADON reviewed 337's clinical records and stated that Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 6/17/25 indicated Resident 337 has no speech, absence of spoken words, sometimes can make self-understood and sometimes understands others due to diagnosis of Aphasia. The ADON further stated that there was no communication problem care plan that was initiated upon admission and up to this day 6/26/25.
During a concurrent interview and record review on 6/26/25 at 11:24 a.m., with Minimum Data Set Coordinator A (MDSC A), MDSC A reviewed Resident 337's MDS and Care plan confirmed the above MDS record review was accurate and there was no communication problem baseline care plan that was developed within 48 Hrs. after admission of Resident 337 on 6/10/25.
Review of the undated facility's policy and procedure titled, Baseline Care Plan, indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan
2. During the observation of Resident 380 on 6/23/25 at 12:33 p.m., Resident 380 was lying in her bed and looked calm and comfortable. She was confused and could not answer questions.
Review of Resident 380's face sheet (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 380 was admitted to the facility on [DATE] with the primary diagnosis of malignant neoplasm (cancerous tumor characterized by uncontrolled growth and potential spread to other parts of the body) of unspecified site of unspecified female breast.
Review of Resident 380's physician order report from 5/24/25 to 6/24/25 indicated, Resident 380 may participate in activity as tolerated if not in conflict with treatment/care plan and the order was started on 6/19/25.
Review of Resident 380's care plans indicated that Resident 380 did not have a resident-centered baseline activity care plan that was created and she did not have an activity care plan at all.
During the concurrent review of Resident 380's clinical records and interview with the activity director (AD) on 6/27/25 at 11:48 a.m., the AD verified that Resident 380 was not assessed for her activities since she was admitted on [DATE] and there was no resident-centered baseline activity care plan that was created for her. The AD further verified that resident-centered baseline activity care plans should be created within 48 hours of admission. The AD also stated that Resident 380 was admitted on [DATE] and her baseline activity care plan should have been created and implemented already, and she did not have an activity care plan at all.
Review of the undated facility's policy and procedure titled, Baseline Care Plan, indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight hours of admission To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive care plans t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive care plans to address the individual care needs for two of thirty-six sampled residents, (Residents 202 and 18), when:
1.Resident 202's care plan interventions were not revised or modified related to falls and cognitive function.
2.Resident 18's care plan for antibiotic, not resolved.
This failure placed the residents at risk of not being provided appropriate, consistent, individualized care.
Findings:
1.Resident 202 was admitted to the facility on [DATE] with diagnosis of Schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), Cerebral infarction cerebral infarction (necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on half of the body) , abnormalities of gait and mobility and weakness.
Review of Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 4/16/25 indicated his cognition (mental, thought processes) and brief interview for mental status (BIMS, cognition level) score of eight is moderately impaired cognition.
During a concurrent interview and record review on 6/26/25 at 2:13 p.m., with the assistant Director of Nursing (ADON), the ADON reviewed Resident 202's long term care plan dated 1/2/25 and the interventions were not revised or modified related to three falls interventions on 1/2/25, 1/7/25 and 2/26/25, and the cognitive function was not indicated. The ADON further stated that it should have been revised and modified for individualized care.
Review of the facility's Comprehensive Plan of Care policy and procedure, undated, indicated Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment; .with significant change in status assessment .
3. A review of Resident 18's Resident Face Sheet, indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (a type of stroke, caused blood to pool between the brain and skull), major contusion of left kidney (injury to the kidney), sepsis (body's extreme and potentially dangerous response to infection) .
Review of Resident 18's clinical record indicated Resident 18 had a Physician order of Cefepime (antibiotic, used to treat bacterial infections) 2 grams (G, unit of measurement) every 12 hours for 7 days, dated 6/5/25.
During a concurrent interview and record review with the Director of Nursing (DON), on 6/26/25 at 2:04 p.m., the DON confirmed Resident 18's antibiotic was completed on 6/12/25. The DON also confirmed the care plan for antibiotic was still active and should have been resolved.
Review of the facility's Comprehensive Plan of Care policy and procedure, undated, indicated Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment; .with significant change in status assessment .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustabl...
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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 the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for one (Resident 380), of six residents who used side rails that were investigated, when Resident 380 did not have a physician's order for her use of side rails.
This failure caused the resident, to not have the proper approval from the physician for her use of side rails which could jeopardize the resident's safety.
Findings:
During the observation of Resident 380 on 6/23/25 at 12:33 p.m., Resident 380 was lying in bed and looked calm and comfortable. She was confused and could not answer questions. Resident 380 had bilateral (both sides) half side rails that were up.
Review of Resident 380's face sheet (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 380 was admitted to the facility on [DATE] with the primary diagnosis of malignant neoplasm (cancerous tumor characterized by uncontrolled growth and potential spread to other parts of the body) of unspecified site of unspecified female breast.
Review of Resident 380's physician order report or MD (Doctor of Medicine) order report from 5/24/25 to 6/24/25 indicated, there was no physician's order for Resident 380's use of side rails.
During the concurrent review of Resident 380's medical records and interview with nurse supervisor D (NS D) on 6/27/25 at 3:19 p.m., NS D verified that Resident 380 had side rails but did have a physician's order for her use of side rails. NS D further stated she would notify Resident 380's physician about side rail use and then update the orders.
Review of the undated facility's policy titled, Side Rails, indicated, Requirements are the same as for other physical restraints, whether or not the side rails enable mobility: Obtain MD order, including diagnosis/medical necessity for use
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, and document review, the facility failed to ensure two of 36 sampled residents (Residents 106 and 195) received their lunch in accordance with scheduled meal times. Th...
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Based on observation, interview, and document review, the facility failed to ensure two of 36 sampled residents (Residents 106 and 195) received their lunch in accordance with scheduled meal times. This failure had the potential to result in reduced food palatability (quality of taste), which could negatively affect the residents' meal intake and nutritional status.
Findings:
During an interview with Resident 106 on 6/23/25, at 9:20 a.m., Resident 106 stated her food always came late and was cold most of the time.
During an interview with Resident 195 on 6/23/25, at 9:54 a.m., Resident 195 also stated her food always came late and was cold most of the time.
The facility's untitled document titled Meal Service Times was reviewed. The document indicated lunch was to be served to the residents between 11:40 a.m. and 1:00 p.m., depending on the area of the facility.
During a dining observation on 6/23/25, the cart containing the lunch trays for Residents 106 and 195 arrived in their area of the facility at 1:32 p.m. Staff delivered the lunch trays for both residents at 1:34 p.m.
During another dining observation on 6/25/25, the cart containing Resident 106's lunch tray arrived in her area of the facility at 1:43 p.m. Staff delivered the lunch tray to Resident 106 at 1:50 p.m.
During an interview with the dietary manager (DM) on 6/25/25, at 2:01 p.m., the DM confirmed the last resident lunch tray should be delivered by 1:00 p.m.
The facility's undated policy titled Resident Dining Program indicated, Lunch shall be served between 11:30 a.m. and 1:00 p.m.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation on 6/25/25, at 1:41 p.m., certified nursing assistant C (CNA C) was feeding lunch to Resident 163, who ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation on 6/25/25, at 1:41 p.m., certified nursing assistant C (CNA C) was feeding lunch to Resident 163, who was lying in bed with the head of the bed slightly elevated. CNA C was standing over Resident 163 while feeding her.
During an observation and concurrent interview with nurse supervisor D (NS D) on 6/25/25, at 1:41 p.m., NS D confirmed the above observation and stated CNA C should sit at eye level while feeding the resident.
During an interview with the director of staff development (DSD) on 6/27/25, at 8:16 a.m., the DSD explained staff should sit at eye level while feeding the residents in order to maintain the residents' comfort and dignity.
The facility's undated policy titled Assisting the Resident to Eat indicated, Sit at eye level in front of the resident.
Based on observation, interview, and record review, the facility failed to ensure respect and dignity were maintained for 2 of 36 sampled residents (Residents 103 and 163) and two non-sampled residents (Residents 381 and 168) when:
1. For Resident 381, the meal tray was served late and not at the same time as with the other residents on the same table at the big dining room;
2. For Resident 168, his food was also served late and not at the same time as the other residents seated in th same table in the big dining room;
3. For Resident 103, his drainage bag was not covered from public view and
4. For Resident 163, certified nursing assistant (CNA) was standing over this resident while feeding her.
These failures had the potential to affect the emotional and psychosocial well-being of the residents.
Findings:
1. During the big dining room observation on 6/23/25 at 11:58 a.m., three residents (Residents 381, 168 and 200), were seated at the same table for lunch. Resident 200 was already eating his lunch while Residents 381 and 168 were still waiting for their meal trays and looking hungry.
During the concurrent observation and interview with Resident 381 on 6/23/25@12:10 p.m., Resident 381 finally received his lunch meal tray. Resident 381 was alert and verbally responsive and verified that his meal tray was served late while the other resident in the same table had been eating his lunch already and almost done with it. He further stated that he was already hungry.
During the interview with the activity director (AD) on 6/27/25 at 1:55 p.m., the AD acknowledged that for residents sitting in the same table, they should be served with their meal trays at the same time or one after the other, before serving the next table.
During the interview with the assistant director of nursing (ADON) on 6/27/25 at 2:04 p.m., the ADON verified that for residents eating in the same table, their meals should be served at the same time or finish serving them first before serving other residents on the next or different table.
2. During the big dining observation on 6/23/25 at 11:58 a.m., Resident 168 was sitting in one of tables in the big dining room waiting for staff to serve his lunch. Another resident (Resident 200), in the same table, was already eating his lunch. Resident 381, who was also in that same table was also waiting for his meal tray to be served.
During an interview with Resident 168 on 06/23/25 at 12:00 p.m., Resident 168 verified that he was waiting for his lunch tray for 5 minutes now and was already hungry while looking at the other resident in front of him, Resident 200 who was already eating lunch at 11:55 a.m.
During an interview with the director of nursing (DON) on 6/26/25 at 4:12 p.m., the DON verified the above observation and stated that the food should be served in short interval not having to wait for a long time. The DON also stated, the resident might not feel good and get impatient when he would wait for a long time for his food while others had been served for their meals already.
Review of the undated facility's policy and procedure (P&P) titled, Resident Dining Program, the P&P indicated, The goal is to ensure that all residents in the facility receive meals that are nutritionally appropriate and served in a respectful, safe, and timely manner, in accordance with their care plans, physician orders, and federal/state regulations Meals will be served in a manner that promotes dignity, autonomy, and social interaction among residents C. Meal service Protocol:1. Food trays are delivered by table order to ensure fairness and minimize cold meals
3. Review of Resident 103's clinical record indicated, Resident 103 was admitted on [DATE] with diagnoses that include urinary tract infection(an infection in any part of urinary system), retention of urine, obstructive and reflux uropathy (a condition in which the flow of urine is blocked), benign prostatic hyperplasia (a non-cancerous condition where the prostate gland grows larger than normal) with lower urinary tract symptoms, acute kidney failure(a sudden and rapid decrease in kidney function) .
During an observation on 6/24/25 at 8:26 a.m., Resident 103 was lying in bed, with indwelling foley catheter connected to drainage bag positioned lower than the bladder. The drainage bag was not covered, and the contents were visible.
During a concurrent observation and interview on 6/24/25 at 8:31 a.m., with the Infection Preventionist (IP), the IP inside Resident 103 room's, confirmed Resident 103's drainage bag was not covered and visible. The IP stated the drainage bag should have privacy bag to cover.
During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Dignity , undated, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: e. Helping the residents to keep urinary catheter bags covered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the residents would know and be reminded o...
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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 that the residents would know and be reminded of the results of the previous state recertification surveys when 5 out of 14 residents who attended the Resident Council meeting, (Residents 5, 33, 52, 80, and 106), did not know about the results of the previous state recertification surveys or where the binder containing the survey results was located.
These failures jeopardized the right of the residents to know and examine the results of the previous state recertification surveys and the plan of corrections that the facility did for those failures.
Findings:
During the resident council meeting (gathering where residents of a facility come together to discuss issues) on 6/24/25 at 10:00 a.m., 5 residents, (Residents 5, 33, 52, 80, and 106), were among the attendees of the meeting.
During a concurrent observation and interview with Resident 5 during the resident council meeting on 6/24/25 at 10:30 a.m., Resident 5 was seated in a wheelchair, alert, oriented and verbally responsive. Resident 5 verbalized that he was not aware of the results of the previous state recertification surveys or where the survey binder was located.
Review of Resident 5's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 5 was readmitted to the facility on [DATE] with diagnoses including acute respiratory disease (a condition that affects the lungs and airways making it difficult for air exchange in the lungs), chronic pulmonary edema (the buildup of fluid in the lungs), atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke) and muscle weakness. Resident 5's BIMS (brief interview for mental status- cognition level score of 13 to 15 points suggests that cognition is intact) score was 15.
During a concurrent observation and interview of Resident 33 on 6/24/25 at 10:30 a.m., Resident 33 was seated in her wheelchair, alert, oriented, verbally responsive and participating in the resident council meeting. Resident 33 stated she was not aware of the results of the previous state recertification surveys or where the binder with the survey results was located.
Review of the admission record of Resident 33 indicated, Resident 33 was readmitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, diabetes mellitus (a condition which affects the way the body processes blood sugar), peripheral vascular disease (a blood vessel disorder that affects blood circulation), and cellulitis (a bacterial infection of the skin and tissues beneath the skin) of the left lower limb. Resident 33's BIMS score was 14.
During a concurrent observation and interview with Resident 52 on 6/24/25 at 10:30 a.m., Resident 52 was alert, oriented, calm, comfortable, verbally responsive and actively participating in the resident council meeting. Resident 52 also stated that she was not aware of the results of the previous state recertification surveys or where the binder containing survey results was located.
Review of the admission record of Resident 52 indicated, Resident 52 was readmitted to the facility on [DATE] with diagnoses including diabetes mellitus, hyperlipidemia (high levels of fat particles in the blood), osteoarthritis (a condition where there's gradual wearing down of protective tissue at the ends of bones) and generalized muscle weakness. Resident 52's BIMS score was 14.
During a concurrent observation and interview with Resident 80 on 6/24/25 at 10:30 a.m., Resident 80 was alert, oriented, verbally responsive and actively participating in the resident council meeting. Resident 80 stated he was not aware of the results of the previous state recertification surveys or where the survey binder was located.
Review of the admission record of Resident 80 indicated, Resident 80 was readmitted to the facility on [DATE] with diagnoses including congestive heart failure (heart works less efficiently and can lead to buildup of fluid in the lungs and shortness of breath), diabetes mellitus, hemiplegia (severe muscle weakness or partial paralysis on one side of the body) affecting the right dominant side, muscle weakness and difficulty walking. Resident 80's BIMS score was 14.
During a concurrent observation and interview with Resident 106 during the resident council meeting on 6/24/25 at 10:30 a.m., Resident 106 was seated in her wheelchair, alert, oriented and verbally responsive. Resident 106 verbalized not being aware of the results of the previous state recertification surveys or where the survey binder was located.
Review of Resident 106's admission record indicated Resident 106 was readmitted to the facility on [DATE] with diagnoses including acute respiratory disease, hypertension (a condition in which the force of the blood against the artery walls in the heart is too high), and seizures (uncontrolled jerking movements of the arms and legs caused by abnormal brain activity). Resident 106's BIMS score was 15.
During an interview on 6/25/25 at 10:55 a.m. with the Activity Director (AD), the AD verified being employed at the facility for twenty-five years and acknowledged not knowing about the results of the previous state recertification surveys or where the survey binder for the results of the previous surveys was located. The AD then stated, It's probably in the administrator's office.
During an interview with the administrator (ADM) on 6/27/25 at 11:56 p.m., the ADM verified that the AD should know where the survey binder for the results of the previous surveys was located so she could in turn inform and remind the residents about the binder location. The ADM stated that he would in-service the AD about it.
During an interview on 6/27/25 at 2:04 p.m., with the Director of Nursing (DON) the DON also verified that the AD should know where the survey binder containing results of the previous surveys is located and that all staff members should know the location of the survey binder.
Review of the facility's policy and procedure titled, Access to Survey Results, undated indicated, Survey results and approved plan of correction, if applicable, are available in a readable form . and are available to residents without having to ask a staff person. Survey results may be placed in a binder . Results of the most recent survey are placed readily accessible to residents in a place such as a lobby or other areas frequented by most residents, where individuals wishing to examine survey results do not have to ask to see them . Residents should be notified at least annually during Resident Council meetings of the survey results . Minutes of Resident Council meetings should reflect that survey results were communicated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the observation of Resident 7 on 6/23/25 at 12:43 p.m., Resident 7 was alert, calm, comfortable, verbally responsive a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During the observation of Resident 7 on 6/23/25 at 12:43 p.m., Resident 7 was alert, calm, comfortable, verbally responsive and able to answer questions.
Review of Resident 7's face sheet indicated, Resident 7 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified paraplegia (a condition characterized by the paralysis of the lower half of the body, typically including the legs and sometimes the torso or the trunk of the human body).
Review of Resident 7's physician order report from 5/24/25 to 6/24/25 indicated, Resident 7 had an order to monitor weekly weights every Saturday, at 9:00 a.m., once a day, ordered on 4/6/25.
Review of Resident 7's weight records indicated that Resident 7's weights were checked on the following dates:
a. 5/20/25 - 190 pounds (lbs, unit used to measure the mass);
b. 5/7/25 - 195 lbs;
c. 4/22/25 - 195 lbs;
d. 3/19/25 - 182 lbs;
e. 2/18/25 - 191 lbs and
f. 1/21/25 - 200 lbs.
During the concurrent review of Resident 7's clinical records and interview with nursing supervisor D (NS D) on 6/26/25 at 2:55 p.m., NS D verified that Resident 7 had an order to monitor her weight weekly every Saturday, once a day at 9:00 a.m., and they were not done. Resident 7's weight was last monitored on 5/20/25, which was 190 lbs. and there were no records that Resident 7's weights were checked weekly after that. NS D further verified that the weight monitoring order of Resident 7 was not followed. NS D then stated that she would clarify with Resident 7's physician about her weight monitoring order and would follow the order.
During the interview with the director of nursing (DON) on 6/27/25 at 8:15 a.m., DON acknowledged that physician orders should be followed and Resident 7's physician order to monitor her weight weekly was not followed and would follow up on it.
Review of the undated facility's policy titled, Carrying Out Physician's Orders, indicated, All physician orders must be documented, reviewed, and carried out accurately and promptly to ensure the highest standard of patient care. This policy applies to all nursing staff and healthcare providers within the facility Nursing staff: Carry out physician's orders accurately and promptly, ensuring patient safety and proper documentation
Based on observation, interview and record review, the facility failed to ensure care and services were provided to meet the professional standard of practice for three of four residents (Residents 116, 30 and 7) when:
1. Two Licensed Vocational Nurses (LVN) did not wear proper Personal Protective Equipment (PPE, equipment worn to minimize exposure to a variety of hazards) when handling hazardous drugs; and
2. The weight monitoring order for Resident 7 was not followed.
These failures had the potential to compromise the residents' health and safety.
Findings:
1. During a medication administration observation at Station 4 with LVN J on 6/25/25 at 8:36 a.m., LVN J was observed removing a medication called Divalproex Sodium (Depakote, anticonvulsant used to treat seizures and bipolar disorders) from a blister pack (packaging used for medications) for Resident 116. LVN J confirmed the blister pack have the Hazardous Drug label and that she did not wear gloves when handling the medication. LVN J stated she should have worn gloves.
During a medication administration observation at Station 5B with LVN M, on 6/25/25 at 10:32 a.m., LVN M was observed removing a medication called Divalproex Sodium from a blister pack for Resident 30. LVN M confirmed the blister pack have the Hazardous Drug label and that she was not wearing gloves. LVN M stated she should wear gloves when handling the medication.
During an interview with the Director of Nursing (DON) on 6/26/25 at 2:01 p.m., the DON stated the Hazardous Drug label on medications was an indication of special instructions on how to administer the medication. The DON also stated the licensed nurses should wear gloves as protection when handling the medication.
During an interview with the Consultant Pharmacist (CP) on 6/27/25 at 10:47 a.m., the CP stated the facility should follow the required precautions for medications with hazardous drug label. The CP stated the staff should wear gloves depending on the risk of exposure to the medication.
Review of the facility's Hazardous Drug Handling policy and procedure (P&P), dated 1/23, indicated Scope: The facility must develop and maintain a health and safety management system which shall, at a minimum, include the following: .5. Proper use of appropriate Personal Protective Equipment (PPE) .D. Personal Protective Equipment .a. Appropriate PPE must be worn when handling HDs .
Review of the facility's Hazardous Drug Handling P&P, dated 1/23, indicated H. Administering 1) The facility should provide all PPE needed and monitor use according to established policies and procedures that minimize employee and patient exposure.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled med...
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Based on interview and record review, the facility failed to ensure accurate accountability of controlled medication (medication with high potential for abuse and addiction) when random controlled medication use audit for seven of 12 residents (Resident 347, 28, 174, 67, 38, 65, and 226) did not reconcile when:
1. The medication was documented on the Medication Administration Record (MAR, used to document medications taken by each individual) to indicate they were administered to Residents 65, 38, and 28 but was not signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications.), and
2. The medication was signed out of the CDR but not documented on the MAR for Residents 347, 67, 174, 65, and 226.
These failures resulted in inaccurate accountability and had the potential for misuse or diversion of controlled medications.
Findings:
1. The Controlled Drug Record (CDR) for 12 randomly selected residents receiving controlled medications were requested for review during the survey.
A review of Resident 65's clinical record indicated he had a Physician's order for Methadone (a narcotic, used to treat moderate to severe pain) 5 milligrams (mg, unit of measurement) two tablets once a day for chronic pain, dated 6/20/25.
During a concurrent interview and record review of the CDR, with Minimum Data Set Coordinator (MDSC) A, on 6/25/25 at 1:48 p.m., MDSC A confirmed three tablets were unaccounted in the CDR.
During a concurrent interview and record review with Licensed Vocational Nurse (LVN) J, on 6/25/25 at 1:50 p.m., LVN J stated she administered the medication and documented in the MAR but did not sign out in the CDR.
A review of Resident 38's clinical record indicated he had a Physician order for Lorazepam (an anti-anxiety medication) 1 mg 1 tablet once a day for anxiety, dated 5/14/25.
During a concurrent interview and record review of the CDR with LVN K, on 6/25/25 at 1:53 p.m., LVN K confirmed the medication was documented in the MAR but was not signed out in the CDR.
A review of Resident 28's clinical record indicated he had a Physician order for Hydrocodone-Acetaminophen (Norco, used for moderate to severe pain) 5-325 mg 1 tablet three times a day.
During a concurrent interview and record review of the CDR with LVN K, on 6/25/25 at 2:04 p.m., LVN K confirmed the medication was documented in the MAR but was not signed out in the CDR.
2. A review of Resident 347's clinical record indicated she had a Physician order for Oxycodone (used to treat moderate to severe pain) 5 mg 1 tablet twice a day as needed for severe pain, dated 6/22/25.
During a concurrent interview and record review on 6/26/25 at 2:20 p.m., with the Director of Nursing (DON), a review of Resident 347's CDR for Oxycodone and the 6/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 6/21/25 at 11:11 a.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR.
A review of Resident 67's clinical record indicated he had a Physician order for Tramadol (used to treat moderate to severe pain) 50 mg 1 tablet every 8 hours as needed for severe pain, dated 6/23/25.
During a concurrent interview and record review on 6/26/25 at 2:24 p.m., with the DON, a review of Resident 67's CDR for Tramadol and the 4/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 4/22/25 at 9:54 p.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR.
A review of Resident 174's clinical record indicated he had a Physician order for 50 mg Tramadol every 4 hours as needed for pain management, dated 6/9/24.
During a concurrent interview and record review on 6/26/25 at 2:32 p.m., with the DON, a review of Resident 174's CDR for Tramadol and the 2/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 2/25/25 at 9:54 p.m. and 2/26/25 at 6:26 a.m., but did not document the respective administrations in the MAR. The DON acknowledged that the controlled medications were not accounted for in the MAR.
A review of Resident 65's clinical record indicated he had a Physician order for Oxycodone 20 mg 1 tablet every 4 hours as needed for severe pain, dated 6/20/25.
During a concurrent interview and record review on 6/26/25 at 2:40 p.m., with the DON, a review of Resident 65's CDR for Oxycodone and the 6/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 6/21/25 at 8:27 a.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication was not accounted for in the MAR.
A review of Resident 226's clinical record indicated he had a Physician order for Oxycodone 5 mg 1 tablet every 4 hours as needed for moderate pain, dated 5/16/25.
During a concurrent interview and record review on 6/26/25 at 2:48 p.m., with the DON, a review of Resident 226's CDR for Oxycodone and the 5/2025 MAR reflected the nursing staff removed the medication from the locked controlled medication compartment in the medication cart and signed of the CDR on 5/17/25 at 11:30 a.m., but did not document the respective administration in the MAR. The DON acknowledged that the controlled medication were not accounted for in the MAR.
A review of the facility's Medication Administration General Guidelines policy and procedure (P&P), dated 1/24, indicated Documentation: 1. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given .
A review of the facility's Medication Administration Controlled Substances P&P, dated 1/23, indicated 4. 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 .5. Administer the controlled medication and document dose administration on the MAR.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with facility policies when:
1. In one of six medication rooms, the were medicat...
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Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with facility policies when:
1. In one of six medication rooms, the were medications with different routes of administration stored in the same bin. There were also active and discontinued medications stored in this bin;
2. One opened bottle of 1,000 milliliters (ml, a unit of measurement for volume) 0.9% sodium chloride solution (known as normal saline- a common medical solution containing 0.9 grams of sodium chloride per 100 milliliters of water. It is an isotonic solution, meaning it has the same concentration of solutes as the blood and body fluids (NS) and small bottle of 0.9% (NS) was stored at Resident 65's bedside table unattended. and
3. One bottle of used 100 ml NS was stored at Resident 205's bedside table unattended.
These failures had the potential to compromise the health and safety of the residents.
Findings:
1. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:32 a.m., one medication room was inspected. Inside the room, there was a clear plastic bin that contained face shields (personal protective equipment meant to protect the face). Upon further inspection, it was observed that this bin also contained the following: 1.) One bottle of liquid Lithium (medication used to treat psychiatric conditions) 8 milliequivalents per 5 milliliters (meq/ml, unit of dose measurement) that belonged to Resident 212; 2.) One bottle of Atorvastatin tablets (medication used to treat high cholesterol) 40 milligrams (mg, unit of dose measurement) that belonged to Resident 212; 3.) One Symbicort inhaler (medication used to treat breathing problems) 80-4.5 micrograms (mcg, unit of dose measurement) that belonged to Resident 4; 4.) One house stock (not belonging to a specific resident) bottle of normal saline (a solution that can be used for several medical purposes, including, but not limited to hydration and wound treatments); and 5.) Multiple house stock wound dressings that contained alginate (a substance added to help promote wound healing). NS H confirmed this observation and confirmed these items should not have been stored together.
During an interview and concurrent record review with the director of nursing (DON) on 6/26/25, at 11:47 a.m., the DON reviewed the medical records for Resident 212 and Resident 4. The DON verified that Resident 212 had active orders for liquid Lithium 8 meq/5 ml and Atorvastatin 40 mg tablets (medications that were stored in the clear plastic bin in the medication room). She also verified that Resident 4's order for Symbicort inhaler 80-4.5 mcg had been discontinued (this medication was also stored in the clear plastic bin in the medication room). The DON confirmed active and discontinued medications should not be stored together. She also confirmed medications with different routes of administration should not be stored together.
The facility's policy titled Medication Storage, dated 1/2024, indicated, Medications should be stored so that various routes of administration are separated. The policy further indicated discontinued medications are immediately removed from stock and disposed of.
2. During an initial tour of the facility on 6/23/25 at 9:55 a.m., one opened bottle of 1,000 ml of 0.9 % sodium chloride (NS) and small bottle of 0.9% (NS) were stored at Resident 65's bedside table unattended.
During a concurrent observation and interview on 6/23/25 at 9:58 a.m., with the minimum Data Set Coordinator B (MDSC B), she confirmed the above observation and stated that the 0.9% NS bottles found was used for wound treatment and should have been stored inside the treatment cart.
3. During an initial tour of the facility on 6/23/25 at 10:15 a.m., one bottle of used 100 ml NS was stored at Resident 205's bedside table unattended.
During a concurrent observation and interview on 6/23/25 at 10:17 a.m., with the MDSC B, she acknowledged the above observation and stated that 0.9% NS was used by a treatment nurse and should have been stored inside the treatment cart and not at the bedside table of the resident.
The facility's policy titled Medication Storage, dated 1/2024, indicated, Medications and biologicals are stored properly to keep their integrity and to support safe,effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff memebers lawfully authorized to administer medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented w...
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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 infection control practices were implemented when:
1.Resident 345's used and opened urinal was next to the spirometer (an apparatus for measuring the volume of air inspired and expired by the lungs- measures ventilation, the movement of air into and out of the lungs) on top of the bedside table;
1a. Resident 46's yankauer suction tube (oral suctioning tool) that was attached to suction machine was stored inside of the open clean gloves box on top of the bedside table;
1b. Resident 9's suction machine and nebulizer machine (device used to deliver medication in the form of a mist for inhalation) were covered by a used wash basin at the bedside table;
1c. Resident 128's used urinal without covering was on top of the bedside table ;
1d. Resident 330's soiled linens were on the floor;
2. Urinal full and on the floor;
3. No EBP sign on door;
3a. Treatment nurse (TN) wearing a surgical face mask below the nose during wound care for one resident and
4. Two kitchen staff were not wearing their face masks properly while preparing foods for the tray line.
These failures could result in the spread of infection and cross-contamination that could affect the 238 residents who reside in the facility, staff, and visitors.
Findings:
1.During an initial tour of the facility on 6/23/25 at 9:03 a.m., Resident 345's used and opened urinal was next to the spirometer on top of the bedside table.
During a concurrent observation and interview on 6/23/26 at 9:04 a.m., with the assistant director of nursing (ADON), She confirmed the above observation and stated the urinal should be stored at the bedrail with cover and should not be stored next to the spirometer to prevent contamination.
1a. During an initial tour of the facility on 6/23/25 at 9:12 a.m., Resident 46's yankauer suction tube that was attached to suction machine was stored inside of the open clean gloves box on top of the bedside table.
During a concurrent observation and interview on 6/23/26 at 9:14 a.m., with the ADON, she confirmed the above observation and stated that the yankauer suction tube should have been detached from the suction machine and stored in a plastic bag with label to prevent contamination.
1b. During an initial tour of the facility on 6/23/25 at 9:31 a.m., Resident 9's suction machine and nebulizer machine were covered by a used wash basin at the bedside table.
During a concurrent observation and interview on 6/23/26 at 9:35 a.m., with Minimum Data Set Coordinator B (MDSC B), she confirmed the above observation and stated that the suction machine and nebulizer machine should not have been covered by the used wash basin to prevent cross contamination.
1c. During an initial tour of the facility on 6/23/25 at 9:44 a.m., Resident 128's used urinal without covering was on top of the bedside table.
During a concurrent observation and interview on 6/23/26 at 9:46 a.m., with MDSC B, she confirmed the above observation and stated the urinal should be stored at the bedrail with cover to prevent contamination.
During a concurrent observation and interview on 6/23/26 at 9:47 a.m., with certified nursing assistant O (CNA O), he confirmed the above observation and stated the urinal should be stored at the bedrail with cover to prevent the spread of infection contamination.
1d. During an initial tour of the facility on 6/23/25 at 10:10 a.m., Resident 330's soiled linenes was on the floor.
During a concurrent observation and interview on 6/23/26 at 10:14 a.m., with the ADON, she confirmed the above observation and stated that soiled linens should not have been on the floor to prevent cross contamination.
Review of the undated facility's policy titled, Linen Storage indicated prevent cross-contamination by storing soiled linen in a room or area that is separate from wash areas and clean linen storage areas Store soiled linen airtight containers Store soiled linen a manner that prevents cross- contamination.
4. During the tray line (a system of food preparation or an assembly line system where individual food trays are prepared for residents) observation and concurrent interview with cook F (COOK F) on 6/25/25 at 11:20 a.m., COOK F was not wearing his face mask properly while preparing the foods for the tray line. His face mask was not covering his nose and mouth. COOK F verified that he was not wearing his face mask properly and fixed it right away.
During the interview with the dietary manager (DM) on 6/25/25 at 11:21 a.m., the DM acknowledged that COOK F should wear his face mask properly while preparing foods for the tray line and would talk to him about it.
During the continued tray line observation and concurrent interview with dietary aide G (DA G) on 6/25/25 at 11:35 a.m., DA G was also not wearing her face mask properly while helping with the tray line preparation. It was only covering her mouth and her nose was still exposed. DA G verified that she was not wearing her face mask properly and fixed it right away.
During the interview with the DM on 6/25/25 at 11:36 a.m., the DM also acknowledged that DA G should wear her face mask properly while helping with the tray line preparation and would also talk to her about it.
During the interview with the registered dietitian (RD) on 6/25/25 at 1:15 p.m., the RD verified that kitchen staffs should wear their face masks properly, covering their nose and mouth and would remind them about it.
Review of the undated facility's policy titled, COVID-19 (coronavirus disease 2019 which is a contagious disease caused by a virus called SARS-CoV-2) Using Personal Protective Equipment (PPE, equipment used to prevent or minimize exposure to hazards), indicated, Personnel working in areas with minimal to no community transmission adhere to the following infection prevention and control strategies: Employees, contracted personnel, and volunteers adhere to standard and transmission-based precautions In addition, universal use of a well-fitting face mask for source control is recommended for personnel if not otherwise wearing a respirator All personnel receive training on and demonstrate an understanding of: how to properly don, use, and doff PPE in a manner to prevent self-contamination
2. During an observation on 6/23/25, at 8:49 a.m., inside Resident 194's room, there was one full urinal, with lid closed, inside a plastic urinal holder (a plastic strap or cage that can be fastened to the resident's bed or wheelchair). There was another half-full plastic urinal, with lid closed, on the floor of Resident 194's room.
During a concurrent observation and interview with certified nursing assistant N (CNA N) on 6/23/25, at 8:57 a.m., CNA N confirmed Resident 194's two urinals were not emptied, and should have been emptied.
During an interview with the infection preventionist (IP) on 6/26/25 at 2:38 p.m., the IP stated urinals should be emptied to prevent the spread of infection.
During a review of the facility's undated policy and procedure (P&P) titled, Bedpan or Urinal, the P&P indicated, To provide for elimination when a resident is unable to use bathroom or bedside commode. After Use of Bedpan or Urinal: 6. Empty and rinse bedpan or urinal with disinfectant .
3. Review of Resident 480's medical record indicated Resident 480 was admitted on [DATE] with diagnoses including acute cholecystitis (redness and swelling of the gallbladder [a small pear-shaped organ located under the liver in the upper right abdomen]), and viral hepatitis (infectious disease that causes liver inflammation and damage).
During an observation on 6/23/25 at 8:15 a.m. in the room of Resident 480, Resident 480 was observed awake, alert and sitting on the side of the bed with a biliary drainage bag (allows the digestive fluid from the gallbladder and liver to flow out from a blocked duct) attached to a band positioned on the right leg of Resident 480. There was no enhanced barrier precaution (EBP) signage posted on the door and no personal protective equipment (PPE) outside the entrance to Resident 480's room.
Review of Resident 480's Physician Order Report dated 6/13/25 indicated biliary drain on right lower abdomen: cleanse with normal saline and pat dry with dry dressing and cover it with patch dressing. Special instructions: change the dressing daily or as needed once a day.
During a concurrent observation and interview on 6/23/25 at 9:36 a.m. with Licensed Vocational Nurse I (LVN I), LVN I stated there should be an EBP sign posted on the door of Resident 480's room and there should be PPE at or near the door since Resident 480 has a biliary catheter.
During an interview on 6/26/25 at 2:00 p.m. with the Infection Preventionist (IP), the IP confirmed there was no EBP signage posted at the entry to Resident 480's room and no PPE. The IP stated there should be an EBP sign and PPE outside the room of Resident 480 because Resident 480 has a biliary catheter to prevent the spread of infection.
Review of the facility's policy and procedure titled, Enhanced Barrier Precautions, undated indicated, EBP are indicated for residents with any of the following: .b. Wounds and/or indwelling devices even if the resident is not known to be infected . 6. For residents for whom EBP are indicated, EBP shall also be used when performing the following high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use, e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care, e.g., any skin opening requiring a dressing . 10 .EBP shall be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed the resident at high risk.
3a. During a concurrent observation and interview on 6/26/25 at 9:49 a.m., with the treatment nurse (TN), the TN was observed wearing a surgical face mask below the nose during wound care for Resident 35. The TN confirmed the face mask was not covering TN's nose during wound care. The TN adjusted the mask to cover the nose. The TN stated the facial surgical mask should have covered both nose and mouth for infection control.
During an interview on 6/26/25 at 10:50 a.m., with the Director of Nursing (DON), the DON stated all personal protective equipment should be worn properly and the surgical face mask should be worn covering both the nose and mouth for infection prevention and control.
Review of the facility's policy and procedure titled, COVID-19 Using Personal Protective Equipment (PPE), undated indicated, 1. a. Employees . adhere to standard and transmission-based precautions based on anticipated exposures and suspected or confirmed diagnoses. B. In addition, universal use of a well-fitting facemask for source control is recommended for personnel . 2. Personnel working in facilities . adhere to the following infection prevention and control strategies: c. One of the following is worn for source control while in the facility and for protection during resident care encounters: (3) A well-fitting facemask, for example: a) selection of a facemask with a nose wire to help the facemask conform to the face.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment when the floors in the dishwashing area of the kitchen were very wet and there was no s...
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Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment when the floors in the dishwashing area of the kitchen were very wet and there was no safety sign in the area. These failures could affect the health and safety of kitchen staffs and individuals that might go inside the kitchen.
Findings:
During the initial kitchen tour observation with dietary manager (DM) on 6/23/25 at 8:16 a.m., the floors in the dishwashing area were very wet with water and there was no caution sign around to warn staffs and individuals that might go inside the kitchen and into the dishwashing area.
During the interview with DM on 6/23/25 at 8:17 a.m., DM acknowledged that the floors in the dishwashing area were very wet with water. DM further acknowledged that he would put a warning sign right away to keep dietary staff safe.
During the interview with the registered dietitian (RD) on 6//25/25 at 1:15 p.m., RD verified that kitchen areas including dishwashing areas should be kept safe at all times. RD further verified that there should be signage for wet floors to warn staffs for safety.
Review of the facility's undated policy titled, Kitchen Safety, indicated, Purpose: To establish and maintain a safe working environment in the dietary department and kitchen area by ensuring adherence to sanitation, equipment use, fire safety and injury prevention practices. This protects staff, residents, and visitors from harm and complies with state and federal regulations. All dietary and kitchen staff must follow established safety guidelines at all times while in the food service area Registered Dietitian: Ensures kitchen sanitation, food service, and compliance with safety procedures during scheduled visits. Dietary Manager: Ensures staff training, implementation, and compliance with kitchen safety procedures Keep walkways clear; promptly clean spills using Wet Floor signs
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0945
(Tag F0945)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to maintain an effective infection control training program for laundry staff regarding routine cleaning of dryer lint. The facility's documen...
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Based on interview and record review, the facility failed to maintain an effective infection control training program for laundry staff regarding routine cleaning of dryer lint. The facility's documentation indicated laundry staff did not clean the dryer lint for several hours on multiple days. This failure had the potential to compromise the health and safety of the residents in the facility.
Findings:
During a record review on 6/26/25, at 1:08 p.m., the facility's laundry lint cleaning log was inspected. The laundry lint cleaning log was left blank from 2:00 p.m. to 8:00 p.m. on 4/11/25, 4/12/25, 4/21/25, 4/29/25, 4/30/25, 5/12/25, 5/14/25, 5/16/25, 5/17/25, 5/28/25, and 6/21/25.
During an interview and concurrent record review with the housekeeping supervisor (HS) on 6/26/25, at 1:19 p.m., the HS reviewed the facility's laundry lint cleaning log and confirmed it was left blank on the above dates and times. The HS explained that the documentation on this log was proof that staff cleaned the laundry lint.
During an interview with the infection preventionist (IP) on 6/27/25, at 10:48 a.m., the IP stated laundry staff needed to check the laundry lint and document on the cleaning log every hour.
During a review of the facility's undated policy and procedure (P&P) titled, Laundry Area Practices, the P&P indicated, To conduct laundry operations in a clean, safe environment. Cleaning Schedule: Establish a schedule to keep the laundry area clean. Modify as necessary, to comply with Company and/or state specific requirements. CAUTION: Clean the dryer lint traps after each load! Place a checkmark in the appropriate column to establish a cleaning schedule.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
3. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:55 a.m., one of the facility's medication rooms was inspected. There was a refrigerator inside this me...
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3. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:55 a.m., one of the facility's medication rooms was inspected. There was a refrigerator inside this medication room, which was designated to store the residents' food. There was one pitcher of pinkish-red fluid and one unopened container of applesauce in this refrigerator. The thermometer inside this refrigerator had a temperature reading of 60 degrees Fahrenheit (F, unit of temperature measurement). NS H confirmed this observation and confirmed the temperature of the food refrigerator should be maintained between 35 and 41 degrees F.
During a follow-up observation and concurrent interview with NS H on 6/23/25, at 9:03 a.m., the thermometer inside the refrigerator was checked again. At this time, the refrigerator door had been closed for eight minutes. The thermometer inside the refrigerator still had a temperature reading of 60 degrees F. NS H confirmed this observation.
During another follow-up observation and concurrent interview with NS H on 6/23/25, at 9:12 a.m., the thermometer inside the refrigerator was checked again. At this time, the refrigerator door had been closed for an additional nine minutes. The thermometer inside the refrigerator still had a temperature reading of 60 degrees F. NS H confirmed this observation.
The facility's document titled REFRIGERATOR TEMPERATURE LOG (FOR FOOD), dated 6/2025, indicated, Normal Temperature: 35-41 DEGREES F. The document further indicated, NOTIFY DON [director of nursing] IF TEMPERATURE IS NOT WITHIN RANGE.
Based on observation, interview, and record review, the facility failed to ensure food items were labeled and stored in accordance with professional standards for food safety when:
1. Ten cups of cottage cheese that were past their use by dates, were still stored in the kitchen refrigerator;
2. A pitcher of colored fluid with no label and an open container of thickened water were found in the refrigerator inside two medication storage rooms.
3. The temperature of one refrigerator designated to store residents' foods which was located in one of the medication rooms was above the desired temperature.
These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the two hundred thirty-four residents who received foods from the facility kitchen.
Findings:
1. During the initial kitchen tour observation on 6/23/25 at 8:10 a.m., there were ten cups of cottage cheese that had use by dates of 6/22/25 and they were all past by the date already, that were still stored in one of the kitchen refrigerators.
During the interview with the dietary manager (DM), who was assisting me with the kitchen tour observation on 6/23/25 at 8:11 a.m., the DM verified that the ten cups of cottage cheese were past their use by dates and should not be stored anymore in the kitchen refrigerator and he removed them right away.
During the interview with the registered dietitian (RD), on 6/25/25 at 1:15 p.m., the RD verified that the cups of cottage cheese that were past their use by dates should not be kept in the kitchen refrigerator and should have been discarded already. RD further verified that she would follow up on this concern.
Review of the undated facility's policy titled, Food Storage Principles, indicated, Proper food storage is essential for preserving food quality Discard foods that have exceeded their expiration date
2a. During a concurrent observation and interview with Minimum Data Set Coordinator (MDSC) A, on 6/23/25 at 8:26 a.m., medication storage 5 was inspected. The refrigerator inside the room, which was designated to store food for residents, contained one pitcher with brown-colored fluid with no label and a container of Lemon Flavored Thickened Water with open date of 6/19/25. The pitcher with brown-colored liquid with a date made label on the lid, indicated June 17. MDSC A stated the pitcher should be labeled and discarded after 2 days. The MDSC A stated the thickened water should be discarded 24 hours after opening.
Review of the facility's Food Storage Principles policy and procedure (P&P), undated, indicated Procedure .2. Label each package, box, can, etc. with the expiration date, date of receipt, or when the item was stored after preparation .b. Discard leftover food that have not been used within 48 hours of preparation .
Review of facility's Labeling and Dating Food/Beverages in Refrigerators P&P, undated, indicated To ensure the safe storage of food and beverages in facility refrigerators by requiring proper labeling and dating in accordance with health regulations and infection control standards. All foods and beverages stored in the facility refrigerators must be clearly labeled and dated to ensure safety, prevent spoilage, and reduce the risk of foodborne illness.
Review of facility's Labeling and Dating Food/Beverages in Refrigerators P&P, undated, indicated Dating & Discard Guidelines: Thickened liquids (premixed), 24 hours max shelf life after opening, after opening discard unused portion.
2b. During an observation and concurrent interview with nurse supervisor H (NS H) on 6/23/25, at 8:55 a.m., medication storage 2 was inspected. One refrigerator inside the room, which was designated to store food for residents, contained one pitcher of pinkish-red fluid. The pitcher was not labeled. NS H confirmed the pitcher was not labeled.
The facility's undated policy, titled Labeling and Dating Food/Beverages in Refrigerators, indicated all food and beverages stored in facility refrigerators must be clearly labeled.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure that garbage was stored properly when two out of four outside dumpsters were overfilled of garbage, with their lids, no...
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Based on observation, interview and record review, the facility failed to ensure that garbage was stored properly when two out of four outside dumpsters were overfilled of garbage, with their lids, not fully closed and plastic bags with trash were not placed in the covered dumpsters.
These failures had the potential to attract insects, rodents, and other pests to the facility that could affect the two hundred thirty-eight residents residing in the facility.
Findings:
During the concurrent observation of the dumpster area and interview with maintenance assistant E (MA E) on 6/25/25 at 2:30 p.m., two out four dumpsters were overfilled with garbage and their lids were not completely closed. There were also plastic bags with trash that were not put in the covered dumpsters. MA E acknowledged that these dumpsters should not be overfilled with garbage and should be properly covered. MA E further acknowledged that plastic bags with trash should be put in the covered dumpsters. He then stated that he would endorse them to have the garbage picked up.
During the interview with the maintenance director (MD) on 6/25/25 at 2:40 p.m., the MD also verified that the dumpsters should not be overfilled with garbage and their lids should be properly closed. The MD further verified that the plastic bags with trash should be placed in the covered dumpsters. He then stated that he would have the garbage, be picked up right away.
During the interview with the director of nursing (DON) on 6/27/25 at 8:17 a.m., the DON acknowledged the above concerns and then stated that she would check on it.
Review of the undated facility's policy titled, Pest Control, indicated, Keep the dumpster area clean and the lid closed
The United States Food and Drug Administration's 2022 Food Code 5-501.110 indicated, Refuse (waste), recyclable and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the physician orders of one of three residents (Resident 1) were followed when a nurse did not perform a blood sugar check, administ...
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Based on interview and record review, the facility failed to ensure the physician orders of one of three residents (Resident 1) were followed when a nurse did not perform a blood sugar check, administer insulin, and administer the correct dose of medication to Resident 1 timely. These failures had the potential to affect the health of Resident 1.
Findings:
Review of Resident 1's face sheet indicated the resident was admitted with diagnoses including nausea with vomiting and Type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing).
Review of Resident 1's Physician Order Report, from 11/16/24 - 12/9/24 indicated the resident had orders for the following:
- Admelog SoloStar (insulin lispro [a short acting medication to helps to lower sugar in the blood]) 100 unit/ milliliter (mL, unit of measurement), per sliding scale for DM before meals 6:45 a.m., 11:45 a.m., 4:45 p.m., dated 12/4/24;
- Myfortic (mycophenolate sodium [medication used to prevent the body from rejecting an organ transplant) tablet, delayed release, 360 mg (milligrams, unit of measurement), 3 tables, oral twice a day; 9 a.m., 9 p.m.
Review of Resident 1's Diabetes Administration History, from 11/26/24 - 12/7/24 indicated on 12/3/24, insulin lispro was administered late.
Review of Resident 1's Progress Note, dated 12/3/24 indicated, Writer was notified by supervisor and charge nurse that the resident missed 2 tabs of his Mycophenate [sic] medication which is supposed to be 3 tabs .
Review of Resident 1's Progress Note, dated 12/4/24 indicated, Writer was informed about the late administration of blood glucose check yesterday 12/3/24 and insulin per sliding scare. LN [licensed nurse] at new station checked resident's blood glucose as soon as nurse received report that it was not done at the previous station .
Review of Resident 1's Risk Meeting Notes Weekly, dated 12/4/24 indicated, MD has an order of Mycophenolate 360 mg 3 tabs BID (9am and 9pm). It was reported that charge nurse only administered 1 out of 3 tabs at 12:20PM . Charge nurse also missed checking blood sugar at 11:45AM before lunch and therefore was not given insulin on time .
During an interview on 1/17/25 at 10:57 a.m., the director of nursing (DON) stated she interviewed the nurse (Registered Nurse A [RN A]). The DON stated RN A only gave one tablet of mycophenolate to Resident 1. The DON stated Resident 1 was given the other two tablets within six hours. The DON stated medications are supposed to be given one hour before or one hour after the scheduled time. The DON stated later they found out in the afternoon that RN A did not check Resident 1's blood sugar before lunch. The DON confirmed the blood sugar check and insulin administration was delayed. The DON stated the physician orders written in the chart should be followed.
Review of the facility's Medication Administration General Guidelines, dated 1/23 indicated, Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times.
Based on interview and record review, the facility failed to ensure the physician orders of one of three residents (Resident 1) were followed when a nurse did not perform a blood sugar check, administer insulin, and administer the correct dose of medication to Resident 1 timely. These failures had the potential to affect the health of Resident 1.
Findings:
Review of Resident 1's face sheet indicated the resident was admitted with diagnoses including nausea with vomiting and Type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing).
Review of Resident 1's Physician Order Report, from 11/16/24 - 12/9/24 indicated the resident had orders for the following:
- Admelog SoloStar (insulin lispro [a short acting medication to helps to lower sugar in the blood]) 100 unit/ milliliter (mL, unit of measurement), per sliding scale for DM before meals 6:45 a.m., 11:45 a.m., 4:45 p.m., dated 12/4/24;
- Myfortic (mycophenolate sodium [medication used to prevent the body from rejecting an organ transplant) tablet, delayed release, 360 mg (milligrams, unit of measurement), 3 tables, oral twice a day; 9 a.m., 9 p.m.
Review of Resident 1's Diabetes Administration History, from 11/26/24 - 12/7/24 indicated on 12/3/24, insulin lispro was administered late.
Review of Resident 1's Progress Note, dated 12/3/24 indicated, Writer was notified by supervisor and charge nurse that the resident missed 2 tabs of his Mycophenate [sic] medication which is supposed to be 3 tabs .
Review of Resident 1's Progress Note, dated 12/4/24 indicated, Writer was informed about the late administration of blood glucose check yesterday 12/3/24 and insulin per sliding scare. LN [licensed nurse] at new station checked resident's blood glucose as soon as nurse received report that it was not done at the previous station .
Review of Resident 1's Risk Meeting Notes Weekly, dated 12/4/24 indicated, MD has an order of Mycophenolate 360 mg 3 tabs BID (9am and 9pm). It was reported that charge nurse only administered 1 out of 3 tabs at 12:20PM . Charge nurse also missed checking blood sugar at 11:45AM before lunch and therefore was not given insulin on time .
During an interview on 1/17/25 at 10:57 a.m., the director of nursing (DON) stated she interviewed the nurse (Registered Nurse A [RN A]). The DON stated RN A only gave one tablet of mycophenolate to Resident 1. The DON stated Resident 1 was given the other two tablets within six hours. The DON stated medications are supposed to be given one hour before or one hour after the scheduled time. The DON stated later they found out in the afternoon that RN A did not check Resident 1's blood sugar before lunch. The DON confirmed the blood sugar check and insulin administration was delayed. The DON stated the physician orders written in the chart should be followed.
Review of the facility's Medication Administration General Guidelines, dated 1/23 indicated, Medications are administered in accordance with written orders of the prescriber . Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on meal times.
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to store medications in a safe manner when nursing staff left medications unattended on the bedside table in a resident room. Thi...
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Based on observation, interview and record review, the facility failed to store medications in a safe manner when nursing staff left medications unattended on the bedside table in a resident room. This failure had the potential to allow residents and unauthorized staff to access medications.
Findings:
Review of Resident 1's clinical record indicated he was admitted to the facility with diagnoses including dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning) and anxiety disorder (a mental health condition characterized by fear and worry that is both intense and excessive).
Review of Resident 1's physician orders indicated he had orders for cyanocobalamin (vitamin B-12) 1000 micrograms (mcg, unit of measurement) once a day and gabapentin (medication used to treat nerve pain) 100 milligrams (mg, unit of measurement) capsule once a day.
During an observation in Resident 1's room on 12/11/24 at 10:18 a.m., there were medications in a medication cup on Resident 1's bedside table unattended. Resident 1 was not inside the room.
During a concurrent interview, registered nurse A (RN A) stated she was assigned to care for patients in 15 rooms, which also included Resident 1's room. RN A was at the nurse's station preparing documents for another resident. When RN A went into Resident 1's room, she confirmed that she left Resident 1's medications on the bedside table. She stated Resident 1 was not in the room, so she left the medications. RN A stated the medications were vitamin B-12 and gabapentin. She stated she should not have left the medications unattended.
Review of the facility's policy, Storage of Medication, dated 1/2023 indicated, The medication supply shall be accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The policy also indicated that medications should be stored in a controlled environment, which includes medication carts, medication rooms, medication cabinets, or other suitable containers.
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
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary behavioral health service to maintain the hig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary behavioral health service to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment to two of three sampled residents (1 and 2) when their psychiatric services were not being followed up. This failure had a potential to affect maintaining Resident 1 and 2's highest practicable mental and psychosocial well-being.
Findings:
Review of Resident 1's face sheet indicated she admitted to the facility on [DATE] and her diagnoses including Obsessive -compulsive personality disorder (is a mental health condition that cause an extensive preoccupation with perfectionism, organization and control), bipolar disorder(is a mental health condition that affects your moods, which can swing from 1 extreme to another) and major depressive disorder(is a common and serious medical illness that negatively affects how you feel, the way you think and how you act).
Review of Resident 1's Psychiatric Visit Progress Report dated 6/22/23, indicated psychiatrist evaluated and reviewed Resident 1's medications and management with stating a follow-up should be done within two to four weeks or as needed (PRN) while in the facility. Further review indicated no follow-up psychiatric services were provided.
Review of Resident 2's face sheet indicated he readmitted to the facility on [DATE] and his diagnoses including dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities).
Review of Resident 2's care plan, dated 11/21/23, indicated he had a plan of care to address not sleeping at night.
Review of Resident 2's Psychiatric Visit Progress Report dated 4/7/22, indicated it was an initial eval for Resident 2 and would need to have follow-up within two to four weeks or as needed (PRN) while in the facility. Further review indicated no follow-up psychiatric services were provided.
During an interview and record review on 7/9/24, at 11:30 a.m., with the social service assistant (SSA), she reviewed Resident 1 and 2's clinical records with stating that Resident 1 and 2 should have followed up with psychiatric services as per their planning of psychiatric visit progress report.
During an interview on 7/9/24, at 12:30 p.m., with the assistant director of nursing (ADON), she confirmed both Residents 1 and 2 should have continued receiving psychiatric services; and that, the facility nursing staff missed following-up.
Review of the facility's undated policy and procedure (P&P) titled, Psychosocial Wellbeing-Behavioral Health Services, the P&P indicated, The company will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow their plan of correction from 2024's recertification survey to have immediate pest treatment to maintain an effective p...
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Based on observation, interview and record review, the facility failed to follow their plan of correction from 2024's recertification survey to have immediate pest treatment to maintain an effective pest control program for ensuring facility is free of pests and rodents when pest sightings were identified, and cockroaches were seen ongoing by staff and residents in the facility. This failure affected residents' quality of life to live in a health and sanitary environment.
Findings:
Review of complaint intake with received date 05/29/2024 21:57, indicated complainant complained about the facility for being very dirty; cockroaches could be seen on the walls and floors in majority of residents' room and some of residents' rooms in station three broke infection guidelines.
Review of the facility's plan of correction, dated 3/1/24, indicated the last survey with exit date was 1/31/24 and the plan of correction included sighting rounds and calling pest control vendor for immediate treatment when pest sightings identified.
Review of the facility's pest control service record from 2/2024 to 5/2024 indicated facility received weekly pest treatment. There were no extra records for receiving immediate treatment after cockroaches were found.
During a review of facility's pest control binder for all nurses' stations, kitchen, housekeeping and maintenance areas, laundry area and rehabilitation department from 1/31/2024 to 6/1/2024 indicated, on different dates and time cockroaches had been identified on 1/31/24, 2/2024, 3/2024, 4/2024, 5/2024 and 6/1/24 and documented on the pest control log for residents' room in the nursing stations one to six, kitchen and activity room including storage room and office.
During an interview on 6/4/24, at 11 a.m., with the licensed vocational nurse A (LVN A), in the nursing station three, she stated that about 2-3 months ago she had seen cockroaches in the nursing station.
During environmental observations and interviews on 6/4/24 , at around 12:00 p.m., with the housekeeping supervisor (HS) in room G, we met one of two sampled residents (1) in the room, the resident stated that he just saw cockroaches yesterday in his room. At 12:14 p.m., in room I, a case of bottled water placed on the floor of bed two with lots of personal stuff placed on the floor blocking screen door pathway. At 12:16 p.m., in Room J, trash residuals and paper tissue were found on the floor. At 12:17 p.m., unclean floor was observed in resident's room L. At 12:18 p.m., a live cockroach was found in the shared restroom between room K and L. HS immediately killed the cockroach and used a paper towel to clean the floor and wrapped it around throwing into the garbage can. At 12:20 p.m., we walked into room H and met with one of two sampled residents (2) who sat in the wheelchair, he stated that he saw ants in his bed and had seen cockroaches in the past. Some food residuals were found left on the floor on his bedside. At 12:30 p.m. to 12:31 p.m., observed unclean floor in rooms M and N.
During an interview on 6/4/24, at 12:33 p.m., with the registered nurse B (RN B) and HS, in nursing station one, she stated that once in a while she would see cockroaches in the resident's room and required documenting on the pest control log which is available in each nursing station, kitchen, activity area HS confirmed after cockroaches are identified, it would be killed immediately and cleaned up, then pest control vendor would come weekly to provide pest treatment.
During a kitchen observation and interview on 6/4/24, at 12:45 p.m., with the dietary manager (DM), staff was in the process with tray line and an overflow water was found under the dishwasher. DM stated the maintenance was notified and would fix the problem. DM further stated that yesterday he just saw a dead cockroach in the kitchen office, it was documented on the kitchen pest control binder after each time he saw cockroaches and pest control vendor would come weekly to provide pest treatment.
During an interview on 6/4/24 , at 1:20 p.m., with the administrator (ADM), he stated, cockroaches was ongoing project and should have at least one year to solve the pest issue especially for German cockroaches.
During an observation and interview on 6/4/24, at 3:36 p.m., with the certified nursing assistant C (CNA C) in room G, observed trash residuals on the floor between bed one and two. CNA C validated the findings.
During an observation and interview on 6/4/24, at 3:40 p.m., the floor of small multipurpose activity-dining room in front of room E and F had lots of food residuals on the floor. CNA D validated the findings.
During a telephone interview on 6/17/24, at 10:58 a.m., with HS, she stated after each time cockroaches are identified in the different areas of the facility, they would need to kill it and used environmental protection agency (EPA, is responsible for the protection of human health and the environment) registered disinfectants for localized cleaning and followed up with deep cleaning at the area where the cockroaches were found. Additionally, the cockroaches' findings would be discussed during daily conference meeting and then followed up with pest control vendor for immediate treatment after pest sightings were identified.
Review of the facility's undated policy and procedure (P&P) titled, Pest Control, indicated Routine inspections are conducted at the Company for evidence of pests. Report the following insect or pest related information: type of problem, location, person reporting, and time reported. Contact with a licensed pest control vendor Keep facility grounds free of trash and brush.
Jun 2024
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure refuse (any disposable materials, which include recyclable and non-recyclable materials) was disposed of properly when the lid of the ...
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Based on observation and interview, the facility failed to ensure refuse (any disposable materials, which include recyclable and non-recyclable materials) was disposed of properly when the lid of the garbage disposal bin in the kitchen was not placed. This failure had the potential to attract insects, rodents, and other pests to the facility and could affect the 238 residents in the facility.
Findings:
During an observation on 6/6/24 at 10:55 a.m., three garbage disposal bins were observed in the kitchen. One garbage disposal bin with a folded box, a cup, two plastic food containers, and a metal food container on top of the closed bin was observed. One garbage disposal bin without its lid was observed, and refuse in the garbage disposal bin was exposed to air.
During an observation and concurrent interview on 6/6/24 at 11:13 a.m. with the registered dietitian (RD), he confirmed the above observation.
During an interview on 6/6/24 at 11:18 a.m. with the RD, he stated that the garbage disposal bin should have been closed with its lid.
During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control dated 2023, the P&P indicated, 2. Kitchen waste that cannot be disposed of by mechanical means will be kept in a clean, leak proof, nonabsorbent, tightly closed metal or plastic container with a plastic liner.
Review of the Food and Drug Administration's 2022 Food Code 5-501.113, Covering Receptacles, indicated waste handling for refuse shall be kept covered.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the environment was free of pests, as evidenced by multiple flying insects seen in the resident's room and the hallway...
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Based on observation, interview, and record review, the facility failed to ensure the environment was free of pests, as evidenced by multiple flying insects seen in the resident's room and the hallway. This failure had the potential to cause a health hazard to the 238 residents residing in the facility.
Findings:
During an interview on 5/1/24 at 1 p.m. with licensed vocational nurse A, she stated there were lots of flies in Resident 1's room because of old foods in the resident's room.
During a concurrent observation and interview on 5/1/24 with certified nurse assistant B (CNA B), approximately more than ten black flying insects (fruit flies) were observed in Resident 1's room. CNA B confirmed the observation.
During an observation on 6/6/24 in Resident 1's room, two fruit flies were observed near bananas on the over-the-bed table in Resident 1's room.
During a concurrent observation and interview on 6/6/24 with CNA B, Resident 1 was sitting up in his electric wheelchair in the hallway in front of the nursing station, and one fruit fly was observed near Resident 1. CNA B confirmed the observation.
During a concurrent interview and the facility's pest control/sightings log on 6/6/24 at 12:55 p.m. with the maintenance supervisor (MS), he confirmed there was no report of fruit fly in Resident 1's room from 5/1/24 to 6/6/24. The MS stated he did not receive any report of fruit fly in Resident 1's room.
During a review of the facility's undated policy and procedure (P&P) titled Pest Control, the P&P indicated, Insect or pest sightings are reported to the housekeeping/maintenance supervisor.
Apr 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that residents received the treatment and care in accordanc...
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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 that residents received the treatment and care in accordance with professional standards of practice related to pain management for one out of three sampled residents (Resident 1) when
1. The licensed nurses did not follow physician's order to administer the pain medications as needed (PRN) based on the pain assessment documented;
2. The licensed nurses did not update Resident 1's care plan for pain management;
3. The licensed nurses did not follow the physician's order to administer the PRN medication for severe pain; and
4. The pain scale did not include the pain levels 1, 3, 5, and 7.
These failures had the potential for Resident 1's pain not being properly managed and could negatively affect Resident 1's comfort and well-being.
Findings:
1. A review of Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including generalized muscle weakness and cervical region spinal stenosis (the space inside the backbone is too small), Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression).
A review of Resident 1's physician order summary indicated:
a. Morphine ( a controlled pain medication) immediate release 15 mg 1 tablet oral special instruction: for spinal stenosis as a breakthrough for moderate to severe pain every 6 hours PRN, started on 2/10/23.
b. Tylenol extra strength tablet 500 mg, two oral tablets for moderate pain every 8 hours PRN, started on 4/7/23.
During a concurrent interview and record review with the ADON on 2/14/24 at 11:20 a.m., the ADON reviewed Resident 1's December 2023 MAR. The pain assessment indicated that the pain level was 4 on 12/13, 5 on 12/15, 8 on 12/17, 6 on 12/18, 4 on 12/20, and 7 on 12/30. The ADON confirmed that there was no documented evidence Resident 1 had refused or declined the PRN pain medication and the licensed nurses did not administer the prescribed PRN pain medication as indicated in the physician's order based on the assessed pain levels. The ADON stated the licensed nurses should have followed the physician's order to administer PRN Tylenol and PRN Morphine to relieve the pain after pain assessment.
2. A review of Resident 1 's care plan initiated on 8/23/19 indicated administer Morphine 15 mg 1 or 2 tabs in the morning and at night, three tabs limited to 24 hours.
During a concurrent interview and record review with the ADON on 2/14/24 at 11:25 a.m., the ADON reviewed Resident 1's care plan for pain and stated the licensed nurse should have updated the care plan to include the PRN medication to manage Resident 1's pain.
3. During a concurrent interview and record review with the ADON on 2/14/24 at 11:35 a.m., the ADON reviewed Resident 1's January MAR of 2024. The ADON confirmed that the licensed nurse administered Tylenol 1000 mg to Resident 1 for severe pain 8 out of 10 on 1/1/24 and 1/ 2/24. The ADON stated the physician prescribed Tylenol 1000 mg for moderate pain and the licensed nurses should have administered Morphine 15 mg instead of Tylenol for severe pain 8/10 according to the physician's order.
4. A review of Resident 1's pain monitoring records with pain scale, started on 6/27/20, indicated 0: no pain, 2: mild pain,4-6: moderate pain, and 8-10: severe pain.
During a concurrent interview and record review with the ADON on 2/14/24 at 11:45 a.m., the ADON reviewed the pain scale and stated the scale should reflect pain levels ranging from 1 to 10, including 1, 3, 5, 7, categorized as mild pain, moderate pain, or severe pain.
A review of the facility's undated policy and procedure titled oral medication administration indicated, To administer oral medications in an accurate, safe, timely and sanitary manner .verify physician's order .
A review of the facility's undated policy and procedure titled Pain Management indicated, administer a therapeutic intervention for pain if ordered .update the patient's care plan to include pain management. The care plan shall include both pharmacological and non-pharmacological interventions and review the patient's response to treatment daily. Adjust the care plan as needed to manage pain .
Jan 2024
26 deficiencies
2 IJ (1 facility-wide)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0925
(Tag F0925)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the Food and Nutrition Services Department, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the Food and Nutrition Services Department, the kitchen, and resident rooms were free from cockroaches, with an effective pest control program maintained.
This failure caused 244 residents to be exposed to potential food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).
Cross reference 812, 908
Findings:
1) Cockroaches in Dietary Department
According to a manufacturer (name of company), A single cockroach sighted during the day can indicate that there is a significant infestation. Cockroaches, also known as 'roaches,' are nocturnal and prefer to live and breed in dark shelters near food and moisture. But if a harborage site is overpopulated, they can be forced out in daylight, often in search of food ., to get to the food they can tread across the floor and through garbage in search of food, then crawl across the food-contact surfaces . (http://www.(name of company).com/pages/the-dangers-cockroaches-bring-to-food-safety)
According to the Food and Drug Administration, Insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment. (FDA 2022 Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected.)
During the initial kitchen tour on 1/22/24 at 8:58 AM, an observation of the back walls in the kitchen with shelves, a metal food prep counter and food prep sink had uncovered holes and pealing baseboards. Additionally, there were multiple broken and non-operation kitchen appliances, including a large reach-in refrigerator, a walk-in refrigerator, and condensation build-up on the ceiling of the walk-in freezer. The kitchen floor had food crumbs, debris, plastic strips, food wrappers, and other trash scattered all throughout the entire kitchen floor. Additionally, unsanitary practices including dirty dishes stored as clean dishes, light brown food crumbs and stains inside the two large reach-in refrigerators inside the DSM's office. One of three refrigerator door gaskets was ripped hanging off the inside of the door with a dark brown sticky substance on it. And a fire sprinkler was inside the walk-in freezer ceiling protruding from a large open hole. These physical environment conditions prevented adequate cleaning and sanitizing that allowed for and contributed to the harborage of pests.
During an observation of the ice machine at station 4 and interview with the DSM and RD on 1/22/24 at 3:17 PM, a dead baby cockroach was found inside the ice machine cover facing the ice curtain. RD and DSM confirmed the finding of the dead baby cockroach inside the ice machine cover, and the DSM stated, Oh wow. RD and DSM stated they did not know the last time the ice machine was cleaned and sanitized.
During an observation on 1/22/24 at 3:23 PM of the ice machine at station 4 and interview with the facility's Regional Maintenance Director (FMD), the FMD acknowledged the black residue and brown buildup inside the ice machine curtain, chute, baffle, and tiny amounts in the bin and stated the ice machine should be always clean, without the residue. RD, DSM and FMD acknowledged the dirty thick black and brown buildup and residue. The FMD further stated the ice machine should be cleaned every month using the manufacturer's guidelines.
During an interview with the Administrator (ADM) on 1/22/24 at 4:01 PM, the Administrator (ADM) stated the maintenance supervisor probably just cleans the inside of the ice machine and the dietary staff cleans the outside of the ice machine.
During a review of the facility's undated policy and procedure (P&P) titled Ice Machines, the P&P indicated .Follow the manufacturer's guidelines for cleaning .Cleaning 1. Disinfect the drop opening of the ice machine once a week with an appropriate disinfectant or use 10-20 cc's (cubic centimeters which equals milliliters of volume) of bleach to 1,000 cc's of warm water .
During a kitchen observation on 1/23/24 at 11:31 AM with the DSM, there was a dead roach was found on the floor in the food prep area. The DSM acknowledged the dead cockroach and stated, not ok. Three more dead cockroaches were spotted in the corner on the floor near the steamer in the food prep area. Then a live cockroach was spotted on the floor crawling from the food prep counter adjacent to the trayline station. The DSM verified the three dead cockroaches and the live cockroach and then stepped on the live cockroach to kill it.
During a kitchen observation on 1/23/24 at 12:26 PM with the DSM, a dead cockroach was found on an electrical outlet under the food prep sink area and confirmed by the DSM.
On 1/23/24 at 12:58 PM, an interview was conducted with the facility's Pest Control company. The Pest Company stated they've instructed the kitchen staff about overall sanitation, and ensuring the building is free of clutter with card boxes to prevent pests including cockroaches. The Pest company further stated they have treated the staff breakrooms, janitorial closets, dining rooms and resident rooms for pests and cockroaches but the focus has been in the kitchen.
During an interview with the RD on 1/23/24 at 2:15 PM, the RD stated cockroaches were identified in the kitchen for several months, but the pest control company came out to spray the kitchen to monitor the cockroaches.
Review of the monthly kitchen inspection reports titled Quality Assessment for Performance Improvement dated 2/5/23, 3/3/23, 4/5/23, 5/5/23, 6/3/23, 7/5/23, 8/7/23, 9/5/23, 10/20/23, 11/6/23, 12/5/23, and 1/5/24 completed by the RD was conducted. The 12/5/23 and 1/5/24 inspection reports indicated .PROBLEM: Broken oven handle, broken middle refrigerator, broken steamer, broken plate warmer, ceiling leaking, fan in walk-in fridge broken, gasket in fridge broken .Notified maintenance .SANITATION .cockroaches in kitchen .
During an interview with the ADM on 1/23/24 at 2:30 PM about the pest control services at the facility, the ADM stated the pest control company the facility used from January 2023- April 2023, was not effective so the facility switched to a different pest control company. The ADM acknowledged the cockroaches found in the kitchen and further stated they have been a problem for a while.
During a review of the recent County of Santa [NAME], Department Environmental Health Inspection report dated 1/23/24, the report indicated .Major Violations .3 live adult cockroaches and 2 live juvenile cockroaches found behind equipment at cookline. 3 juvenile cockroaches found on the wall at the dish station. One live adult cockroach laying an egg sack found on wall at dish station. Moderate amount of dead cockroaches found throughout the kitchen (behind tape). [CA] The premises of each food facility shall be kept free of vermin. A food facility shall not operate when there is a vermin infestation that has resulted in the contamination of food contact surfaces, food packaging, utensils, food equipment, or adulteration of food(s). The food facility shall cease operation of the food facility immediately. The food facility shall remain closed until there is no longer evidence of a vermin infestation; all contaminated surfaces have been cleaned and sanitized; and contributing factors such as cleaning, repairs, and the elimination of harborages have been resolved.
Review of an outside company pest control report dated 7/20/23 indicated .Heavy roach infestation in kitchen .recommending roach clean out services .
Review of an outside company pest control report dated 10/19/23 indicated .treated kitchen .12 refrigerators that (DSM name) pulled out due to German cockroaches being spotted on them .
Further review of pest control reports dated from 5/2/23 to 1/18/24 indicated treated kitchen and under food carts and repeated comments of treated food cart storage room .
According to the Centers for Disease Control and Prevention (CDC), the German cockroach is a known vector for diseases including:
Salmonellosis - Salmonella food poisoning causes diarrhea, fever, and abdominal cramps within 12 to 72 hours. Symptoms are generally mild, but can be severe, especially for those with a compromised immune system.
Staphylococcus infections - This gastrointestinal [stomach and intestines] illness develops soon after food is eaten and usually last about a day. The toxins are heat resistant so are not destroyed by cooking.
Escherichia coli (E. coli) bacteria normally lives in the intestines of people and animals and some types can cause illness with diarrhea.
Typhoid fever - This life-threatening illness is caused by Salmonella Typhi. When a contaminated food is consumed, the bacteria multiply and spread into the bloodstream.
Gastroenteritis - inflammation of the stomach and small and large intestines, generally leading to vomiting or diarrhea.
General diarrhea. People may become infected with any of these by eating or drinking a contaminated food or beverage .
https://www.cdc.gov/healthypets/pets/wildlife/rodent-control.html
During a review of the County of Santa [NAME], Department of Environmental Health Inspection reports dated 4/15/22 and 5/3/23, the reports indicated .Many dead cockroaches and one live cockroach was observed on cockroach traps located inside the (Dietary) office which is also used for food storage .Major Violations .Multiple dead cockroaches were observed below the cooking, preparation, washing, storage tables in the kitchen area. Many live cockroaches were observed below these structures .The dead cockroaches must be cleaned, and the floor area properly sanitized immediately .
2) Cockroaches in Resident rooms and Care areas:
a) During an interview with Resident 223 on 1/22/24 at 10:20 a.m., Resident 223 stated he saw a cockroach in his room on the wall last week.
b) During a review of Resident 8's minimum data set (MDS- an assessment tool), dated 12/20/23 indicated her brief interview for mental status (BIMS, measure of cognition level) was 15 (score 13 to 15 indicates the resident is cognitively intact). During an interview on 1/23/23 at 1:30 p.m. with Resident 8, the resident stated she had seen one baby cockroach crawling on the plastic top of her juice cup. Resident 8 further stated that there was another dead cockroach on her meal tray not too long ago.
c) Review of Resident 218's face sheet (a document that contains a summary of a patient's personal and demographic information) indicated, Resident 218 was admitted to the facility with diagnoses including severe sepsis (the body's extreme response to an infection), depression (loss of pleasure or interest in activities for long periods of time), and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days). Review of Resident 218's MDS dated [DATE], indicated, Resident 218 had a brief interview for mental status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition) score of 15 (cognition is intact).
During a concurrent observation and interview with Resident 218 on 1/22/2024 at 9:05 a.m., inside his room, Resident 218 was lying on bed and stated there were some cockroaches in their room in the past and could not remember the date.
d)
Review of Resident 176's MDS Annual assessment dated [DATE], indicated Resident 176 had a BIMS score of 15. During an interview with Resident 176 on 1/22/2024 at 10:51 a.m., Resident 176 stated there were small cockroaches found inside the food cart. Resident 176 further stated the Surveyors needed to check the kitchen because there were small cockroaches found on the plate's lid. During a subsequent interview with Resident 176 on 1/23/2024 at 1:20 p.m., Resident 176 stated he found a cockroach under his bed at night on 1/22/2024 and has seen cockroaches crawling under his bed in the past. Resident 176 felt upset knowing that there were cockroaches under his bed.
e) Review of Resident 213's MDS, dated [DATE] indicated her BIMS score was 15 (score 13 to 15 indicates the resident is cognitively intact).
During an interview on 1/22/24 at 10:29 a.m., Resident 213 stated she had a concern about roaches coming on her bed. She stated she told the facility about the roaches. Resident 213 stated the facility said they would move her out of the room and clean the room. She stated her room has not been cleaned yet. Resident 213 stated there was a roach problem ever since she was admitted to the facility in April 2023. Resident 213 also stated she bought her own traps to deal with the roach problem.
f) During an interview on 1/23/24 at 12:59 p.m. with licensed vocational nurse (LVN) C, LVN C stated, approximately one week ago during the evening shift, she saw three (3) small cockroaches crawling out of a drawer in nursing station A (NS A). She said, I killed one [cockroach] .housekeeping sprayed [insecticide] right away.
g) During an interview on 1/23/24 at 1:02 p.m. with Certified Nursing Assistant (CNA) D, CNA D stated, one resident complained about cockroaches two weeks ago. She could not recall the name of the resident.
h) During an interview on 1/23/24 at 1:03 p.m. with Registered Nurse (RN) E, RN E stated, she could recall two recent cockroach incidents. RN E stated the most recent incident was 11/2023 when Resident 35's family member saw a cockroach alive in the resident's room and complained to her. RN E said, Resident 35 was moved .janitor sprayed the room .48 hours later the resident was moved back .[Resident 35] currently still in the facility. RN E stated, the second cockroach incident occurred in 8/2023 when Resident 192 saw a cockroach and called the nursing station. RN E stated, she went to the room, saw the cockroach alive, moved the resident to another room, and a janitor sprayed a pest control spray. RN E stated, a facility janitor sprayed the cockroach at that time, and added, not a pest control company. When asked to describe the process for reporting cockroach incidents, RN E stated, both times the administrator was informed, and she added, If we see cockroaches we spray and tell [the] infection control manager.
During a review of the County of Santa [NAME], Department of Environmental Health Inspection report dated 5/3/23, indicated .2. This routine inspection is conducted because of a complaint reported by residents about the cleanliness of the kitchen .
During a review of the facility's undated policy and procedure (P&P) titled Pest Control, the P&P indicated .2. Train employees on preventive measures, unsanitary conditions .4. Keep all food storage and preparation areas clean .This includes walls, floors, shelving, cabinet tops, sinks, and equipment 7. Keep facility grounds free of trash .
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Food Safety
(Tag F0812)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a sanitary environment and safe food handling p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a sanitary environment and safe food handling practices were maintained within the food service operation for 240 of 244 residents, which led to a cockroach infestation at the facility. This was evidenced by:
1. a) Live and dead cockroaches found in the kitchen under the meal tray line station and in food cooking preparation areas, confirmed by dietary staff, who reported the kitchen had a cockroach problem; Walls in the kitchen had uncovered holes with peeling baseboards, shelves had openings, and there were multiple broken kitchen appliances, which prevented adequate cleaning and sanitizing, and harbored pests; b) One of two ice machines managed by the Dietary Department had a dead baby cockroach inside on the ice curtain that covers the ice making grid water trough; c) Potentially hazardous foods (foods capable of supporting bacterial growth), also known as time control for food safety (TCS) foods, that were expired or incorrectly stored in the kitchen, which harbored pests; and d) Sanitizer solution in two red buckets were not at an effective concentration to sanitize food contact surfaces, and kitchen staff were unable to correctly demonstrate the process to test the sanitizer solution; and e) previous non-compliance of unsanitary kitchen conditions and evidence of heavy cockroach infestation at the facility identified by the County of Santa [NAME], Environmental Health Department in 2022 and 2023, per County health inspection reports;
2. Six (6) resident complaints about live and dead cockroaches in their rooms, and on their meal trays.
The unsanitary kitchen practices exposed medically vulnerable residents to contaminated food that had the potential to cause widespread foodborne illnesses within this highly susceptible resident population.
According to the 2022 Federal FDA (Food and Drug Administration) Food Code, .A 'Highly susceptible population' means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised (a weaker immune system); . or older adults; and (2) Obtaining food at a facility that provides services such as .health care .
According to the 2022 Federal FDA Food Code, sections 4-601.11, Non-food contact surfaces, 4-602.11 Food contact surfaces, and Annex 4-602.13, indicated .equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms (tiny harmful particles like bacteria that can only be seen by a microscope), which employees may inadvertently transfer to food. If these areas are not kept clean, they may provide harborage (shelter or place providing shelter) for insects, rodents, and other pests.
An immediate jeopardy (IJ) (an immediate situation where harm or potential harm could jeopardize the resident's safety) was called on 1/23/24 at 4:30 PM, and served to the Administrator (ADM) the due to the cockroach infestation in the kitchen, resident reports of cockroaches in meal trays, and repeated non-compliance of unsanitary dietary conditions in the kitchen which led to the extensive cockroach infestation.
On 1/31/24 at 4:40 PM, the IJ was removed in the presence of the facility's ADM, Regional [NAME] President of Operations (RVPO), and Chief Executive Officer (CEO) after an acceptable plan of action (POA) was provided by the facility, and observations, interviews, and record reviews were conducted to validate the POA. The POA included:
a)
Kitchen closure by the County of Santa [NAME], Environmental Health Department on 1/23/24 at 5:00 PM, and thorough cleaning and sanitizing of kitchen equipment, appliances, floors, and walls.
b)
Resident meals were prepared at an outside skilled nursing facility, transported to the facility and served in disposable Styrofoam trays and utensils;
c)
Thorough cleaning and sanitizing of the entire facility including the following departments: Dietary, Nursing stations, Laundry, Rehabilitation, Maintenance, and the individual residents' rooms who had live and dead cockroaches inside the rooms;
d)
Kitchen staff training and in-services by the Registered Dietitian (RD) on cleaning and sanitizing food contact surfaces and safe food storage practices to prevent harboring of pests;
e)
During an interview on 1/31/24 PM at 2:56 PM with the ADM, RVPO, RD, and RD PP, the facility is not using the [NAME] menus (a corporate nutrition company who create menus and recipes) as previously decided but are using the emergency menu approved by the facility's RDs;
f)
Daily Pest control services in the kitchen and in the resident's rooms with live and dead cockroaches;
g)
Nursing staff in-services by the Director of Staff Development (DSD) on infection control practices, sanitation, and pest sightings in the facility;
h)
Kitchen and Facility staff monitoring and logging of pests and cockroach sightings in 'Pest Binders' located in the kitchen area, nurse's stations, laundry department, rehabilitation department, and other common areas;
i)
The facility's Environmental Services Director (ESD)/Designee (Administrator) will review the pest control schedule weekly or as necessary based on the results of the program. Any issues identified will be reviewed with the Administrator for resolution. All trends from these observations will be reported to the facility's Quality Assurance Performance Improvement (QAPI) committee daily x 60 days, weekly x 60, then reevaluated until compliance is sustained. The facility's QAPI committee will provide further recommendations when indicated to confirm that the facility follows protocols and regulations. The facility's QAPI committee meetings will return to monthly after full compliance is achieved.
j)
Approval by OSHPD (Office of Statewide Healthcare Planning and Development/HCAI (Healthcare Access and Information) to install new kitchen appliance equipment for food preparation, food storage, and food production to replace damaged, inoperable, unclean kitchen equipment which provided an entry access to cockroaches.
In addition, the plan included daily routine monitoring of pests in the kitchen, an updated dietary staff cleaning schedule; and daily pest control services increased to weekly to ensure a safe, clean, and sanitary kitchen is maintained, in accordance with Federal Food & Drug Administration (FDA) Food Code, county, state, federal and OSHPD/HCAI requirements.
Findings:
1.
Unsanitary Foodservice Practices
(a) Ice machine:
According to a manufacturer (name of company), A single cockroach sighted during the day can indicate that there is a significant infestation. Cockroaches, also known as 'roaches,' are nocturnal and prefer to live and breed in dark shelters near food and moisture. But if a harborage site is overpopulated, they can be forced out in daylight, often in search of food ., to get to the food they can tread across the floor and through garbage in search of food, then crawl across the food-contact surfaces . (http://www.(name of company).com/pages/the-dangers-cockroaches-bring-to-food-safety)
During a concurrent observation of the ice machine at station 4 on 1/22/24 at 3:17 PM, a dead baby cockroach was found inside the ice machine cover facing the ice curtain. The RD and Dietary Services Manager (DSM) confirmed the finding of the dead baby cockroach inside the ice machine cover, and the DSM stated, Oh wow. The RD and DSM stated they did not know the last time the ice machine was cleaned and sanitized.
During an observation on 1/22/24 at 3:23 PM of the ice machine at nursing station 4 (NS 4) and interview with the facility's Regional Maintenance Director (FMD), the FMD acknowledged the black residue and brown crusty buildup inside the ice machine curtain, chute, and tiny black residue in the ice bin. The FMS stated the ice machine should be always clean, without the residue. The RD, DSM and the FMD acknowledged the dirty thick black and brown buildup and residue. The FMD further stated the ice machine should be cleaned every month using the manufacturer's guidelines.
During an interview with the ADM on 1/22/24 at 4:01 PM, the ADM stated the maintenance supervisor probably just cleaned the inside of the ice machine and the dietary staff cleaned the outside of the ice machine.
According to the 2022 Federal FDA Food Code, section 4-204.17, titled Ice Units, Separation of Drains, Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice . the potential for mold .growth in this area is very likely due to the high moisture environment. Molds . that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin.
During a review of the facility's undated policy and procedure (P&P) titled Ice Machines, the P&P indicated .Follow the manufacturer's guidelines for cleaning .Cleaning 1. Disinfect the drop opening of the ice machine once a week with an appropriate disinfectant or use 10-20 cc's (cubic centimeters which equals milliliters of volume) of bleach to 1,000 cc's of warm water .
(b)
Kitchen Cockroach Infestation:
During the initial kitchen tour on 1/22/24 at 8:58 AM, an observation of the back walls in the kitchen with shelves, a metal food prep counter and food prep sink had uncovered holes and pealing baseboards. Additionally, there were multiple broken and non-operation kitchen appliances, including a large reach-in refrigerator, a walk-in refrigerator, and condensation build-up on the ceiling of the walk-in freezer. The kitchen floor had food crumbs, debris, plastic strips, food wrappers, and other trash scattered all throughout the entire kitchen floor. Additionally, unsanitary practices including dirty dishes stored as clean dishes, light brown food crumbs and stains inside the two large reach-in refrigerators inside the DSM's office. One of three refrigerator door gaskets was ripped hanging off the inside of the door with a dark brown sticky substance on it. And a fire sprinkler was inside the walk-in freezer ceiling protruding from a large open hole. These physical environment conditions prevented adequate cleaning and sanitizing that allowed for and contributed to the harborage of pests.
On 1/23/24 at 11:31 AM, during a kitchen observation, a dead roach was found on the floor in the food prep area. The DSM acknowledged the dead cockroach and stated not ok. Three more dead cockroaches were spotted in the corner on the floor near the steamer in the food prep area. A live cockroach was spotted on the floor crawling from the food prep counter adjacent to the tray line station. The DSM verified the three dead cockroaches and the live cockroach and then stepped on the live cockroach to kill it.
On 1/23/24 at 12:26 PM, during a subsequent observation and interview in the kitchen, a dead cockroach was found on an electrical outlet under the food prep sink area and acknowledged by the DSM.
Review of an outside company pest control reports dated 5/2/23, 7/20/23, 10/19/23, and 1/18/24 indicated, .Heavy roach infestation in kitchen .recommending roach clean out services .treated kitchen .12 refrigerators .pulled out due to German cockroaches being spotted on them .
Further review of the outside company's pest control reports from 5/2/23 to 1/18/24 indicated treated kitchen and under food carts and repeated comments of treated food cart storage room .
According to the Food and Drug Administration, Insects and rodents carry disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment. (FDA 2022 Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected)
According to the Centers for Disease Control and Prevention (CDC), the German cockroach is a known vector for diseases including:
Salmonellosis - Salmonella food poisoning causes diarrhea, fever, and abdominal cramps within 12 to 72 hours. Symptoms are generally mild, but can be severe, especially for those with a compromised immune system.
Staphylococcus infections - This gastrointestinal [stomach and intestines] illness develops soon after food is eaten and usually last about a day. The toxins are heat resistant so are not destroyed by cooking.
Escherichia coli (E. coli) bacteria normally lives in the intestines of people and animals and some types can cause illness with diarrhea.
Typhoid fever - This life-threatening illness is caused by Salmonella Typhi. When a contaminated food is consumed, the bacteria multiply and spread into the bloodstream.
Gastroenteritis - inflammation of the stomach and small and large intestines, generally leading to vomiting or diarrhea.
General diarrhea. People may become infected with any of these by eating or drinking a contaminated food or beverage .
https://www.cdc.gov/healthypets/pets/wildlife/rodent-control.html
During a review of the recent County of Santa [NAME], Department Environmental Health Inspection report dated 1/23/24, the report indicated .Major Violations .3 live adult cockroaches and 2 live juvenile cockroaches found behind equipment at cookline. 3 juvenile cockroaches found on the wall at the dish station. One live adult cockroach laying an egg sack found on wall at dish station. Moderate amount of dead cockroaches found throughout the kitchen (behind tape) .The premises of each food facility shall be kept free of vermin (pests). A food facility shall not operate when there is a vermin infestation that has resulted in the contamination of food contact surfaces, food packaging, utensils, food equipment, or adulteration of food(s). The food facility shall cease operation of the food facility immediately. The food facility shall remain closed until there is no longer evidence of a vermin infestation; all contaminated surfaces have been cleaned and sanitized; and contributing factors such as cleaning, repairs, and the elimination of harborages have been resolved.
Review of the County of Santa [NAME], Department of Environmental Health Inspection dated 4/15/22, the inspection indicated .Observed some uncovered holes in the kitchen walls behind storage shelves .to prevent rodent/insect infestation, seal all possible holes leading to the kitchen area .
Review of the County of Santa [NAME], Department of Environmental Health Inspection dated 5/3/23 indicated, .Many dead cockroaches and one live cockroach was observed on cockroach traps located inside the (Dietary) office which is also used for food storage; .Major Violations .Multiple dead cockroaches were observed below the cooking, preparation, washing, storage tables in the kitchen area. Many live cockroaches were observed below these structures .The dead cockroaches must be cleaned, and the floor area properly sanitized immediately .
During a review of the facility's undated policy and procedure (P&P) titled Pest Control, the P&P indicated .2. Train employees on preventive measures, unsanitary conditions .4. Keep all food storage and preparation areas clean .This includes walls, floors, shelving, cabinet tops, sinks, and equipment 7. Keep facility grounds free of trash .
(c) Expired, Mold-like substances, and Exposed food:
During the recertification survey initial kitchen tour on 1/22/24 at 8:55 AM, the kitchen was overall had food crumbs, debris, plastic strips, food wrappers, and other trash scattered all throughout the entire kitchen floor. Additionally, unsanitary practices including dirty dishes stored as clean dishes, light brown food crumbs and stains inside the two large reach-in refrigerators inside the DSM's office. One of three refrigerator door gaskets was ripped hanging off the inside of the door with a dark brown sticky substance on it. And a fire sprinkler was inside the walk-in freezer ceiling protruding from a large open hole.
On 1/22/24 at 9:14 AM, an observation and interview were conducted in the Dietary Manager's office. A large Ziploc bag labeled puree kit dated 1/18/24 was found in the larger reach-in refrigerator with other nourishments. The Ziploc bag had a container of cooked cream of wheat and a bowl of soup. The DSM acknowledged the expired food items and stated they should have been thrown out.
On 1/22/24 at 9:31 AM, a concurrent observation and interview were conducted with the DSM. There was a large clear plastic bin found in an open space underneath a food prep counter with a bag of 32 yellow onions, and 23 had multiple dark black, gray, and brown spots resembling mold, and soft to touch. The DSM acknowledged the 'mold-like' colored areas on the onions and stated the onions should have been rejected when they were delivered.
On 1/22/24 at 9:59 AM, a concurrent observation and interview were conducted with the DSM. There was a scooper left inside a box of diced carrots in the walk-in freezer. The DSM acknowledged the scooper and stated, it should not be left there. The DSM did not know how long the scooper was left inside the case of carrots.
During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control, dated 2023, the P&P indicated .All perishable food items .will be stored properly .8. Fresh .vegetables should be stored in designated bins or containers in a designated area of the refrigerator .
During a review of the facility's policy and procedure (P&P) titled Food Purchasing, Receiving and Production dated 2023, the P&P indicated .All food will be of good quality and obtained from sources approved or considered satisfactory .3. All fresh .vegetables will be of good quality and freshness. Fresh produce should be purchased 1-2 times per week to ensure freshness and maximum nutritional value .
(d) Sanitizer solution:
During a kitchen observation on 1/22/24 at 10:03 AM and interview with a dishwasher Diet Aide (DA) J and the DSM, DA J stated the dish machine wash temperature should be 110 degrees F, and he thinks the sanitizer should be at 200 ppm (parts per million). DA J tested the sanitizer with a test strip from a chlorine test strip container and dipped it into the sanitizer solution from the dish machine for 13 seconds. DA J then compared the result against the test strip container results and shook his head. DA J took another test strip and redipped it for 10 seconds in the dish machine solution, then redipped the same strip for 8 more seconds and stated he is looking for a different result than what he's getting. DA J stated the sanitizer solution was not hot enough, that is why he did not get the desired result on the test strip because the color was gray, which was close to 200 ppm but not at 200 ppm. DA J stated he got trained on testing the sanitizer level in 2016 when he was hired and then again last week, but he doesn't remember the training.
On 1/22/24 at 10:17 AM, the DSM acknowledged DA J's sanitizer test demonstration and stated he should know how to test this correctly. The DSM then placed a stainless-steel container upside down and ran it through the dish machine. She dipped a test strip from the chlorine test strip container on top of the stainless-steel container. The test strip was medium gray, which read 50-100 ppm (parts per million). The DSM stated, this is the correct level, it should be between 50-100 ppm.
During an observation on 1/23/24 at 10:18 AM and interview with DA CC, DA CC tested the sanitizer solution by dipping the test strip in the red bucket for 15 seconds then compared the result with the test strip container and it was mostly orange with dark green on the tip. DA CC stated the strip should be at 400 ppm, which is acceptable and dark green because that is a good level. The DSM acknowledged the incorrect sanitizer test demonstration by DA CC. The DSM stated, the sanitizer in the red bucket should be between 200 ppm, and DA CC should know the correct process.
During a review of the manufacturer's label on the sanitizer bottle for the sanitizer used in the red buckets, the effective concentration to sanitize should be at 150-400 PPM. The chem test strips from the vial that the facility used provided a color-coded graph in increments of 100 PPM, 200 PPM, 300 PPM, 400 PPM, and 500 PPM. There was no measurement on the chem strip vial available to determine 150 PPM.
According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-302.14, titled Sanitizing Solutions, Testing Devices, A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided.
During a review of the facility's undated policy and procedure (P&P) titled Dietary Cleaning, the P&P indicated .Proper cleaning and sanitation of equipment ensures removal of residual food, chemicals, and bacteria .More sanitizer is not better; too much sanitizer can cause chemical poisoning. Use test strips to determine the proper strength of sanitizer .4.Removable parts can be washed, rinsed, and sanitized manually .Non-removable parts will be washed, rinsed, air dried, and sprayed with sanitizing solution .
2.
Residents cockroach complaints
a)
During an interview with Resident 223 on 1/22/24 at 10:20 a.m., Resident 223 stated he saw a cockroach in his room on the wall last week.
b)
During a review of Resident 8's minimum data set (MDS, an assessment tool), dated 12/20/23 indicated her brief interview for mental status (BIMS) score was 15 (a score 13 to 15 indicates the resident is cognitively intact). During an interview on 1/23/24 at 1:30 p.m. with Resident 8, the resident stated she had seen one baby cockroach crawling on the plastic top of her juice cup. Resident 8 further stated that there was another dead cockroach on her meal tray not too long ago.
c)
Review of Resident 218's face sheet (a document that contains a summary of a patient's personal and demographic information) indicated, Resident 218 was admitted to the facility with diagnoses including severe sepsis (the body's extreme response to an infection), depression (loss of pleasure or interest in activities for long periods of time), and paroxysmal atrial fibrillation (occurs when a rapid, erratic heart rate begins suddenly and then stops on its own within 7 days). Review of Resident 218's MDS, Quarterly assessment, dated 1/3/2024, indicated, Resident 218 had a brief interview for mental status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition) score of 15 (cognition is intact).
During a concurrent observation and interview with Resident 218 on 1/22/2024 at 9:05 a.m., inside his room, Resident 218 was lying on bed and stated there were some cockroaches in their room in the past and could not remember the date.
d)
Review of Resident 176's MDS Annual assessment dated [DATE], indicated Resident 176 had a BIMS score of 15. During an interview with Resident 176 on 1/22/2024 at 10:51 a.m., Resident 176 stated there were small cockroaches found inside the food cart. Resident 176 further stated the Surveyors needed to check the kitchen because there were small cockroaches found on the plate's lid. During a subsequent interview with Resident 176 on 1/23/2024 at 1:20 p.m., Resident 176 stated he found a cockroach under his bed at night on 1/22/2024 and has seen cockroaches crawling under his bed in the past. Resident 176 felt upset knowing that there were cockroaches under his bed.
e)
Review of Resident 213's MDS, dated [DATE] indicated her BIMS score was 15 (score 13 to 15 indicates the resident is cognitively intact).
During an interview on 1/22/24 at 10:29 a.m., Resident 213 stated she had a concern about roaches coming on her bed. She stated she told the facility about the roaches. Resident 213 stated the facility said they would move her out of the room and clean the room. She stated her room has not been cleaned yet. Resident 213 stated there was a roach problem ever since she was admitted to the facility in April 2023. Resident 213 also stated she bought her own traps to deal with the roach problem.
f)
Review of Resident 168's MDS, dated [DATE] indicated his BIMS score was 15. During an interview on 1/25/24 1:37 pm, Resident 168 stated his room was treated by a pest control company in December 2023 after weeks of asking. During the time when the pest control company did the pest treatment in his room, he claimed the cockroaches were crawling on him at night and waking him up. Resident 168 stated he also saw a cockroach in his lunch tray one time. He stated he went to the kitchen the next day to tell them about the cockroach, and the kitchen staff told him the cockroach was not from the kitchen.
During a review of the County of Santa [NAME], Department of Environmental Health Inspection report dated 5/3/23, indicated .2. This routine inspection is conducted because of a complaint reported by residents about the cleanliness of the kitchen .
During an interview with the Administrator (ADM) on 1/26/24 at 11:30 AM, the ADM indicated a Pest Control company treated the kitchen and the six residents' rooms. Per interview with the ADM and the Regional [NAME] President of Operations (RVPO), the pest control company will continue the pest treatment for the entire building in the following days/weeks.
Review of a pest control company invoice dated 1/26/24 indicated .Full kitchen clean out for German cockroaches' infestation: performed crack and crevice treatment in the kitchen using several methods. 1) open up all electrical sockets drilled holes in the walls and treated .2) .did a baseboard treatment under and behind all equipment .strongly recommend weekly services along with daily follow ups, and placing out monitors to evaluate activity .
During an observation of the kitchen to monitor cockroach activity on 1/27/24 at 8:50 AM, there was one (1) live cockroach and 15-20 dying cockroaches at the various areas in the kitchen. The kitchen was not under a sanitary condition for use and remained closed.
During an observation and interview on 1/28/24 at 12:20 PM of the kitchen with the ADM and RD, the kitchen was moderately cleaned but still had food particles in drawers under the metal food prep counter. Per the ADM, the kitchen area was deep cleaned by a company on Saturday 1/27/24 and pest control sprayed on Friday, 1/26/24. New kitchen equipment including a new combi oven and 2 free standing industrial refrigerators were purchased for installation because the facility felt they could not clean and sanitize the old equipment effectively.
During an observation and interview with the Housekeeper (HK) QQ, RD, and RD BB on 1/28/24 at 12:50 PM in the kitchen. HK QQ stated she cleaned the kitchen floor this morning at 8:30 AM and did not see any live or dead cockroaches. There were no bait traps observed in the kitchen. RD and RD PP also validated the absence of bait traps in the kitchen.
On 1/28/24 at 1:30 PM, during an observation and interview with the director of staff development (DSD), the DSD acknowledged resident rooms were deep cleaned as part of the Plan of Action (POA), however she had not done any training to staff of the importance of keeping the traps in place to monitor activity prior to surveyor identification that they were missing. There were no entries documented for cockroach activity observed in the binders for the previous 24 hours. The DSD acknowledged the blank entries in the Pest binder.
During a concurrent observation and interview on 1/29/24 at 8:37 AM of the kitchen with the RD, the RD confirmed there was a total of 37 dead carcasses found in five of eight monitors and on the floor of the kitchen.
During an observation on 1/30/24 at 9:08 AM of the kitchen, there was a total of six dead carcasses of roaches found in one of 13 monitors and on the floor of the kitchen near the three-compartment sink.
During an observation on 1/30/24 at 3:27 p.m., in room [ROOM NUMBER] to 220, each of the rooms had a cockroach trap but no cockroach activity was seen.
During an observation and concurrent interview on 1/30/24 at 3:32 PM with Certified Nursing Assistant (CNA) S, there was a pest control logbook binder available in the nurses' station. The log dated 1/26/24 indicated during the afternoon shift, there was one cockroach seen in resident room at nursing station 2 (NS 2).
During an observation on 1/31/24 at 8:24 AM of the breakfast tray line, the therapeutic emergency menu was followed to feed residents.
During a concurrent observation and interview on 1/31/24 at 9:15 AM in the kitchen, with Administrator in Training (AIT) and ADM, one dead carcass was found in one of 20 monitors. AIT confirmed the finding.
During this kitchen observation and inspection on 1/31/24 at 9:15 AM, kitchen inspection with the ADM and AIT, the 20 traps were observed. Two (2) traps had 1 roach each on them. Facility was instructed to clean and sanitize the kitchen prior to installing the new equipment.
During an interview with DA DD on 1/31/24 at 11:12 AM, DA DD stated in-services were done either yesterday or the day before for kitchen staff on how to check for the roach traps, any signs of roaches on the traps, they need to inform the DSM. If she is not there, then write it in the maintenance log that was in the kitchen.
During an interview on 1/31/24 at 11:21 AM with the RD and RD PP, both RDs stated they conducted kitchen staff trainings and in-services, including the DSM on basic handwashing, labeling of food for food storage, fire extinguisher use, 3-compartment sink use, test strip sanitizer solution testing 200 ppm for testing quat (ammonia), and clean and sanitize kitchen areas.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 58's face sheet indicated, Resident 58 was admitted to the facility with diagnoses including quadriplegia ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 58's face sheet indicated, Resident 58 was admitted to the facility with diagnoses including quadriplegia (is a form of paralysis that affects all four limbs, plus the torso), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well resulting for the bladder to not fill or empty correctly), and depression.
Review of Resident 58's MDS, Annual assessment dated [DATE] indicated, Resident 58's brief interview for mental status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition) score was 15 (cognition is intact).
During an initial pool observation on 1/22/2024 at 10:32 a.m., Resident 58 was lying flat on bed, watching on his computer tablet using a mouthpiece to navigate on it. Resident 58 had inability to move both arms and legs. Further observation inside Resident 58's room, an anti-fungal (a medication to prevent the growth of fungus [a type of organism including molds, and yeast]) liquid and a supplement with elderberry, vitamin C and zinc gummies were observed on top of the bedside drawer.
During a concurrent interview with Licensed Vocational Nurse U (LVN U), and record review on 1/22/2024 at 12:08 p.m., LVN U reviewed Resident 58's physician orders. LVN U confirmed Resident 58 did not have orders to have medication at bedside and there were no orders for the anti-fungal liquid and the supplement with elderberry, vitamin C and zinc gummies. LVN U stated Resident 58 should not have medication at bedside. LVN U confirmed there was no self-administration assessment done for Resident 58.
During an interview with LVN T on 1/25/2024 at 3:02 p.m., LVN T stated medications should not be left at bedside. LVN T further stated there should be a physician's order before leaving medication at bedside and medications should be stored in a locked box.
During an interview with the Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 4:14 p.m., IDON/IP stated residents could have medication at bedside when: there was a physician's order, a self-administration assessment was done, and if it was safe to keep the medication at bedside.
During a review of the facility's undated policy and procedure titled, Self-Administration of Medication, indicated, 1. When admitted , residents with capacity will be informed of their right to self-administer medications. 2. If a resident desires to participate in self-administration, the interdisciplinary team will assess the ability of the resident to participate, by completing a Resident Self Administration of Medication assessment. 3.The nurse will interview the resident to determine their ability to identify, prepare, secure, and administer medications. 4. The nurse will obtain a physician's order for each resident conducting self-administration of medications. 5. Nurses will assess accuracy and compliance of self-administration by periodic observation and counting of doses. 6. Storage of self-administered medications will comply with state and federal requirements for medication storage.
Based on observation, interview, and record review, the facility failed to implement their policies on self-administration of medication (resident takes medication without staff assistance) when there were no assessments performed for self-administration of medications, and medications were left at the bedside for 3 of 35 sampled residents (33, 58, and 90).
These failures had the potential for unsafe and improper administration of medications.
Findings:
1a. Review of Resident 33's face sheet indicated, Resident 33 was admitted to the facility with diagnoses including paraplegia (is a form of paralysis that affects the legs and lower body).
Review of Resident 33's Minimum Data Set (MDS, an assessment tool) dated 10/19/23 indicated, Resident 33's had a brief interview for mental status (BIMS) score of 14 (a score of 13 to 15 indicates cognitively intact).
During an observation on 1/23/24 at 10:02, in Resident 33's room, there were two tubes of cream in a basin on the Resident 33's bedside cabinet. The pharmacy label on the tubes identified the contents as hydrocortisone cream 1% (a steroid medication used to reduce pain, itching, and inflammation) and clotrimazole 1% (a medication used to treat fungal infections). When Resident 33 was asked what the medications were used for, he stated he did not know.
During an interview and concurrent record review with Licensed Vocational Nurse Z (LVN Z), on 1/23/24 at 10:15 a.m., LVN Z confirmed the two tubes of cream at Resident 33's bedside were the hydrocortisone cream and clotrimazole cream. LVN Z further stated Resident 33 did not have physician orders for the use of the hydrocortisone 1% cream. LVN Z also stated Resident 33's physician order for clotrimazole 1% cream had been discontinued on 1/15/24, and Resident 33 did not have orders to have medications at bedside and there was no self-administration assessment done for Resident 33. LVN Z stated Resident 33 should not have medications at bedside and the medications should be removed.
1b. Review of Resident 90's face sheet indicated, Resident 90 was admitted to the facility with diagnoses including blindness, one eye.
Review of Resident 90's MDS dated [DATE] indicated Resident 90 had short term memory problem.
Review of Resident 90's physician order, dated 11/25/23, indicated Resident 90 had fluctuating capacity to make healthcare decisions.
During an observation on 11/23/24 at 9:34 a.m., in Resident 33's room, there was a large tube of cream on Resident 90's bedside table. The tube read hydrocortisone cream 1% and there was no cap on the tube. When Resident 90 was asked what the medication was used for, she stated I use it when I have itchy skin
During an interview and concurrent record review with Licensed Vocational Nurse AA (LVN AA), on 1/23/24 at 9:42 a.m., LVN AA confirmed the tube of hydrocortisone cream at Resident 90's bedside. LVN AA stated Resident 90 did not have orders to have medication at bedside and there was no self-administration assessment done. LVN AA also stated Resident 90 should not have medication at bedside and the medication should be removed.
During an interview with the Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 9:15 a.m., the IDON/IP stated medications should not be left at bedside. She further stated residents could be screened and determined to be able to self-administer medication but the medications would need to be stored safely at bedside to prevent access by other residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to ensure resident's needs were accommodated for one of 39 sampled residents (Resident 544) when Resident 544's call button (a re...
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Based on observation, interview, and record review the facility failed to ensure resident's needs were accommodated for one of 39 sampled residents (Resident 544) when Resident 544's call button (a red button used by residetns to request assistance) was not within reach to use. This failure had the potential to affect residents' physical and psychosocial well-being.
Findings:
Review of Resident 544's face sheet (is a document that contains a summary of a patient's personal and demographic information) indicated, Resident 544 was admitted to the facility with diagnoses including hypertensive chronic kidney disease with stage 1 through stage 4 (a damage to kidney due to high blood pressure), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and chronic obstructive pulmonary disease, unspecified (COPD - a long lasting lung disease).
Review of Resident 544's Admission's Minimum Data Set (MDS, assessment tool) assessment, dated 1/14/2024, indicated Resident 544's brief interview for mental status (BIMS, cognition level) score was 14 (cognition is intact).
During a concurrent observation and interview with Resident 544 on 1/22/2024 at 9:21 a.m., Resident 544 was lying in bed, and his call light button was observed tied at the bottom part of his left bedrail. Resident 544 tried to reach for the call light button at the bottom part of the left bedrail with his right hand and left hand but unable to reach it. Resident 544 stated he couldn't reach the call light button.
During a concurrent interview and photo review with Licensed Vocational Nurse T (LVN T) on 1/25/2024 at 3:05 p.m., LVN T reviewed the photo of Resident 544's call light button taken on 1/22/2024 at 9:18 a.m. LVN T agreed Resident 544's call light button was not within his reach to use on 1/22/2024. LVN T stated the call light button should be within resident's reach. LVN T further stated they usually clipped the call light button cord near the resident's dominant side for easy access.
During a concurrent interview and photo review with the Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 4:07 p.m., IDON/IP reviewed the photo of Resident 544's call light button taken on 1/22/2024 at 9:18 a.m. IDON/IP confirmed Resident 544's call light button positioning was not within his reach on 1/22/2024. IDON/IP stated there should be a clip attached to the call light button cord and it should be clipped to resident's clothing.
During a review of the facility's policy and procedure titled, Call Lights-Answering of, dated 06/11, indicated, Facility staff will provide an environment that helps meet the Resident's needs .ensure that the call light is placed within the Resident's reach.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to protect the confidentiality of personal and medical records of one resident (Resident 116) when a Resident Face Sheet (a docu...
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Based on observation, interview, and record review, the facility failed to protect the confidentiality of personal and medical records of one resident (Resident 116) when a Resident Face Sheet (a document that contains personal and medical information) was left on top of an unattended medication cart.
This failure had the potential to put a resident at risk for identity theft, insurance fraud and discrimination.
Findings:
During an observation on 1/30/24, at 10:22 a.m. in nurse station B, Resident 116's face sheet was left uncovered on top of an unattended medication cart.
During an interview on 1/30/24, at 10:24 a.m. with Registered Nurse (RN) U, resident face sheet should not be left unattended and should have been placed face down.
During a review of undated facility policy titled Uses & Disclosures of Protected Health Information, it indicated, Protected Health Information must be safeguarded against loss and unauthorized access, use, and destruction.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on interview on record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) assessment, Section N - Medications for one of 39 sampled residents (Resident...
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Based on interview on record review, the facility failed to accurately code the minimum data set (MDS, an assessment tool) assessment, Section N - Medications for one of 39 sampled residents (Resident 213). This failure resulted in Resident 213's inaccurate MDS.
Findings:
Review of Resident 213's clinical record indicated she was admitted to the facility with diagnoses including metabolic encephalopathy (brain disease, damage, or malfunction caused my an imbalance of chemicals in the blood) and morbid obesity (health condition that results from an abnormally high body mass, weight 100 pounds greater than ideal body weight).
Review of Resident 213's physician orders dated 10/12/23 included an order for Ozempic pen injector 0.25 milligrams (mg, unit of measurement) subcutaneous (injected into the fat tissue under the skin) once a day on Friday for weight loss.
Review of Resident 213's MDS Section N - Medications, dated 10/31/23 indicated the resident received one insulin (hormone produced by the pancreas or an injectable medication used to control blood sugar levels) injection during the last seven days.
During a telephone interview on 1/30/24 at 11:22 a.m., the consultant pharmacist (CP) stated Ozempic is not considered a type of insulin. The CP also stated Ozempic is a glucagon-like peptide-1 agonist (class of medications used to treat diabetes [disease that can result in high blood sugar levels] or obesity).
According to Lexi-comp, a nationally recognized drug information resource, Ozempic was listed under Injectable Agents (Non-Insulin) for Type 2 Diabetes and Noninsulin Antidiabetic Agents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
2. During a review of Resident 82's document titled PASARR Level I Screening dated 8/5/22, it indicated a positive result of Level I Screening.
During a concurrent interview, and record review on 1/29...
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2. During a review of Resident 82's document titled PASARR Level I Screening dated 8/5/22, it indicated a positive result of Level I Screening.
During a concurrent interview, and record review on 1/29/24 at 3:20 p.m. with Licensed Vocational Nurse (LVN) K, a letter from Department of Health Care Services dated 8/17/2022 indicated Unable to complete Level II Evaluation for Resident 82. It also indicated After reviewing a Positive Level I Screening and speaking with staff, a Level II Mental Health Evaluation was not scheduled for the following reason: The individual was isolated as a health or safety precaution. The case is now closed. To reopen, please submit a new Level I Screening. LVN K confirmed that a new Level I screening was not done for Resident 82. LVN K also stated a new Level I screening should have been done.
Based on observation, interview and record review, the facility failed to ensure two of 39 sampled residents (Resident 221 and 82) completed a Level II Mental Health Evaluation as part of the pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care).
These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability or related conditions.
Findings:
1. Review of Resident 221's face sheet indicated, Resident 221 was admitted to the facility with diagnoses including other specified anxiety disorders (a mental illness that causes constant fear), post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), other schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and pedestrian on foot injured in collision with a vehicle in traffic accident.
Review of Resident 221's physician order report dated 1/29/2024, indicated Resident 221 was taking Trazodone ( a medication to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for depression manifested by inability to sleep, Buspirone (a medication for anxiety) for anxiety manifested by yelling/shouting and screaming, and Abilify (antipsychotic medication, used to treat psychotic disorders) for schizophrenia manifested by sudden angry outbursts.
Review of Resident 221's preadmission PASRR Level 1 screening, dated 8/14/2023, indicated Resident 221 had a positive Level I screening which indicated he should have a Level II Mental Health Evaluation.
Review of Resident 221's Level II Evaluation, dated 8/16/2023, indicated Level II evaluation was not completed. It indicated, The individual was unable to participate in the Evaluation .To reopen, please submit a new Level I Screening. Please note this letter is a courtesy notice for administrative purposes only and does not comprise a completed individualized determination.
During a concurrent interview and document review on 1/29/2024 at 3:29 p.m., licensed vocational nurse Q (LVN Q) reviewed Resident 221's Level II Evaluation. LVN Q stated he was the one assigned to do the PASRR Level I Screening, he had an access to retrieve any Level II evaluation result and the determination letter. LVN Q confirmed he did not do another Level I Screening for Resident 221. LVN Q further reviewed the Level II Evaluation and stated, Oh I got your point. I should have done another Level I Screening.
Review of the Department of Health Care Services (DHCS) letter, titled, The State of California's Preadmission Screening and Resident Review (PASRR) Compliance by July 1, 2023, dated 3/7/2023, indicated the PASRR process starts with Level I Screening to be completed at the hospital, Level II Evaluation will follow if the Level I Screening was positive for suspected mental illness and a Determination letter issued by DHCS or Department of Developmental Services (DDS) regional center.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a pre-admission screening and resident review (PASRR, a fede...
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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 pre-admission screening and resident review (PASRR, a federal requirement to help ensure that individuals who have mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was completed for two of 39 sampled residents (Residents 127 and 132). These failures had the potential for inaccurate care and services provided to residents with a mental disorder, intellectual disability or related conditions.
Findings:
1. Review of Resident 127's face sheet indicated he was admitted to the facility with diagnoses including sepsis and psychotic disorder with hallucinations.
Review of Resident 127's PASSR, dated 8/5/23 indicated the result of Level I Screening was negative. It also indicated for the question, Does the Individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, SchizophreniaSchizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? the answer No was marked.
During an interview and concurrent record review on 1/25/24 at 3:34 p.m., licensed vocational nurse Q (LVN Q) confirmed Resident 127 had a diagnosis of psychotic disorder with hallucinations. LVN Q stated the answer to the question regarding whether Resident 127 had a serious mental illness should have been marked, Yes.
2. Review of Resident 132's face sheet indicated he was admitted to the facility with diagnoses including schizoaffective disorder and brief psychotic disorder. The face sheet also indicated Resident 132's latest return from hospital was on 5/15/23.
Review of Resident 132's documents indicated the resident's last PASRR was completed on 1/16/21.
During an interview and concurrent record review on 1/25/24 at 3:41 p.m., LVN Q stated Resident 132 should have a PASRR done when he was readmitted on [DATE]. LVN Q confirmed there was no PASARR done for Resident 132.
Review of the Department of Health Care Services (DHCS) letter, titled, The State of California's Preadmission Screening and Resident Review (PASRR) Compliance by July 1, 2023, dated 3/7/2023, indicated the PASRR process starts with Level I Screening to be completed, Level II Evaluation will follow if the Level I Screening was positive for suspected mental illness and a Determination letter issued by DHCS or Department of Developmental Services (DDS) regional center.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 135's face sheet indicated Resident 135 was admitted to the facility on [DATE] with diagnosis of acute res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 135's face sheet indicated Resident 135 was admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia (lungs cannot release enough oxygen into the blood), Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly).
During an observation on 1/25/24 at 4:26 pm, Resident 135 was observed opening the latch of a food cart located in the hallway and drank the cranberry juice cocktail leftover from another resident.
During an interview on 1/25/24 at 4:39 pm, with CNA HH, CNA HH stated that Resident 135 was seen going through the old food trays that were in a food cart a week ago. CNA HH stated she informed the nurse.
During a concurrent interview and record review on 1/25/24 at 4:41 pm, with Licensed Vocational Nurse (LVN) II, LVN II confirmed that Resident 135 did go through the old food tray a week ago and informed the supervisor. LVN II stated that it was not okay for the resident to go through old food trays because it was dirty and maybe contaminated. LVN II stated the resident was not being monitored and MD not notified.
Review of Resident 135's Care Plan titled Has a problem of rummaging through food carts and eats leftovers, but refuses to eat served food despite explaining risks of doing so, dated 3/20/24, indicated Redirect resident; notify MD/NP/PA; monitor for ill effects.
During an observation on 1/27/24 at 10:36 am, Resident 135 was observed opening the tray cart with old food trays and drinking a juice leftover from another resident.
During an interview on 1/29/24 at 2:13 pm, with Registered Nurse (RN) JJ, RN JJ stated Resident 135 should be monitored and redirected to prevent the resident from going through the old food trays.
During a concurrent interview and record review on 1/30/24 at 8:42 am, with the IDON/IP, the IDON/IP stated that they need to do more to prevent Resident 135 from going through the old food trays because he was at risk of getting an infection and having food borne illness. The IDON/IP confirmed Resident 135's care plan was not being implemented.
Review of the facility's Comprehensive Care Plan policy and procedure, undated, indicated The comprehensive plan of care must include treatment goals with measurable objectives; reflect interventions to meet both short and long term resident goals; be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur.
Based on observation, interview, and record review, the facility failed to develop and implement a care plan for two of 39 sampled residents (Resident 83 and 135) when:
1. Resident 83's language barrier care plan was not initiated and the communication binder (it is a compilation of photos, symbols, or illustrations to help people with limited language skills express themselves) was not available for Resident 83 and staff's use; and
2. Resident 135's care plan was not implemented.
These failures had the potential for inaccurate development and implementation of personalized and resident-centered care plans that would address the residents' identified concerns and needs.
Findings:
Review of Resident 83's face sheet (a summary page of a patient's important information) indicated Resident 83 was admitted to the facility with diagnosis of hemiplegia (one-sided muscle paralysis or weakness), unspecified affecting left non-dominant side. Further review of Resident 83's face sheet indicated she was Asian, Korean and her preferred language was Korean.
Review of Resident 83's admission MDS dated [DATE], indicated a Resident 83's BIMS score was 14 (intact cognition) and her preferred language was non English language.
During an initial observation on 1/22/2024 at 3:27 p.m., Resident 83 was lying in bed, talking to herself in non-English language. There was no communication binder found inside the room or in the drawer.
During an observation on 1/29/2024 at 8:46 a.m., Certified Nursing Assistant F (CNA F) and another CNA went inside Resident 83's room. CNA F tried to speak in simple English to let Resident 83 know she would have a shower and she needed to be transferred to a shower chair. Resident 83 couldn't understand them and continued to speak in her foreign language. There was no communication binder found inside Resident 83's room.
During an interview with the Interim Director of Nursing/Infection Preventionist (IDON/IP), on 1/29/2024 at 3:54 p.m., IDON/IP confirmed they missed Resident 83's communication binder and her language barrier should have been care planned.
During an interview with Social Service Director (SSD) on 1/31/2024 at 9:54 a.m., SSD confirmed residents with language barrier should have a communication book inside the room and should be with residents when they were sitting on a wheelchair. SSD stated she provided the communication book to residents with language barrier upon admission. SSD further stated staff should use the communication book when communicating to residents with language barrier.
During a concurrent interview and record review on 1/31/2024 at 1:40 p.m., SSD reviewed Resident 83's clinical record and list of care plans. SSD confirmed Resident 83 was admitted to the facility on [DATE]. SSD stated Resident 83 had a language barrier and the care plan should have been developed.
During a review of the facility's undated policy and procedure titled, Comprehensive Plan of Care, indicated, The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. The comprehensive plan of care must: Address the resident's individual needs, strengths, and preferences .Comprehensive Care Plan is completed within 7 days after the completion of the comprehensive assessment (MDS).
During a review of the facility's undated policy and procedure titled, Resident Communication, indicated, .Use communication boards and picture books .An interpreter will be utilized for non-English speaking resident/patient and document in the resident's/patient's health records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure proper foot care was provided to one of 39 sampled residents (Resident 221) when Resident 221's long, jagged (has a ro...
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Based on observation, interview, and record review, the facility failed to ensure proper foot care was provided to one of 39 sampled residents (Resident 221) when Resident 221's long, jagged (has a rough, uneven shape) toenails were not trimmed by either licensed nurses or podiatrist (medical specialists who help with problems that affect your feet or lower legs). This failure had the potential to increase the risk for the development of foot ulcer and infection.
Findings:
Review of Resident 221's face sheet (summary page of a patient's important information) indicated, Resident 221 was admitted to the facility with diagnoses including multiple fractures of pelvis (the area of the body below the abdomen that is located between the hip bones and contains the bladder and the rectum), displaced bicondylar fracture of right tibia (severe injuries where the bone in the lower leg was broken), dislocation of left knee, other specified anxiety disorders (a mental illness that causes constant fear), post-traumatic stress disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), other schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and pedestrian on foot injured in collision with a vehicle in traffic accident.
During a concurrent observation and interview with Resident 221 on 1/23/2024 at 8:49 a.m., Resident 221 complained of pain to his right foot. Resident 221's right four toenails were long, with sharp edges and the skin of his toes were dry. Resident 221's right big toe looked like it was about to come off.
During an interview with licensed vocational nurse BB (LVN BB) on 1/23/2024 at 8:55 a.m., LVN BB stated they were waiting for the podiatrist to trim Resident 221's toenails. LVN BB further stated the social service director (SSD) was the one responsible for the podiatry visit.
During an interview with SSD on 1/23/2024 at 4:15 p.m., SSD confirmed Resident 221 was not seen by the podiatrist December 2023.
During a follow up interview with the SSD on 1/24/2024 at 11:55 a.m., SSD stated she called the podiatrist on 1/23/2024 for Resident 221 to be seen. SSD further stated nurses should report to her if resident needed to be seen right away.
During an interview with the Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 4:04 p.m., IDON/IP confirmed Resident 221's toenails should have been trimmed by certified nursing assistants (CNAs) since Resident 221 was not diabetic (a person with chronic, metabolic disease characterized by elevated levels of blood sugar) and the podiatry consult should have been done right away.
During an interview with the Director of Staff Development (DSD) on 1/31/2024 at 9:49 a.m., DSD stated nail care should be done by CNAs but if residents were diabetic, the nurses should do it. DSD further stated CNAs should check resident's nails and toenails during shower days. DSD confirmed if a resident needed to be seen by a podiatrist, nurses should write it down in the social services (SS) binder for referral.
Review of the podiatrist progress note dated 1/23/2024, indicated, Dried blood .No opening, pointing to right big toe illustration. Further review indicated, Remarks: Poor foot hygiene, Foot very sensitive to touch.
During a review of the facility's undated policy and procedure titled, Personal Care Needs Policy, indicated, A patient who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal and oral hygiene .Proper treatment and care for the feet is provided.
During a review of the facility's undated policy and procedure titled, Referral to Outside Agencies, indicated, Referrals can be made by the Social Service Director, licensed nurse, or a member of the IDT (Interdisciplinary Team, a group of health care professionals from diverse fields who work toward a common goal for residents) based on a resident's individualized, specific needs identified through interviews, evaluations, and assessments .Referral for Professional Routine Services .podiatry .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident, (Resident 210) with an unintende...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure a resident, (Resident 210) with an unintended, unplanned severe weight loss of 12.69% in six months had acceptable parameters of nutritional status was monitored from (5/4/23-10/18/23) according to facility policy and standards of practice when:
1)
The facility did not reassess the resident's nutritional status, obtain regular laboratory values, or modify the interventions after severe percent of weight loss occurred, according to facility policy and standards of practice.
2)
Weekly weights to monitor Resident 210's weight status after a loss of five or ten percent of body weight was not available or provided, according to policy.
3)
The resident's meals and snack/nourishment consumption were not monitored to determine the resident's actual food intake to evaluate nutrition status, according to facility policy.
These failures led to Resident 210 experiencing a 12.69% weight loss and the potential to have further decline of lean body mass (the body weight that includes muscles, bones, and organs and excludes fat) and an increased risk malnutrition. The facility census was 244 residents.
Findings:
According to the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, Treatment of unintended weight loss is imperative to ensure optimal outcomes for the older adult. Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death. Unintended weight loss often results in protein-energy undernutrition (low protein or calorie intake resulting in insufficient nutrient absorption), as the older adult loses critical lean body mass and is more prone to pressure ulcers (injuries to the skin and underlying tissue due to consistent pressure), infections (when a virus or bacteria enters the body and causes harm), immune dysfunction (when the body's system does not fight off infections or illness), anemia (low levels of oxygen in the blood), falls resulting in hip fractures (breaks or tears), and other conditions. https://www.nutritioncaremanual.org/
Per the facility's undated Face Sheet, Resident 210 was admitted on [DATE] and re-admitted on [DATE] with diagnoses of metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), gastro-esophageal reflux disease-GERD (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and dysphagia (difficulty swallowing).
Review of Resident 210's weight history from April 2023 to October 2024 indicated the following:
3/18/22-149 pounds
4/22/23 -136 pounds
5/4/23 -134 pounds
6/4/23 -128 pounds
7/3/23 - 125 pounds
8/9/23 - 126 pounds
9/24/23 - 118 pounds
10/4/23 - 117 pounds
Resident 210 experienced an unplanned unintentional severe weight loss of 8.7% in one month from March 2023 to April 2023, and unplanned insidious weight loss of 13.97% in six months from April 2023 to October 2023.
During an interview on 1/22/24 at 3:16 PM with Resident 210's caregiver, the caregiver stated the resident weighed 115 pounds.
Review of Resident 210's Quarterly Nutrition assessment dated [DATE] completed by RD, indicated resident 210's ideal body weight (IBW)=121 pounds, and height= 5 feet, 4 inches. The Assessment also indicated .weight history: 11 pounds/9% significant weight change at 3 months, 20 pounds/15% significant weight change at 6 months . Average meal intake: 75%-85% for Breakfast-Dinner; Regular diet, Low sodium, ground veggies, Mechanical soft texture, thin liquids; Supplements: yogurt, egg sandwich, PM (evening) snacks- cookies, milk ice cream.
Review of Resident 210's Initial Nutrition assessment dated [DATE] completed by the RD, indicated the resident's daily estimated nutrition needs (ENN): calories= 1715 to 2,058; protein= 55-69 grams per day; Regular Diet, Double portions
Review of Resident 210's meal intake percentage (%) records from 12/1/23 - 1/25/24 indicated the meal intake percentage was 26%-100% per week.
Review of Resident 210's lab reports provided by the facility indicated:
1)
3/24/23: .cholesterol 131 L (134-199 mg/dL normal)
2)
5/8/23: Total Protein=6.3 g/dL (low)(6.4-8.9 g/dL normal), Vitamin D-25 Hydroxy=18 ng/dL(low)(30-50 ng/dL)
3)
10/16/23: Protein 5.8 g/dL (low)
Review of Resident 210's Care plan, dated 3/18/23, indicated .Nutrition Risk start 5/2/23; last reviewed on 12/28/23- Diet as ordered, regular, double portions, supplements .
Reviewed Resident 210's Situation Background Assessment and Recommendation (SBAR)- Change of Condition, dated 6/27/23 indicated .Weight/nutrition weight loss, continue to encourage food and fluids. Snacks TID (three times a day), Ensure (liquid supplement) BID (twice a day), between meals; significant weight loss 1 and 3 months .
Reviewed Resident 210's SBAR- Change of Condition, dated 10/10/23 indicated .continue to monitor weekly weights, no significant weight changes for the past week . SBAR dated 10/18/23, .One to one (1:1), Feeding assistance, monitor weekly weights . SBAR dated 9/28/23 .Weights, risk factors - low BMI, dementia, history of behavior/psych issues, variable PO (eat by mouth) intake, dependence on feeding assistance; Resident significant weight loss in 1 and 3 months; Receives 1:1 feeding assistance . SBAR dated 6/22/23 .Weight loss, RD indicated resident confused and disoriented, difficult to redirect her with her eating.
During an observation and interview on 1/24/24 at 9:51 A.M. with Certified Nursing Assistant Z (CNA Z), CNA Z stated Resident 210 likes cookies, cheese sandwiches, and juice. CNA Z stated the resident did not have Ensure supplement at breakfast.
During an interview on 1/24/24 at 10:28 AM with Resident 210's family member, stated when he visits the resident that she always complains of being hungry. The family member stated nursing, or the dietitian had not told him about the weight loss his family member experienced.
During an observation and interview on 1/27/24 at 1:45 P.M. with CNA Z about Resident 210's Ensure supplements, CNA Z stated she did not give the supplement at breakfast or lunch.
During an interview with the RD on 1/26/24 at 10:53 AM, the RD stated he is involved in Resident 210's wt. loss through the facility's monthly Resident risk meetings. The RD stated he used the resident's actual weight when the weight loss interventions were established. The RD stated the resident's progress notes dated 5/22/23 indicated resident 210 was on psychotic medications that could alter her weight status. The RD stated he did not know which psych meds contributed to her weight loss. The RD stated he looked at the resident's weekly and monthly meal and Ensure supplement intake percentages (%) documented in the nursing notes. The RD also stated the resident had numerous hospital visits from April 2023 to May 2023 that may have contributed to her weight loss. The RD further stated he would change the regimen to address the weight loss when a resident continues to lose weight. The RD stated when someone refuses to eat then he would pay a visit to observe the resident eating and ask nursing or feeding assistant about their food preferences and feeding assistance. The RD stated if changes are needed, then he would make them in the progress notes. The RD stated he spoke with family about Resident 210's weight loss but does not remember when he spoke to them. The RD stated if the PO intake is low with a resident especially losing weight, then he would do more observations of the resident's meal intake. The RD stated he does not recall when he visually observed the resident consume food intake.
During an interview and record review on 1/26/24 at 11:40 AM with the RD, the RD stated the Resident Nutrition Assessment document dated 3/21/23, indicated double portions as the diet order. The RD stated the 'double portions' Diet Order ended on 5/2/23. The RD stated the meal intake % in April 2023 indicated she was eating at least 75% of meals and supplements. However, the RD did not recall why the double portions was discharged from the diet order. The RD stated Resident 210 is on the same plan of care (POC) with the diet order recommendations and snacks. The RD stated he should have conducted more follow ups with nursing and observed the resident eating during the time she had the severe weight loss to recommend additional supplements or foods.
During an interview with the Director of Nursing (DON) on 1/31/24 at 1:24 PM, the DON stated the main person in the facility responsible for managing the resident's weight loss is the RD. The DON stated the RD communicates with the nursing staff about how the plan to address the resident's weight loss with interventions like food and supplements. The DON stated once the pt/resident with significant or severe wt. loss, they identify the root cause of the problem. She stated if it were food preferences, they would interview the resident and the family about the food preferences. Ask the nurses and CNAs about the residents' intake and issues with food intake. Then ask the RD about whether supplements or other food sources could help. The DON stated weekly weights help with monitoring the resident's medical status.
During an interview with the resident's physician (PHYS) on 1/31/24 at 1:56 PM, the PHYS stated the resident had psychotic issues and was refusing everything. The PHYS stated the resident was on lorazapem (medication to treat anxiety and sleeping difficulties) since June 2024, because of her pinching. The PHYS stated the RD typically recommends interventions like foods and supplements including ensure and propass (protein supplement) to help residents like Resident 210 with weight gain. PHYS further stated she is notified by nursing when a resident misses two consecutive meals and has significant or severe weight loss. The PHYS stated when a patient is losing weight with psych issues and receiving psych meds then she is notified to make modifications in the dosage or medication, if needed. The PHYS stated the Resident has dementia, so her weight loss is not a concern since her last weight was 121 pounds this month, January 2024. The PHYS stated the resident had labs drawn a couple of times, including in 10/16/23 and 1/17/24 but the labs were normal, so the PHYS stated she was not concerned. The MD acknowledged the facility could have implemented additional measures clinically, including ordering weekly weights, supplements like protein powders or puddings, or other parameters to increase the calories with a resident who has severe weight loss, and behavior concerns.
During a review of the facility's policy and procedure (P&P) dated 12/1/05, rev 10/20, titled Weights & Vitals, the P&P indicated .To monitor, document and initiate appropriate interventions to significant monthly weight variances .5. All significant weight variances .will be reported to the physician and responsible party by the Licensed Nurses .Documentation of this notification with date will be completed on the Weight and Vital Sign Record form's comments section or progress notes .6. All patients with significant weight variances will have a timely intervention initiated by the .RD .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) was provided for one of two sampled residents (Resident 22) wh...
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Based on observation, interview, and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) was provided for one of two sampled residents (Resident 22) when Resident 22's physician order for oxygen administration was not followed. This failure had the potential to result in complications related to improper treatment while receiving O2 therapy.
Findings:
Review of Resident 22's face sheet indicated Resident 22 was admitted to the facility with diagnoses including paraplegia (a paralysis that occurs in the lower half of the body. It can be a result of an accident or a chronic condition), type 2 diabetes mellitus (occurs when the body is unable to regulate glucose [sugar] in the blood), hydrocephalus (a buildup of fluid in cavities called ventricles deep within the brain), hypertension (high blood pressure), and acute respiratory failure (a condition when lungs cannot release oxygen to blood causing shortness of breath) with hypoxia (occurs when oxygen level in the body organs are low).
Review of Resident 22's Physician Order Report, dated 1/29/2024, indicated an order since 10/11/2023 of O2 at 2 liters (L- a metric unit of capacity) per minute (min or M).
During an observation on 1/24/2024 at 9:28 a.m., Resident 22 was lying in bed with O2 in placed at 3 LPM thru nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration).
During a concurrent interview and record review on 1/25/2024 at 3:09 p.m., Licensed Vocational Nurse N (LVN N) reviewed Resident 22's physician order of oxygen use. LVN N confirmed the order for oxygen should be at 2 LPM.
During a follow up observation and interview with LVN N on 1/25/2024 at 3:12 p.m., inside Resident 22's room, LVN N confirmed Resident 22's O2 was administered at 3 LPM. LVN N stated, Resident 22's O2 flow rate should be at 2 LPM.
During an interview with the Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 3:58 p.m., IDON/IP stated, the oxygen order should always be followed.
Review of Resident 22's care plan problem, Alteration in Respiratory status due to Dx (Diagnosis) Acute Respiratory Failure with Hypoxia, dated 7/8/2023, indicated an approach, Administer oxygen as ordered.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0710
(Tag F0710)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication ...
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Based interview and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication use audits did not reconcile for one out of six (6) randomly checked (Resident 168) residents. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the resident. There were two controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications.
Finding:
The Controlled Drug Records (CDRs) for six (6) random residents receiving PRN (meaning as-needed) controlled medications were requested for review during the survey.
Resident 168 had a physician's order, dated 8/28/23, for oxycodone (a potent controlled medication for pain) 5 milligrams (mg, unit of measurement), 1 tablet by mouth every 6 hours as needed for moderate or severe pain.
During a concurrent interview and record review on 1/22/23 at 3:52 p.m. with licensed vocational nurse A (LVN A), Resident 168's CDR for oxycodone 5 mg and the MAR dated 1/2024 were reviewed. The CDR for oxycodone 5 mg indicated the nursing staff removed 1 tablet on 1/6/24 at 2 p.m. and 1/7/24 at 10 a.m. from the medication cart and documented on the CDR (meaning they removed the medication from the locked controlled medication compartment in the medication cart). The MAR indicated, on 1/6/24 for the 2 p.m. administration time and 1/7/24 for the 10 a.m. administration time, there were no nursing staff initials in the box for Resident 168's oxycodone 5 mg, to demonstrate the medication was administered. LVN A stated, there was no documentation on the MAR dated 1/2024 that indicated Resident 168 received the oxycodone 5 mg on 1/6/24 at 2 p.m and 1/7/24 at 10 a.m.
During a concurrent interview and record review on 1/24/24 at 10:03 a.m. with the Interim Director of Nursing (IDON), a review of Resident 168's CDR for oxycodone 5 mg and the MAR dated 1/2024 reflected the nursing staff signed oxycodone 5 mg out of the CDR but did not document the respective administration on the MAR: on 1/6/24 at 2 p.m. and 1/7/24 at 10 a.m. The IDON verified this finding and acknowledged two (2) oxycodone tablets were not accounted.
During a review of the facility's policy and procedures (P&P), titled Controlled Substances, dated January 2023, the P&P indicated, Administer the controlled medication and document dose administration on the MAR.
During a review of the facility's P&P, titled Medication Administration, dated 1/2023, the P&P indicated, The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.
During a review of the facility's guideline titled, Medication Pass Guidelines, (undated), the guideline indicated, Record the name, dose, route, and time of medication on the Medication Administration Record .initial the record after the medication is administered to the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility had a medication error rate of 10.71% when three (3) medication errors occurred out of 28 opportunities during the medication administr...
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Based on observation, interview, and record review, the facility had a medication error rate of 10.71% when three (3) medication errors occurred out of 28 opportunities during the medication administration for one out of four residents (Resident 190). The failure resulted in medications not given according to the physician's orders and had the potential for Resident 190 not receiving the full therapeutic effects of medications.
Findings:
During a medication pass observation on 1/22/24 at 9:15 a.m., licensed vocational nurse (LVN) B was observed preparing and administering 15 medications to Resident 190. The medications included one lidocaine patch (to treat pain) to Resident 190's middle/upper back and one puff of Symbicort (budesonide-formoterol, medication to treat lung disease) inhaler.
During a review of Resident 190's medical record indicated the following physician's orders:
a. Lidocaine 4% patch, apply 1 patch to each Shoulder at 9 a.m. and remove at 9 p.m. for pain management, dated 10/26/23;
b. Symbicort (budesonide-formoterol, medication to treat lung disease) 160-4.5 micrograms (mcg, unit of measurement), inhale 2 puffs twice a day at 9 a.m. and 5 p.m. for COPD (Chronic Obstructive Pulmonary Disease), dated 11/21/23; and
c. Cholecalciferol (vitamin D3, a supplement) 50 mcg (2000 unit), one capsule oral (by mouth) once a day at 9 a.m. for supplement, dated 8/17/23.
There was no cholecalciferol (vitamin D3) capsule given during the medication administration observation as mentioned above.
During a concurrent interview and record review on 1/22/23 at 3:09 p.m. with LVN B, Resident 190's physician's order for Lidocaine 4% patch was reviewed and LVN B verified the physician's order indicated, 1 patch to each shoulder. LVN B acknowledged one patch was applied to Resident 190's middle/upper back, instead of one patch to each shoulder as indicated on the physician's order. LVN B stated, Patch is moved often, need to check with doctor to update the order. LVN B reviewed Resident 190's physician order for Symbicort inhaler which indicated 2 puffs. LVN B acknowledged the resident inhaled one puff instead of two puffs as indicated on the physician's order. LVN B said, I will teach him again. Regarding the cholecalciferol (vitamin D3), LVN B acknowledged it was not given to Resident 190 on 1/22/24 at 9 a.m. LVN B said, I don't know how I missed it .I will check with the [doctor] if it is ok to give now.
During a follow-up interview on 1/23/24 at 8:53 a.m. with LVN B, LVN B stated, Resident 190's cholecalciferol (vitamin D3) order was updated by the doctor to be given in the evening on 1/22/23 at 5 p.m.
During a concurrent interview and record review on 1/24/24 at 10:03 a.m. with the Interim Director of Nursing (IDON), in the presence of Regional Clinical Operations (RCO), Resident 190's physician's orders for lidocaine patch, Symbicort inhaler, and cholecalciferol (vitamin D3) were reviewed. Regarding the lidocaine patch, the IDON stated, .if 2 patches ordered, expect to give 2 patches. If pain location changed, the doctor should be notified to change the order. Regarding the Symbicort inhaler, the IDON stated, If order says 2 puffs, expect (nurses) to give 2 puffs. Regarding the cholecalciferol (vitamin D3) not being given by the nurse on 1/22/24 at 9 a.m., the IDON stated, When a medication is ordered for 9 a.m., it is expected to be given as ordered.
During a review of the facility's guideline titled, Medication Pass Guidelines, (undated), the guideline indicated, To assure the most complete and accurate implementation of physician's medications orders .Medications are administered in accordance with written orders of the attending physician .Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.
During a review of the facility's policy and procedures (P&P) titled, Medication Administration, dated 1/2023, the P&P indicated, Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an interview on 1/23/24, at 10:22 a.m., with Certified Nursing Assistant (CNA) C, in the hallway outside Resident 229'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an interview on 1/23/24, at 10:22 a.m., with Certified Nursing Assistant (CNA) C, in the hallway outside Resident 229's room, CNA C stated, She is a feeder referring to Resident 229. CNA C stated, Resident 229 needs full assistance to eat her meals.
During an interview on 1/25/24, at 1:45 p.m., with Director of Staff Development (DSD), DSD stated, staff should not refer to residents as feeders.
During a review of the facility's policy and procedure (P&P) titled, Resident Dignity & Personal Privacy, (undated), the P&P indicated, Care for residents in a manner that maintains dignity.
2. Review of Resident 58's face sheet indicated, Resident 58 was admitted to the facility with diagnoses including quadriplegia (is a form of paralysis that affects all four limbs, plus the torso), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well resulting for the bladder to not fill or empty correctly), and depression.
Review of Resident 58's MDS Annual assessment dated [DATE] indicated, Resident 58's BIMS score was 15 (cognition is intact). Further review indicated Resident 58 used a wheelchair and able to wheel 50 feet with two turns.
Review of Resident 58's care plan titled, Suprapubic catheter (the placement of a drainage tube into the urinary bladder just above the pubic symphysis [a joint in between the left and right pelvic bone]), date started 10/18/2021, the approach indicated, Provide privacy and promote dignity. Provide dignity bag.
During an initial pool observation on 1/22/2024 at 10:32 a.m., Resident 58 was in his room lying in bed, and the urine drainage bag (a bag that collects urine) was hanging at the bottom of the bed without a cover.
During a concurrent observation and interview on 1/22/2024 at 12:04 p.m., Certified Nursing
Assistant F (CNA F) was observed providing a dignity bag to Resident 58's urine drainage bag. CNA F stated, I am putting this because you guys are here. CNA F further stated, This urine bag did not have a cover for months. CNA F agreed the urine drainage bag should have been covered to provide dignity.
During an interview with Licensed Vocational Nurse T (LVN T) on 1/25/2024 at 3:02 p.m., LVN T stated urine bag should be covered to provide dignity to residents with urinary catheter (a flexible tube used to empty bladder and collect urine in a drainage bag).
During an interview with the facility's interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 4:12 p.m., IDON/IP agreed residents' urine drainage bag should have been covered with a dignity bag.
During a review of the facility's undated policy and procedure titled, Urinary Catheters, indicated, 20. Place a privacy bag for the drainage bag.
Based on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for 4 of 35 sampled residents (Resident 50, 58, 226, and 229) and one non-sampled resident (Resident 67) when:
1. For Residents 50, 67, and 226, staff provided feeding assistance while standing;
2. Staff failed to provide a privacy bag for Resident 58's urinary drainage device;
3. Staff referred to Resident 229 as a feeder.
These failures had the potential to affect the emotional and psychosocial well-being of the residents.
Findings:
1. Review of Resident 50's minimum data set (MDS, an assessment tool) dated 10/13/23 indicated her cognition was severely impaired and she was dependent on staff for eating.
During a breakfast meal observation on 1/22/24 at 10:38 a.m., Resident 50 was in her room lying in bed. CNA X stood beside Resident 50 her while providing spoon-feeding assistance.
During a concurrent interview with CNA X, she confirmed she was standing while feeding Resident 50. CNA X stated she should be sitting down when she is feeding the residents. CNA X stated, I could not find a chair.
Review of Resident 67's MDS dated [DATE] indicated his cognition was severely impaired and he was dependent on staff for eating.
During a breakfast meal observation on 1/23/24 at 9:45 a.m., Resident 67 was lying in bed in his room. CNA Y stood beside Resident 67 while providing spoon-feeding assistance to him.
During a concurrent interview with CNA Y, she was asked if she should be standing while feeding Resident 67. She stated, I am very busy, I can stand.
Review of Resident 226's MDS dated [DATE] indicated his cognition was moderately impaired. His physician order dated 11/15/23 indicated 1:1 feeding assistance with all meals.
During a breakfast meal observation on 1/23/24 at 10:06 a.m., Resident 226 was in his room lying in bed. CNA Y stood beside Resident 226 while providing spoon-feeding assistance to him.
During a concurrent interview with CNA Y, she was asked if she should be standing while feeding Resident 226. CNA Y stated she was being asked too many questions and she walked out of Resident 226's room.
During an interview with the director of staff development (DSD) on 1/25/24 at 9:30 a.m., she stated staff were trained to sit down and be at eye level when they are feeding residents. The DSD stated when residents were in the bed, the bed should be lowered so staff could be seated in a chair at eye level with the resident. She further stated staff should not stand and hover over the resident while feeding.
Review of the facility's undated policy and procedure, Assisting the Resident to Eat indicated to prepare the resident and the environment for mealtime . 11. a. sit at eye level in front of the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe water temperature level...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comfortable and safe water temperature level for residents in Station 6 hallway. This failure had the potential for 11 residents to have an uncomfortable water temperature.
Findings:
Review of Resident 58's face sheet indicated, Resident 58 was admitted to the facility with diagnoses including quadriplegia (is a form of paralysis that affects all four limbs, plus the torso), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well resulting for the bladder to not fill or empty correctly), and depression.
Review of Resident 58's Minimum Data Set (MDS, assessment tool) Annual assessment dated [DATE] indicated, Resident 58's Brief Interview for Mental Status (BIMS, cognition level) score was 15 (cognition is intact).
During an interview with Resident 58 on 1/23/2024 at 8:38 a.m., Resident 58 stated the water in their bathroom sink was cold. Resident 58 further stated his certified nursing assistant (CNA) had to get hot water from other bathrooms.
During an interview with the Regional Maintenance of Director (RDM) on 1/25/2024 at 9:22 a.m., RDM stated the facility did not have their maintenance director since 12/22/2023. RDM recalled some residents complained of water heater not working well.
During a concurrent observation and interview with the RDM on 1/25/2024 at 9:44 a.m., the RDM brought the thermometer they used to check the water temperature. The RDM went to the bathroom shared by residents in Room CC and Room DD. The RDM turned on the hot water faucet inside the bathroom, let it run for 30 seconds and placed the thermometer under the running water for 30 seconds. The water temperature was 99 degrees Fahrenheit ((F, a scale of temperature at which water freezes at 32 degrees and boils at 212 degrees under standard conditions). At 9:46 a.m., the RDM went to the bathroom shared by residents in Room EE (Resident 58's room) and Room FF. The RDM did the same process to test the water temperature in the shared bathroom and the water temperature was 97.2 degrees F. At 9:54 a.m., the RDM went to the bathroom shared by residents in Room AA and Room BB. RDM did the same process in testing the water temperature in the shared bathroom and the water temperature was 97 degrees. At 10:01 a.m., the RDM confirmed the water temperature in the bathrooms shared by 11 residents were all too low than the required temperature.
During a follow up interview with RDM on 1/25/2024 at 12:35 p.m., the RDM stated the water temperature in each bathroom should have been checked daily by the director of maintenance. At 1:08 p.m., the RDM confirmed the water temperature was never checked.
During a concurrent observation and interview with Resident 58 on 1/25/2024 at 1:19 p.m., Resident 58 was at the hallway sitting on his electric wheelchair. Resident 58 stated, I had a bed bath, and the water was cold.
During an interview with Certified Nursing Assistant F (CNA F) on 1/29/2024 at 2:16 p.m., CNA F confirmed Resident 58 complained that the water in his bathroom was cold. CNA F stated he needed to get water from other resident's bathroom to provide hot water to Resident 58.
During a review of the facility's undated policy and procedure titled, Monitoring Water Temperatures, indicated, The acceptable temperature range for hot tap water is 105 degrees F - 120 degrees F.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 1/22/24, at 10:39 a.m., 4 cigarette packs were seen with Resident 145's belongings in paper bags on ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 1/22/24, at 10:39 a.m., 4 cigarette packs were seen with Resident 145's belongings in paper bags on the floor at bedside.
During a concurrent observation and interview on 1/23/24, at 1:09 p.m. with Resident 145, she stated she keeps her own cigarettes and lighter. There were four cigarette packs on the side of her wheelchair , one had a lighter inside .
During an interview on 1/25/24, at 9:28 a.m., with Certified Nursing Assistant (CNA) V, CNA V stated that cigarette lighters should be kept at the nurses' station.
During a review of the facility's Policy and Procedure (P&P) titled Smoking Policy [undated], P&P indicated, .Residents, regardless of Safe Smoking Assessment, will need to keep smoking materials in the nurses' station.
3. Review of Resident 208's face sheet (summary page of a patient's important information) indicated, Resident 208 was admitted to the facility with diagnoses including unspecified dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), anxiety disorder (a mental illness that causes constant fear) and adjustment disorder with anxiety (feeling worried, anxious, and overwhelmed).
Review of Resident 208's Quarterly Minimum Data Set (MDS, assessment tool), dated 12/15/2023, indicated Resident 208's brief interview for mental status (BIMS, cognition level) was 05 (severe impairment of cognition) and there was daily wandering (when a person with dementia roams around) behaviors.
Review of Resident 208's Elopement (an individual's behavior of leaving an area without permission or supervision) Risk assessment dated [DATE], indicated, Resident 208 was ambulatory (resident can walk around), with searching behavior and was considered at risk for elopement.
During an initial observation on 1/22/2024 at 12:14 p.m., Resident 208 was sitting at the edge of his bed with wander guard on his right wrist.
During another observation on 1/24/2024 at 9:32 a.m., Resident 208 was observed walking to the dining area without the use of an assistive device (a device designed to assist a person to perform a particular task like a walker, cane, or wheelchair).
During an interview with Registered Nurse P (RN P) on 1/24/2024 at 9:33 a.m., RN P confirmed she did not check the wander guard's functionality. RN P stated, she did not know who checks the functionality of the wander guard. RN P further stated, she only checked the wander guard's placement.
During an interview with the Regional Director of Maintenance (RDM) on 1/25/2024 at 9:22 a.m., RDM stated, nurses had a gadget (tester) to test the wander guard's functionality. RDM confirmed maintenance were the ones testing the exit doors and elevator alarms for wander guard's functionality.
During a concurrent observation and interview with Licensed Vocational Nurse T (LVN T) on 1/25/2024 at 3:06 p.m., LVN T showed the gadget to check the wander guard's functionality and it was stored inside the medication cart. LVN T confirmed nurses were checking the placement of Resident 208's wander guard which was on his right wrist every shift. LVN T further stated she was not aware they have to use the gadget to check the wander guard's functionality.
During an interview with the Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 4:17 p.m., IDON/IP stated, nurses should test the wander guard's functionality. IDON/IP further stated, They should know how to use the gadget.
During a follow up interview with RDM on 1/31/2024 at 9:11 a.m., RDM confirmed maintenance staff should check each lobby elevator and front door lobby to make sure the wander guard was in good working condition. RDM stated, they have a worksheet to log their daily checks of the wander guard's alarms.
During a concurrent interview and record review on 1/31/2024 at 11:14 a.m., RDM reviewed the wander guard's daily signing maintenance log. RDM confirmed the wander guard's alarm located at the front door's lobby and elevators were not checked on December 2023 and January 1-19, 21, 28 and 30, 2024.
During a review of the facility's undated policy and procedure titled, Wander/Elopement Alarm System Testing, indicated, Regular testing of door monitors and signaling devices in the alarm system verifies the integrity of the system and helps to maintain employee awareness and vigilance. Regular testing is essential .Signaling Device Testing: 1. Test signaling devices at least daily. Use a Signaling Device Tester. 2, Test the tester. 3. Test the Signaling Device .Door Monitor Test: 1. Inspect and test each door monitor daily. 2. Any door alarm that is not tested at least once per shift should be intentionally activated at least once a day as a test.
Based on observation, interview and record review, the facility failed to provide an environment free of accident hazards for three of 39 sampled residents (Residents 143, 145 and 208) when:
1. Resident 143 was smoking in his room
2. For Resident 145, cigarettes and smoking materials were at the bedside
3. Resident 208's wander guard (small device placed on the ankle or wrist of a resident, alarms to notify the staff if a resident tries to leave the facility) functionality was not tested.
These failures placed the residents at risk for accidents and subsequent harm.
Findings:
1. Review of Resident 143's face sheet indicated he was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (mental disorder including schizophrenia {disorder that affects a person's ability to think, feel, and behave clearly} and mood disorder), major depressive disorder, Bipolar disorder (disorder associated with episodes of mood swings ranging from depression lows to manic highs), lack of coordination, muscle weakness, and tobacco use.
Review of Resident 143's smoking assessment evaluation, dated 1/5/24, indicated Resident 143 was an independent safe smoker. The smoking assessment indicated the smoking policy and/or contract was given to the resident.
Review of Resident 143's care plan indicated resident was non-compliant with the smoking contract. The care plan indicated an approach, dated 10/26/23, to continue to monitor resident every 30 minutes, making sure that he is not smoking in the room and he needs to keep the door open at all times.
During an observation on 1/22/24 at 9:13 a.m., a pack of cigarettes was noted on Resident 143's bedside table. When asked if he is a smoker, Resident 143 stated Yes I am a smoker and I keep my cigarettes and lighter with me here in my room.
During an observation on 1/26/24 at 10:18 a.m., Resident 143's room door was closed. When the door was opened there was a strong odor of marijuana and cigarette smoke inside Resident 143's room. There was a pack of cigarettes on Resident 143's bedside table. During a concurrent interview with Resident 143, he was asked if he was smoking in his room. He stated No and added that he smokes outside on his balcony. When asked how he extinguishes the cigarette butts, Resident 143 stated he puts his cigarette butts inside an empty potato chip can. Resident 143 stated I just drop it in the can, it's safe because there is foil in there. A potato chip can was observed with multiple cigarette butts at the bottom of the can on Resident 143's bedside table.
During a record review of Resident 143's progress notes, there were multiple notes, authored by various disciplines within the facility, indicating Resident 143 was smoking in his room. The progress notes read as follows:
On 1/22/24: Resident was caught smoking by staff in his room with another resident watching television .
On 1/13/24: CNA noted resident's food tray with burnt papers and marijuana odor inside the room .
On 1/9/24: . Pt room currently smells like smoke, with towel tucked underneath the door .
On 12/30/23: The resident denied smoking inside his room but the smell of cigarette and marijuana coming from his room is very strong. Noted resident smoking 2x during the shift .
On 12/26/23: Odor of marijuana continues to come from resident's room . resident continues to refuse to leave door open .
On 12/21/23: Resident continues to smoke marijuana in his room and balcony . refuses to leave his door open and keeps it closed so that he can smoke .
On 12/2/23: . smelled marijuana coming from resident's room. Upon entering patient's room, resident is sitting outside in the balcony .
On 11/3/23: During rounds noted that the resident's room was closed and noted the smell of marijuana . resident outside smoking .
On 10/25/23: Writer went to resident's room to give his AM meds and resident found smoking inside the room .
During an interview with registered nurse GG (RN GG) on 1/26/24 at 8:10 a.m., she was asked if Resident 143 smokes in his room. RN GG stated she has observed Resident 143 smoking in his room on multiple occasions. She further stated when she smells cigarette smoke or marijuana, she tells Resident 143 he cannot smoke in his room. RN GG stated Resident 143 keeps his room door closed and gets angry when she tries to enforce the smoking policy. When asked if staff conduct room checks every 30 minutes for Resident 143 to monitor for smoking in his room and keeping the room door open. RN GG stated there is no monitoring 30-minute monitoring in place.
During an interview with the Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/24 at 9:15 a.m., she was asked if Resident 143 was smoking in his room. She stated that he has episodes of smoking in his room and is non-compliant with the smoking rules. The IDON/IP was asked if there was any monitoring in place for Resident 143's smoking in his room. The IDON/IP reviewed Resident 143's care plan related to non-compliance - smoking in the room and confirmed the interventions were to monitor every 30-minutes and keep the door open at all times, and she stated the facility did not have that monitoring in place. The IDON/IP stated it is not safe for the residents to smoke in their rooms. She further stated resident's cigarettes and lighters should be kept at the nurse's station.
During an Interview with the administrator (ADM) on 1/26/24 at 9:57 a.m., he was asked if Resident 143 smokes in his room. The ADM stated he has been told that Resident 143 smokes in his room but he has not witnessed this himself. The ADM stated Resident 143 is non-compliant, refuses to follow the rules, and continues to smoke in his room despite education about the facility smoking policy. The ADM stated there is no smoking permitted in resident rooms and there is a designated smoking patio for residents to smoke. The ADM stated it is not safe for Resident 143 to smoke in his room. When asked about the safety of the other residents in the facility who are impacted by Resident 143's non-compliance with the smoking policy, the ADM stated There is nothing we can do, we have tried everything.
Review of the facility undated policy titled Smoking Policy indicated the purpose was to establish a process for residents who wish to smoke to do so in a safe manner. The policy further indicated . 6. Residents, regardless of Safe Smoking Assessment result, will need to keep smoking materials in the nurses' station. They may smoke only in the designated smoking area outside the building . 8. Violation of this policy or the smoking contract (Attachment B) will bring restrictions of smoking privileges or possible discharge from the facility if behaviors present a danger to others. Actions such as smoking in non-designated areas, allowing any other resident to use, borrow, buy, or have access to smoking material, or any other behavior considered to exhibit poor safety awareness may result in revocation of smoking privileges.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
12. During an observation on 1/31/24 at 8:30 am, Dietary Services Manager (DSM) was observed to have long fingernails while working at the food tray line.
During an interview on 1/31/24 at 8:58 am, w...
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12. During an observation on 1/31/24 at 8:30 am, Dietary Services Manager (DSM) was observed to have long fingernails while working at the food tray line.
During an interview on 1/31/24 at 8:58 am, with Interim Director of Nursing/Infection Preventionist (IDON/IP), IDON/IP stated long fingernails are not allowed for all staff regardless of their job. IDON/IP also stated the nails harbor bacteria especially the staff working in the kitchen.
According to Centers for Disease Control and Prevention (CDC) Nail Hygiene, dated 6/15/22, indicated Appropriate hand hygiene includes diligently cleaning and trimming fingernails, which may harbor dirt and germs and can contribute to the spread of infections .Fingernails should be kept short .
11. During an observation on 1/23/24, at 1:08 p.m., outside Resident 229's room, an Enhanced Droplet Precaution sign was posted on the door. The sign informed staff to perform hand hygiene before and after entering the room, and to wear a gown, gloves, N95, and goggles if providing direct care, if providing non-direct care hand hygiene and an N95 are required before entering.
During an observation on 1/23/24, at 1:10 p.m., outside Resident 229's room, Certified Nurse Assistant (CNA) D picked up a lunch meal tray and entered Resident 229's room without performing hand hygiene, CNA D left the room, was seen empty handed then opened the linen closet next to Resident 229's room, picked up a linen, placed linen onto another residents meal tray and brought a new meal tray with the linen back into Resident 229s room without performing hand hygiene. CNA D then exited the room into the hallway without performing hand hygiene.
During an interview on 1/23/24, at 1:12 p.m., with CNA D, CNA D stated, she did not perform hand hygiene before and after exiting Resident 229's room because she was in a hurry and got distracted. CNA D stated, she is aware she should have performed hand hygiene before and after entering the room, but she did not.
During an interview on 1/29/24, at 10:34 a.m., with Interim Director of Nursing (IDON), IDON stated, when staff enter and exit rooms, they should be performing hand hygiene, especially rooms that are on transmission-based precautions.
During a review of the facility's policy & procedure (P&P) titled, Transmission Precautions: Droplet, (undated) the P&P indicated, 2. Handwashing wash hands thoroughly between residents, after removing gloves, and before leaving the residents room.
10. During an observation and concurrent interview with LVN G on 1/24/24 at 8:40 a.m., the door to room GG was open. There was a sign at the doorway indicating personal protective equipment (PPE, gloves, gown, mask, face shield, etc.) was required when entering room GG. LVN G confirmed these precautions were necessary because the residents in room GG were on isolation for Covid-19. LVN G stated the door to room GG should have been closed.
During an interview with the IDON/IP on 1/26/24 at 8:32 a.m., she stated that for Covid-19 isolation rooms, the door must be closed.
During a review of the facility's undated policy and procedure (P&P) titled, Transmission Precaution: Droplet, the P&P indicated, Droplet precautions will be initiated when a resident is believed to have infection requiring such precautions.
During a review of the facility's P&P titled, Interim infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (Covid 19) Pandemic, dated May 8, 2023, the P &P indicated, Place a patient with suspected or confirmed SAR-Cov-2 infection in a single room. The door should be kept closed.
Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:
1. Housekeeper did not change gloves in between rooms and did not perform hand hygiene after removal of gloves;
2. Resident 22's nasal cannula was not stored properly when not in use;
3. Restorative Nursing Assistant did not perform hand hygiene while serving and setting up lunch trays in between residents;
4. Licensed Vocational Nurse N (LVN N) did not wear the proper personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while inside the enhanced droplet precaution (used to prevent the spread of pathogens [an organism causing disease to its host] that are passed through respiratory secretions) room;
5. Occupational Therapist LL (OT LL) did not wear the proper PPE while inside the enhanced droplet precaution room;
6. Three bins full of dirty briefs were stored inside one of Station 6's shower rooms, and a makeshift dirty linen room next to it which was a shower room, had a bag of residents' dirty gowns placed on top of the laundry container and one bin full of dirty briefs was stored inside;
7. One shower room in between Station 6 and Station 5 had a used surgical mask hanging at the door, and a wet washcloth was on the shower room floor;
8. Certified Nursing Assistant MM (CNA MM) did not wear the proper PPE while inside the enhanced droplet precaution room;
9. Minimum Data Set Assistant NN (MDSA NN) did not wear the proper PPE while inside the enhanced droplet precaution room;
10. An enhanced droplet precaution room was left open;
11. Certified Nurse Assistant D (CNA D) was observed entering and exiting a transmission based precaution (safety measures used for patients who are known or suspected to be infected or colonized with infectious agents) room without performing hand hygiene (washing hands or using hand sanitizer); and
12. Dietary Service Manager (DSM) had long fingernails.
These failures could result in the spread of infection and cross-contamination that could affect the 244 residents who resides in the facility, staff, visitors.
Findings:
1.During an observation on 1/22/2024 at 11:00 a.m., in Station 6 hallway, housekeeper KK (HK KK) was observed mopping the floor inside Room EE with gloves on. HK KK went out of the room and went straight to Room FF to continue mopping the floor with the same pair of gloves. After mopping Room FF's floor, HK KK went out of the room, tried to get hand sanitizer located right outside Room FF with the gloves on. HK KK continued to sweep the floor at the hallway with same dirty gloves and once done, HK KK removed her gloves, did not perform hand hygiene, went back to the housekeeper cart, touched the cart, and removed the dirty garbage bag from the trash can at the hallway with bare hands. HK KK throw the garbage on her cart and did not perform hand hygiene. HK KK pushed her cart and parked it in front of Room HH, donned (put on) another pair of gloves without hand hygiene, took the plastic of trash from her cart to the janitorial room, still with same gloves on, pushed her cart and parked at nurse station 6, then removed gloves, did not perform hand hygiene.
During an interview with HK KK on 1/22/2024 at 11:07 a.m., HK KK confirmed the observation. HK KK stated, she should have performed hand hygiene before donning (putting on) and after removal of gloves, after handling garbage and before entering and upon exiting the resident's rooms.
2. During a concurrent observation and interview with Resident 22 on 1/22/2024 at 12:30 p.m., Resident 22 was lying in bed with the oxygen's nasal cannula ((NC - a device that consists of plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostrils for oxygen administration) lying beside her touching the beddings. Resident 22 stated, I used my oxygen last night.
During an interview with Licensed Vocational Nurse T (LVN T) on 1/25/2024 at 3:03 p.m., LVN T stated the nasal cannula should be stored in a bag when not in use, and it should be dated.
During a concurrent observation and interview with Licensed Vocational Nurse N (LVN N) on 1/25/2024 at 3:12 p.m., LVN N went inside Resident 22's room to look for the bag used to store the nasal cannula. Resident 22 was currently using the nasal cannula. LVN N couldn't find the bag, stated the oxygen cannula should be stored in a bag when not in use. Resident 22 heard LVN N's statement and Resident 22 made a comment, I never had a plastic bag for my oxygen tubing.
During an interview with Interim Director of Nursing/Infection Preventionist (IDON/IP) on 1/29/2024 at 3:58 p.m., IDON/IP stated the nasal cannula should be stored inside a plastic bag when not in use.
During a review of the facility's undated policy and procedure titled, Oxygen Storage & Assembly, indicated, Equipment .nasal cannula or face mask and tubing, oxygen stand, container for cannula or mask (plastic, paper, or cloth bag) .
3. During a dining observation on 1/22/2024 at 1:04 p.m., Restorative Nurse Assistant (RNA) served lunch tray to Resident 117. RNA removed all the lids of Resident 117's food covers, set up the food in front of the resident and RNA went back to the food cart and picked another lunch tray, without hand hygiene. RNA served the lunch tray to Resident 207, removed all the lids and covers of the food. Resident 207 requested for cups of juice, RNA got two cups of juice, delivered them to Resident 207 by holding the cup on its lid. RNA touched her pants while talking to Resident 207. RNA went back to the food cart and took Resident 185's lunch tray, set up the food by removing the lids of the food and juice, then RNA took Resident 106's lunch tray that was on top of Resident 185's table. RNA still did not perform hand hygiene, served the lunch tray to Resident 106, opened a carton of milk, and removed all the lids of his food. RNA went back to the food cart, did not perform hand hygiene, and pulled out one more lunch tray and handed to another certified nursing assistant (CNA).
During a follow up interview with RNA on 1/22/2024 at 1:16 p.m., RNA confirmed the surveyor's observation and stated, Oh, I should have done it (referring to performing hand hygiene). RNA further stated, I even have hand sanitizer in my pocket. I did not use it.
4. During an observation on 1/23/2024 at 12:40 p.m., Resident 148 was in an enhanced droplet precaution room. Resident 148 pressed his call light. Licensed Vocational Nurse N (LVN N) went inside the room with N95 (a particulate-filtering facepiece respirator that meets the United States National Institute for Occupational Safety and Health N95 classification of air filtration, meaning that it filters at least 95% of airborne particles) and donned a disposable gown and gloves. LVN N did not wear a face shield (an item of PPE covering for all or part of the face that is commonly made of clear plastic and is worn especially to prevent injury [as from impact, extreme temperature, or a dangerous substance] or to reduce the spread of transmissible disease) inside the enhanced droplet precaution room. LVN N stood beside Resident 148's bed and started talking to him.
During a follow up interview on 1/23/2024 at 12:44 p.m., LVN N confirmed Resident 148 and the other two residents inside the enhanced droplet precaution room was positive for Coronavirus disease (COVID-19, a disease caused by a contagious virus). LVN N confirmed she did not wear a face shield when she entered the enhanced droplet precaution room. LVN N stated, there was no face shield available in the isolation container located at Resident 148's room door.
5. During another observation on 1/23/2024 at 12:51 p.m., Occupational therapist LL (OT LL) went inside Resident 148's room together with another staff. Both staff donned PPE prior to entering Resident 148's room with signage of Enhanced Droplet Precaution. OT LL was observed not wearing a face shield inside the room and when he talked to Resident 148. The room door was not equipped with face shields.
During a follow up interview with OT LL on 1/23/2024 at 12:56 p.m., OT LL confirmed he did not wear a face shield inside Resident 148's room. OT LL apologized for not wearing a face shield inside an enhanced droplet precaution room.
During an interview with IDON/IP on 1/26/2024 at 8:46 a.m., IDON/IP stated full PPE should be worn by staff when they go inside the COVID-19 rooms, including face shields. IDON/IP further stated, they have enough PPE's available for use until the following week and central supply staff had ordered more.
During a review of the signage in Resident 148's room door titled, Enhanced Droplet/Contact Precautions direct care staff should wear a gown, face mask, gloves, and a goggles or face shield.
6. During an interview with Resident 176 on 1/23/2024 at 1:20 p.m., Resident 176 was sitting on his wheelchair, able to move around his room and along the hallway. Resident 176 complained of the two shower rooms in Station 6, the one near the nurse station. Resident 176 stated the two shower rooms in Station 6 were dirty and cluttered.
During a concurrent observation and interview with Certified Nursing Assistant B (CNA B) on 1/23/2024 at 1:25 p.m., one shower room in Station 6 had three bins full of dirty briefs and the makeshift linen room (which was a shower room) beside it had two laundry containers and a bin full of dirty briefs. One of the laundry containers had a plastic full of dirty resident's gowns on top. CNA B confirmed they used both shower rooms for residents and the dirty briefs and laundry containers should not be stored inside the shower rooms. CNA B stated, the bag full of dirty gowns should be placed inside the laundry container. CNA B further stated, they have a room where to store the bins and laundry container in Station 5.
During an interview with IDON/IP on 1/26/2024 at 8:46 a.m., IDON/IP stated, dirty linens or resident's gowns should be bagged and placed in a hamper and stored in a designated area. IDON/IP further stated, hampers and trash bins should not be stored in the shower room.
During a review of the facility's undated policy and procedure titled, Soiled Linen Collection & Transfer, indicated, Place soiled linen in containers labeled Soiled Linen. Keep lids closed at all times .Ensure soiled linen containers are not filled over 2/3 full and that lids are airtight .Store soiled linen in designated area(s) .
7. During a concurrent observation and interview on 1/26/2024 at 10:34 a.m. with IDON/IP, one shower room in between Station 6 and Station 5 had a used surgical mask hanging at the door, and a wet washcloth was laying on the shower floor. IDON/IP stated, the wet washcloth and the dirty surgical mask should not be placed in the shower room. IDON/IP further stated, staff should clean up after they used the shower rooms.
8. During a concurrent observation and interview with Certified Nursing Assistant MM (CNA MM) on 1/30/2024 at 9:50 a.m., CNA MM had N95 and was observed sitting inside Resident 89's room. Resident 89's room door was halfway closed. CNA MM stated, Resident 89 was confirmed positive for COVID-19 just on this date. CNA MM further stated, nurses posted the sign about the enhanced droplet precaution at the door to warn all staff. CNA MM stated, Oh I'm sorry. I didn't know I should wear PPE. At 9:55 a.m., CNA MM started wearing the PPE: did not perform hand hygiene, put on gloves first, face shield, and gown. CNA MM reviewed the posted sequence for putting on PPE and confirmed she did not follow it. CNA MM stated, she did not perform hand hygiene prior to putting on the PPE.
During a concurrent observation and interview with IDON/IP on 1/30/2024 at 9:59 a.m., in front of Resident 89's room. IDON/IP confirmed Resident 89 was positive for COVID-19 and CNA MM should wear the proper PPE and should follow the proper sequence of putting on PPE.
Review of the postings at Resident 89's room door titled, Enhanced Droplet/Contact Precautions direct care staff should wear a gown, face mask, gloves, and a goggles or face shield.
Another review of the postings at Resident 89's room door titled, SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE), indicated, 1. to start with putting on gown first; 2. mask or respirator; 3. goggles or face shield; and 4. gloves.
9. During a concurrent observation and interview with the Minimum Data Set Assistant NN (MDSA NN) on 1/31/2024 at 9:27 a.m., MDSA NN went inside Resident 89's room to drop off a straw on Resident 132's overbed table. Resident 132 was just transferred to the room with enhanced droplet precaution. MDSA NN talked to Resident 132 for a minute and stepped out of the room. MDSA NN stated, I did not see the droplet precaution sign. I should have worn the full PPE. The signs about the enhanced droplet precaution sign, the sequence of putting on and safe removal of the PPE were posted at the entrance door.
During an interview with Certified Nursing Assistant OO (CNA OO) on 1/31/2024 at 9:30 a.m., CNA OO confirmed both residents (Residents 89 and 132) in room FF were positive for COVID-19 and they should wear the proper PPE before they enter the room.
During a review of the facility's undated policy and procedure titled, Transmission Precautions: Droplet, indicated, Droplet precautions will be initiated when a resident is believed to have an infection requiring such precautions. In addition to Standard Precautions, Droplet Precautions are use with resident's known to be infected, or suspected of being infected, with microorganisms transmitted by droplets that can be generated during coughing, sneezing, talking .
During a review of the facility's undated policy and procedure titled, COVID-19 Infection Control Measures, indicated, The infcetion prevention and control measures that are implemented to address the SARS-CoV2 [severe acute respiratory syndrome coronavirus] pandemic are incorporated into the facility's infection prevention and control plan. These measures include: .standard precautions (hand hygiene and respiratory hygiene); transmission based precautions, where indicated; universal source control; appropriate use PPE; and environmental cleaning and disinfection.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure three ice machines, a nourishment reach-in refrigerator, walk-in freezer's fans, a walk-in refrigerator, and two reach...
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Based on observation, interview, and record review, the facility failed to ensure three ice machines, a nourishment reach-in refrigerator, walk-in freezer's fans, a walk-in refrigerator, and two reach-in refrigerators, were maintained in a safe, operating, and fully functioning manner, according to the manufacturer's guidelines and standards of practice.
This failure had the potential to expose 244 residents to food contaminants that could cause food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).
Findings:
According to the 2022 Federal FDA Food Code, Section 4-501.11 Good Repair and Proper Adjustment, indicated Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk .refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures.
According to the 2022 Federal FDA Food Code, Section 4-204.17 Ice Units, Separation of Drains, indicated Liquid waste drain lines passing through ice machines and storage bins present a risk of contamination due to potential leakage of the waste lines and the possibility that contaminants will gain access to the ice through condensate migrating along the exterior of the lines. Liquid drain lines passing through the ice bin are, themselves, difficult to clean and create other areas that are difficult to clean where they enter the unit as well as where they abut other surfaces. The potential for mold and algal growth in this area is very likely due to the high moisture environment. Molds and algae that form on the drain lines are difficult to remove and present a risk of contamination to the ice stored in the bin.
During the initial kitchen tour on 1/22/24 at 8:55 am, with Dietary Services Manager (DSM), the following observations were conducted of the kitchen equipment. Inside the DSM office of the kitchen, the nourishment refrigerator gasket (refrigerator door seal) was ripped, and a large reach-in refrigerator located between two large reach-in refrigerator coolers, was not working. The walk-in refrigerator was not working, and the walk-in freezer behind the walk-in refrigerator had fans with ice and condensation build-up. Additionally, the drink machine gun had connections missing from the base and was hanging off a mobile metal shelf with hoses semi-connected to open bag-in-the juice boxes filled with liquid juice. The DSM confirmed the findings and stated the maintenance department was notified of the ice build-up and walk-in refrigerator not working.
During an observation on 1/22/24 at 12:30 pm of the two reach-in refrigerators in the Cart Room next to the Emergency Storage Room, there were several puddles of water on the floor leaking from the condensation buildup on the door gaskets and on the actual refrigerator.
Review of the facility's maintenance log, dated 5/22/23 and 7/23/23, indicated walk-in ref needs to be fixed; nourishment ref gasket broken.
Review of the drink machine gun connector manufacturer's instructions dated 4/9/21, indicated Adding B-T-F Chloromelamine sanitizer powder to five gallons of warm potable water (100 degrees Fahrenheit) in a clean five gallon bucket .Immerse the sheathing brush in the cleaning solution. Move the brush up and down the entire length of the sheathing six more times .remove nozzle and place in a cup of cleaning solution .
Review of the monthly kitchen inspection reports completed by the Registered Dietitian (RD), titled Quality Assessment for Performance Improvement from 2/5/23 to 1/5/24 was conducted. The 12/5/23 and 1/5/24 inspection reports indicated .PROBLEM: Broken oven handle, broken middle refrigerator, broken steamer, broken plate warmer, ceiling leaking, fan in walk-in fridge broken, gasket in fridge broken .Notified maintenance .
During a concurrent observation and interview on 1/22/24 at 3:09 pm, with the RD and DSM at nurses station 6, there was black residue and brown build-up inside the ice machine curtain (controls the flow of water for the machine to make ice), chute (the passage through which ice falls into the dispenser), baffle (direct ice away from the front of the unit and prevent contact with the front panel during dispensing), and tiny amounts in the bin. A dead baby cockroach was found inside the ice machine cover. The RD and DSM confirmed the findings.
During an observation on 1/22/24 at 3:23 PM of the ice machine at station 4 and interview with the facility's Regional Maintenance Director (FMD), the FMD acknowledged the black residue and brown buildup inside the ice machine curtain, chute, baffle, and tiny amounts in the bin and stated the ice machine should be always clean, without the residue. RD, DSM and FMD acknowledged the dirty thick black and brown buildup and residue. The FMD further stated the ice machine should be cleaned every month using the manufacturer's guidelines to maintain safe operation.
During an interview on 1/22/24 at 4:01 pm with the Administrator (ADM), the ADM stated the maintenance staff probably just clean the outside of the ice machine and not the inside.
During a review of the outside vendor ice machine work invoice dated 10/27/24, the invoice indicated .Note: one ice machine is not working for long-time! Need troubleshooting next time! One ice machine need to be trustworthy because not working- Manitowoc Ice machine .
During a review of the outside vendor ice machine work invoice dated 7/1/22, the invoice indicated .Remove all mold .there is another ice machine that needs cleaning at nurse's station 6 .
Review of the ice machine's manufacturer's maintenance instructions, Section 4 titled Maintenance, dated 5/22, indicated Detailed de-scaling and sanitizing procedure must be performed a minimum of once every six months.
Review of the facility's Cleaning & Maintaining Ice Machines policy and procedure, undated, indicated Follow manufacturer's guidelines for cleaning.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0912
(Tag F0912)
Could have caused harm · This affected multiple residents
Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms. This failure could affect the residents' safety an...
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Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms. This failure could affect the residents' safety and impede provision of care to the residents.
Findings:
Rm. No. # of beds/Rm. Sq. Ft./Res.
108, 109 3 73.6
114, 115, 2 76.5
210, 211
314, 315, 3 74.0
316, 317,
403, 201
thru 208
110, 111, 2 74.0
112, 217,
218, 219,
220
116, 117, 2 75.0
308, 311,
312, 619
309, 310 3 74.3
404, 405, 3 73.5
406, 409,
501 thru 509
407, 408 2 72.9
411, 412, 2 76.0
414, 415
thru 419
510, 511, 3 74.8
515, 516
512, 514, 2 71.4
601, 602,
614, 615
603, 604 3 75.6
609, 610, 3 77.0
611, 612
Interviews with staff and residents indicated the room sizes did not adversely impact the quality of care received by the residents.
Recommend continuance of the room size waiver.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment when there was water leaking from the ceiling in multiple areas inside the facility due to rain. This failure had the potential to compromise the health and safety of the residents, staff, and visitors in the facility.
Findings:
During an observation on 1/22/24, starting at 9:11 a.m., there was water leaking from the facility's ceiling in the following locations:
1. Inside the doorway of resident room [ROOM NUMBER] under a ceiling vent;
2. In the Hallway outside resident room [ROOM NUMBER];
3. In the Hallway outside resident rooms 114;
4. Inside the doorway of resident room [ROOM NUMBER] under a ceiling vent;
5. Inside the doorway of resident room [ROOM NUMBER] under a ceiling vent;
6. Inside resident room [ROOM NUMBER];
7. In the Hallway by room [ROOM NUMBER];
8. In the hallway by station 2;
11. In the lobby;
12. Near the library;
13. In the conference room at the ceiling light;
14. In the rehabilitation gym;
15. Inside Social services office;
16. In station 4; and
17. In the hallways by resident room [ROOM NUMBER].
In some of these locations, the ceiling had bubbles and leak marks.
During a concurrent observation and interview on 1/22/24 at 9:14 a.m , with the Regional [NAME] President of Operations (RVPO), the RVPO explained it was her first time seeing the leaks in resident room [ROOM NUMBER]. She confirmed it was not safe and requested a room change for the residents in room [ROOM NUMBER].
During a concurrent observation and interview on 1/22/24 at 9:50 a.m., with Certified Nurse Assistant R (CNA R), he stated the ceiling leak in room [ROOM NUMBER] was reported to maintenance staff. CNA R confirmed the room ceiling leaks were not safe for the the three residents staying in that room.
During a concurrent observation and interview on 1/22/24 at 9:44 a.m., with the Regional Director of Maintenance (RDM), he verified the facility's ceiling room [ROOM NUMBER] was leaking. The RDM stated the maintenance staff was fixing the leaks on the rooftop.
During an interview on 1/25/24 at 9:23 a.m., with the RDM, he verified the safety of the residents was compromised due to the leaking ceiling in the resident rooms and facility hallways.
During an interview on 1/31/24 at 9:28 a.m., with the Interim Director of Nursing /Infection Preventionist (IDON /IP), she stated she was not aware that the ceiling in resident room [ROOM NUMBER] was leaking. The IDON/IP acknowledged the residents' safety was compromised.
During a concurrent observation and interview on 1/24/24 at 8:55 a.m., with Administrator, he confirmed the ceiling in several areas of the facility were leaking. He also confirmed there were leak marks in some of these areas.
During a review of the facility's undated policy and procedure (P&P) titled, Maintaining Resident Rooms, the P&P indicated, Residents rooms are inspected and maintained on a periodic basis to ensure proper function . Procedure #6 .Check walls and ceilings for damage, mars, or evidence of water stains .
During a review of the facility's undated P&P titled, Physical Plant Exterior Maintenance , the P&P indicated, Roof #2. Check all areas of the building's interior for sign of roof leaks.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to offer and/or attempt alternatives prior to the use of...
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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 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 38 of 39 sampled residents (Residents 65, 642, 221, 21, 33, 86, 226, 68, 120, 64, 89, 16, 182, 58, 41, 50, 31, 208, 22, 210, 83, 213, 132, 127, 443, 168, 82, 145, 160, 56, 139, 128, 792, 184, 692, 201, 229, and 192). The survey team expanded the sample and identified that a total of 230 residents had side rails. The facility failed to ensure proper use of side rails when:
1. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of side rails for 230 of 230 residents with siderails;
2. There was no documentation that indicated the facility conducted consistent routine maintenance of the facility's beds and side rails;
3. For Residents 58 and 83, the residents' side rails were documented as being used as an enabler (a device used to hold onto to help with transfers and mobility) and it was not used as intended, as an enabler;
4. For Residents 128, 792, and 41 the residents' Siderail Evaluation (side rail assessment) indicated side rails were not required, though the residents were observed to have side rails.
These failures had the potential to place the residents at risk of entrapment and serious injury.
Findings:
1. During an observation in Resident 65's room on 1/22/24 at 9:05 a.m., Resident 65's bed had bilateral half side rails.
Review of Resident 65's physician order, dated 12/2/23 indicated he had an order for half side rails up when in bed to enable independent repositioning and transfers.
Review of Resident 65's Siderail Evaluation, dated 12/2/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 642's room on 1/22/24 at 9:11 a.m., Resident 642 was in bed. Resident 642's bed had bilateral half side rails.
Review of Resident 642's physician order, dated 1/8/24 indicated she had an order for half side rails up when in bed to enable independent repositioning and transfers.
Review of Resident 642's Siderail Evaluation, dated 1/3/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During a concurrent observation and interview with Resident 221 on 1/22/2024 at 9:13 a.m., inside his room, Resident 221 was lying in bed, with bilateral upper bed rails. Resident 221 stated he held on to his bed rails when staff turned or repositioned him.
During a follow up observation in Resident 221's room on 1/24/2024 at 9:51 a.m., Resident 221 was lying in bed with bilateral upper bed rails.
Review of Resident 221's Physician Order dated 1/11/2024, indicated the resident had an order for half side rails (bed rails) as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 221's Siderail Evaluation dated 1/11/2024, indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 21's room on 1/22/2024 at 9:21 a.m., Resident 21 was lying in bed, asleep, and the right upper bed rail was in use.
During another observation in Resident 21's room on 1/23/2024 at 12:40 p.m., Resident 21 was in bed and the left side of the bed was against the wall and the right upper bed rail was in use.
Review of Resident 21's Physician's Order dated 4/17/2023, indicated the resident had an order for half side rails up when in bed to enable independent repositioning and transfers.
Review of Resident 21's Siderail Evaluation dated 11/5/2023, indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 33's, 86's, and 226's room on 1/22/24 at 9:28 a.m., bilateral partial side rails were observed on the beds of Residents 33, 86, and 226.
Review of Resident 33's physician's order, dated 1/9/24, indicated may have two half side rails as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 33's Siderail Evaluation, dated 1/11/24, indicated there was no documentation that the facility offered and/or attempted alternatives prior to installing side rails.
Review of Resident 86's physician's order, dated 6/12/22, indicated may have two half side rails as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 86's Siderail Evaluation, dated 12/20/23, indicated there was no documentation that the facility offered and/or attempted alternatives prior to installing side rails.
Review of Resident 226's physician's order, dated 9/30/23, indicated may have two half side rails as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 226's Siderail Evaluation, dated 1/11/24, indicated there was no documentation that the facility offered and/or attempted alternatives prior to installing side rails.
During an observation in Resident 68's room on 1/22/24 at 9:33 a.m., Resident 68's bed had bilateral half side rails.
Review of Resident 68's physician order, dated 10/6/22 indicated she had an order for half side rails up when in bed to enable independent repositioning and transfer.
Review of Resident 68's Siderail Evaluation, dated 1/1/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 120's room on 1/22/24 at 10:16 a.m., Resident 120's bed had bilateral half side rails.
Review of Resident 120's physician order, dated 3/27/23 indicated she had an order for half side rails up when in bed to enable independent repositioning and transfers.
Review of Resident 120's Siderail Evaluation, dated 12/16/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 64's room on 1/22/24 at 10:16 a.m., Resident 64 was in bed. Resident 64's bed had bilateral half side rails.
Review of Resident 64's physician order, dated 1/8/24 indicated she had an order for half side rails up when in bed to enable independent repositioning and transfers.
Review of Resident 64's Siderail Evaluation, dated 12/28/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 89's room on 1/22/2024 at 10:21 a.m., Resident 89 was lying in bed, asleep, right side of the bed was against the wall and the bilateral upper bed rails were raised up.
During a concurrent observation in Resident 89's room and interview with the Certified Nursing Assistant E (CNA E) on 1/24/2024 at 9:12 a.m., Resident 89's bilateral upper bed rails were raised up. CNA E who was Resident 89's sitter (a caregiver who provides patients in need of supervision with companionship and care) stated Resident 89 used the bedrails when he turned and repositioned.
Review of Resident 89's Physician Order dated 7/27/2023, indicated the resident had an order for half side rails up as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 89's Siderail Evaluation dated 1/11/2024, indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 16's room on 1/22/24 at 10:22 a.m., Resident 16 was in bed. Resident 16's bed had bilateral half side rails.
Review of Resident 16's physician order, dated 12/22/22 indicated she had an order for half side rails up when in bed to enable independent repositioning and transfers.
Review of Resident 16's Siderail Evaluation, dated 12/12/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 182's room on 1/22/24 at 10:22 a.m., Resident 182's bed had bilateral half side rails.
Review of Resident 182's physician order, dated 1/22/22 indicated she had an order for half side rails up when in bed to enable independent repositioning and transfers.
Review of Resident 182's Siderail Evaluation, dated 12/12/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 58's room on 1/22/2024 at 10:32 a.m., Resident 58 was lying flat on bed, watching on his computer tablet using a mouthpiece to navigate on it. Resident 58 had inability to move both arms and legs. The resident's bilateral upper bed rails were raised up.
During a concurrent observation in Resident 58's room and interview with Certified Nursing Assistant F (CNA F) on 1/22/2024 at 12:04 p.m., Resident 58's bilateral upper bed rails were raised up. CNA F confirmed Resident 58 never used his bed rails for repositioning or even for transfers. CNA F stated the nurses were the ones who wanted the bed rails raised up.
During another observation in Resident 58's room on 1/23/2024 at 8:38 a.m., Resident 58 was in bed and the bilateral upper bed rails were raised up.
Review of Resident 58's Physician Order dated 7/15/2022, indicated the resident had an order for half side rails up as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 58's Siderail Evaluation dated 1/1/2024, indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 41's room on 1/22/24 at 10:21 a.m., Resident 41 was in bed. Resident 41's bed had bilateral half side rails.
Review of Resident 41's physician orders, dated 1/7/24 indicated he had an order for half side rails up both sides when in bed to enable independent repositioning and transfers.
Review of Resident 41's Siderail Evaluation, dated 12/5/23 indicated there was no documentation that indicated the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 50's room on 1/22/24 at 10:38 a.m., bilateral partial side rails were observed on the bed of Resident 50.
Review of Resident 50's physician's order, dated 1/9/24, indicated may have two half side rails as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 50's Siderail Evaluation, dated 1/11/24, indicated there was no documentation that the facility offered and/or attempted alternatives prior to installing side rails.
During an observation in Resident 31's room on 1/22/24 at 11:09 a.m., bilateral partial side rails were observed on the bed of Resident 31.
Review of Resident 31's physician's order, dated 1/9/24, indicated may have half side rails when in bed to enable independent repositioning and transfers.
Review of Resident 31's Siderail Evaluation, dated 12/21/23, indicated there was no documentation that the facility offered and/or attempted alternatives prior to installing side rails.
During an observation in Resident 208's room on 1/22/2024 at 12:14 p.m., Resident 208 was sitting at the edge of his bed and the bilateral upper bed rails were raised up.
Review of Resident 208's Physician Order dated 6/7/2023, indicated the resident had an order for half side rails up as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 208's Siderail Evaluation dated 12/2/2023, indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 22's room on 1/22/2024 at 12:30 p.m., Resident 22 was lying in bed and the bilateral upper bed rails were raised up.
Review of Resident 22's Physician Order dated 10/12/2023, indicated the resident had an order for half side rails up as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 22's Siderail Evaluation dated 1/11/2024, indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 210's room on 1/22/24 at 3:19 p.m., Resident 210 was in bed. Resident 210's bed had bilateral (on both sides) half side rails (bars attached to the side of the bed and its size spans half the length of the bed).
Review of Resident 210's physician orders, dated 1/10/24 indicated she had an order for half side rails up both sides when in bed to enable independent repositioning and transfers.
Review of Resident 210's Siderail Evaluation, dated 12/6/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During initial observation in Resident 83's room on 1/22/2024 at 3:27 p.m., Resident 83 was lying in bed, and the bilateral bed rails located in the middle part of the bed were raised up.
During multiple observations in Resident 83's room on 1/23/2024 at 8:45 a.m., 1/24/2024 at 9:22 a.m., and 1/25/2024 at 4:25 p.m., Resident 83 was lying in bed, and the bilateral bed rails located in the middle part of the bed were raised up.
Review of Resident 83's Physician Order dated 11/12/2023, indicated the resident had an order for half side rails up as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 83's Siderail Evaluation dated 11/12/2023, indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 213's room on 1/23/24 at 8:35 a.m., Resident 213 was in bed. Resident 213's bed had bilateral half side rails.
Review of Resident 213's physician orders, dated 4/23/23 indicated she had an order for half side rails up both sides when in bed to enable independent repositioning and transfers.
Review of Resident 213's Siderail Evaluation, dated 4/22/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 132's room on 1/23/24 at 9:30 a.m., Resident 132 was in bed. Resident 132's bed had bilateral half side rails.
Review of Resident 132's physician orders, dated 1/9/24 indicated he had an order for half side rails up both sides when in bed to enable independent repositioning and transfers.
Review of Resident 132's Siderail Evaluation, dated 1/11/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 127's room on 1/23/24 at 9:54 a.m., Resident 127 was in bed. Resident 127's bed had bilateral half side rails.
Review of Resident 127's physician orders, dated 1/10/24 indicated he had an order for half side rails up both sides as an enabler.
Review of Resident 127's Siderail Evaluation, dated 12/5/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 443's room on 1/23/24 at 11:01 a.m., bilateral partial side rails were observed on the bed of Resident 443.
Review of Resident 443's physician's order, dated 1/16/24, indicated may have two half side rails as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 443's Siderail Evaluation, dated 1/16/24, indicated there was no documentation that the facility offered and/or attempted alternatives prior to installing side rails.
During an observation in Resident 168's room on 1/25/24 at 9:32 a.m., Resident 168 was in bed. Resident 168's bed had bilateral half side rails.
Review of Resident 168's physician orders, dated 1/10/24 indicated he had an order for half side rails up both sides when in bed to enable independent repositioning and transfers.
Review of Resident 168's Siderail Evaluation, dated 12/2/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 82's room on 1/25/24 at 4:25 p.m., Resident 82's bed had bilateral half side rails.
Review of Resident 82's physician orders, dated 6/11/22 indicated he had an order for bilateral half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 82's Siderail Evaluation, dated 1/11/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 145's room on 1/25/24 at 4:25 p.m., Resident 145's bed had bilateral half side rails.
Review of Resident 145's physician orders, dated 1/9/24 indicated he had an order for bilateral half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 145's Siderail Evaluation, dated 1/11/24 indicated there was no documentation the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 160's room on 1/25/24 at 4:25 p.m., Resident 160's bed had bilateral half side rails.
Review of Resident 160's physician orders, dated 3/8/23 indicated he had an order for bilateral half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 160's Siderail Evaluation, dated 1/1/24 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 56's room on 1/25/24 at 4:30 p.m., Resident 56's bed had bilateral half side rails.
Review of Resident 56's physician orders, dated 1/9/24 indicated he had an order for half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 56's Siderail Evaluation, dated 1/11/24 indicated there was no documentation the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 139's room on 1/25/24 at 4:30 p.m., Resident 139's bed had bilateral half side rails.
During a review of Resident 139's Physician Orders, dated 5/4/23, the Physician Orders indicated, Half side rails up as enabler when in bed to enable independent repositioning and transfers.
During a review of Resident 139's Siderail Evaluation, dated 11/17/23, the Siderail Evaluation indicated, there was no documentation that the facility offered and/or attempted alternatives prior to installation of side rails.
During an observation in Resident 128's room on 1/25/24 at 4:30 p.m., Resident 128's bed had bilateral half side rails.
Review of Resident 128's physician orders, dated 1/9/24 indicated he had an order for half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 128's Siderail Evaluation, dated 1/1/24 indicated there was no documentation that indicated the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 792's room on 1/25/24 at 4:30 p.m., Resident 792's bed had bilateral half side rails.
Review of Resident 792's physician orders, dated 1/20/24 indicated he had an order for bilateral half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 792's Siderail Evaluation, dated 1/20/24 indicated there was no documentation that indicated the facility offered and/or attempted alternatives prior to the use of side rails.
During an observation in Resident 184's room on 1/25/24 at 5 p.m., Resident 184's bed had bilateral half side rails.
During a review of Resident 184's Physician Orders, dated 3/30/23, the Physician Orders indicated, Half side rails up as enabler when in bed to enable independent repositioning and transfers.
During a review of Resident 184's Siderail Evaluation, dated 12/14/23, the Siderail Evaluation indicated, there was no documentation that the facility offered and/or attempted alternatives prior to installation of side rails.
During an observation in Resident 692's room on 1/25/24 at 5 p.m., Resident 692's bed had bilateral half side rails.
During a review of Resident 692's Physician Orders, dated 1/11/24, the Physician Orders indicated, Half side rails up as enabler when in bed to enable independent repositioning and transfers.
During a review of Resident 692's Siderail Evaluation, dated 1/11/24, the Siderail Evaluation indicated, there was no documentation that the facility offered and/or attempted alternatives prior to installation of side rails.
During an observation in Resident 201's room on 1/25/24 at 5 p.m., Resident 201's bed had bilateral half side rails.
During a review of Resident 201's Physician Orders, dated 1/10/24, the Physician Orders indicated, Half side rails up as enabler when in bed to enable independent repositioning and transfers.
During a review of Resident 201 Siderail Evaluation, dated 1/11/24, the Siderail Evaluation indicated, there was no documentation that the facility offered and/or attempted alternatives prior to installation of side rails.
During an observation in Resident 229's room on 1/25/24 at 5 p.m., Resident 229's bed had bilateral half side rails.
During a review of Resident 229's Physician Orders, dated 10/26/23, the Physician Orders indicated, Half side rails up as enabler when in bed to enable independent repositioning and transfers.
During a review of Resident 229's Siderail Evaluation, dated 10/26/23, the Siderail Evaluation indicated, there was no documentation that the facility offered and/or attempted alternatives prior to installation of side rails.
During an observation in Resident 192's room on 1/25/24 at 5:30 p.m., Resident 192 was in bed. Resident 192's bed had bilateral half side rails.
Review of Resident 192's physician orders, dated 1/10/24 indicated he had an order for half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 192's Siderail Evaluation, dated 12/2/23 indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
The survey team (seven surveyors) expanded the sample and identified an additional 192 residents had side rails during observation on 1/25/24 from 4:05 p.m. to 5:15 p.m. with the Interim Director of Nursing/Infection Preventionist (IDON/IP). Review of the Siderail Evaluations for the 192 residents indicated there was no documentation that the facility offered and/or attempted alternatives prior to the use of side rails.
During concurrent interview and record review of the facility's side rail assessment on 1/26/23 at 4:24 p.m., the IDON/IP stated the facility's side rail evaluation did not address any alternatives that were offered and/or attempted prior to the use of side rails.
During an interview on 1/29/24 at 10:50 a.m., the IDON/IP confirmed there was no documentation that indicated the facility offered and/or attempted alternatives to all of the 230 residents who had side rails.
Review of the facility's undated policy, Side Rails indicated for residents who have no voluntary movement, it is still necessary for the Interdisciplinary Team (IDT) to determine if there is a medical need to use side rails. The policy also indicated nursing is required to complete the Side Rail Evaluation form, complete informed consent, reviewing risks and benefits with responsible party, including risk for entrapment. The policy did not address that the facility must attempt to use appropriate alternatives prior to installing a side rail. The policy did not address the installation and maintenance of the bed and side rails.
2. During an interview with the Regional Director of Maintenance (RDM) on 1/25/2024 at 9:22 a.m., RDM confirmed the facility's director of maintenance was on vacation since 12/22/2023 and RDM just visited the facility when needed. RDM stated bed and side rail assessments (maintenance) should be done annually. He stated no record of bed/side rail maintenance was found.
During a review of the undated bed owner's manual provided by the facility titled, Operation and Maintenance Manual for Elite EX, indicated, Maintenance and cleaning procedures should be performed at least once a year or as required. The manual indicated periodic inspection included: perform the procedure Steps to Prevent Bed Fires listed in this manual; review Reducing the Risk of Entrapment listed in this manual; review and inspect for compliance to the Warnings listed in this manual; check casters to ensure they lock, if applicable, and roll properly; inspect all bed components for damage or excessive wear; visually examine all welds for cracks; check all cords for cuts or other damage.
3. During an observation in Resident 58's room on 1/22/2024 at 10:32 a.m., Resident 58 was lying flat on bed, watching on his computer tablet using a mouthpiece to navigate on it. Resident 58 had inability to move both arms and legs. The resident's bilateral upper bed rails were raised up.
During a concurrent observation in Resident 58's room and interview with Certified Nursing Assistant F (CNA F) on 1/22/2024 at 12:04 p.m., Resident 58's bilateral upper bed rails were raised up. CNA F confirmed Resident 58 never used his bed rails for repositioning or even for transfers. CNA F stated the nurses were the ones who wanted the bed rails raised up.
During another observation in Resident 58's room on 1/23/2024 at 8:38 a.m., Resident 58 was in bed and the bilateral upper bed rails were raised up.
Review of Resident 58's face sheet indicated, Resident 58 was admitted to the facility with diagnoses including quadriplegia (is a form of paralysis that affects all four limbs, plus the torso), neuromuscular dysfunction of bladder (the nerves and muscles do not work together very well resulting for the bladder to not fill or empty correctly), and depression.
Review of Resident 58's Minimum Data Set (MDS, assessment tool) Annual assessment dated [DATE] indicated, Resident 58's brief interview for mental status (BIMS, an assessment used in nursing homes and other long-term care facilities to monitor cognition [mental process involved in knowing, learning, and understanding things]) score was 15 (cognition is intact). Further review indicated, Resident 58 did not attempt to: roll from lying on back to left and right side, sit to lying on bed, sit to stand and chair/bed-to-chair transfer.
Review of Resident 58's Physician Order dated 7/15/2022, indicated the resident had an order for half side rails up as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 58's Siderail Consent dated 7/15/2022, indicated, Half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 58's care plan titled, Side rails, dated 12/02/2021, indicated, 1/2 side rails/rails at side of bed bilateral as an enabler to promote independent mobility while in bed.
Review of Resident 58's Activities of Daily Living (ADLs, are essential and routine tasks that most young, healthy individuals can perform without assistance) Administration History indicated Resident 58's half side rails were used since 7/15/2022.
During initial observation in Resident 83's room on 1/22/2024 at 3:27 p.m., Resident 83 was lying in bed, and the bilateral bed rails located in the middle part of the bed were raised up.
During multiple observations in Resident 83's room on 1/23/2024 at 8;45 a.m., 1/24/2024 at 9:22 a.m., and 1/25/2024 at 4:25 p.m., Resident 83 was lying in bed, and the bilateral bed rails located in the middle part of the bed were raised up.
During a concurrent observation and interview on 1/29/2024 at 8:41 a.m., inside Resident 83's room, Licensed Vocational Nurse U (LVN U) was unable to state the reason for the bed rail used. LVN U confirmed the middle part of the bed had bilateral bed rails. LVN U agreed Resident 83 would not be able to transfer out of bed with the bed rails raised up.
During a concurrent observation and interview on 1/29/2024 at 8:46 a.m., inside Resident 83's room, CNA F stated the location of the bed rails in the middle of the bed would prevent Resident 83 in getting out of bed. During an additional observation on 1/29/24 at 8:48 a.m., CNA F had to put the left bed rail down in order to transfer Resident 83 in a shower chair. Resident 83 did not use the bed rail to transfer independently.
During an interview with the IDON/IP on 1/29/2024 at 3:50 p.m., IDON/IP confirmed Resident 83's bed rails would restrict her from getting out of bed.
Review of Resident 83's face sheet indicated Resident 83 was admitted to the facility with diagnosis of hemiplegia (one-sided muscle paralysis or weakness), unspecified affecting left non-dominant side.
Review of Resident 83's admission MDS dated [DATE], indicated Resident 83's BIMS score was 14 (intact cognition). Further review indicated Resident 83 was dependent with sit to lying in bed, roll from lying on back to left and right side and with sit to stand.
Review of Resident 83's Physician Order dated 11/12/2023, indicated the resident had an order for half side rails up as an enabler when in bed to enable independent repositioning and transfers.
Review of Resident 83's care plan titled Side Rails, dated 1/11/2024, approach indicated, half side rails/rails on side of the bed while in bed .
Review of Resident 83's ADL Administration History indicated Resident 83's bed rails were in use since 11/12/2023.
4. During an observation in Resident 128's room on 1/25/24 at 4:30 p.m., Resident 128's bed had bilateral half side rails.
Review of Resident 128's physician orders, dated 1/9/24 indicated he had an order for half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 128's Siderail Evaluation, dated 1/1/24 indicated the resident did not require the use of side rails. For the question, Does the Resident require the use of siderail(s) at this time of evaluation? the box No. (Do not proceed with evaluation) was checked. The evaluation was not completed.
During an observation in Resident 792's room on 1/25/24 at 4:30 p.m., Resident 792's bed had bilateral half side rails.
Review of Resident 792's physician orders, dated 1/20/24 indicated he had an order for bilateral half side rails up as enabler when in bed to enable independent repositioning and transfers.
Review of Resident 792's Siderail Evaluation, dated 1/20/24 indicated the resident did not require the use of side rails. For the question, Does the Resident require the use of siderail(s) at this time of evaluation? the box No. (Do not proceed with evaluation) was checked. The evaluation was not completed.
During an observation in Resident 41's room on 1/22/24 at 10:21 a.m., Resident 41 was in bed. Resident 41's bed had bilateral half side rails.
Review of Resident 41's physician orders, dated 1/7/24 indicated he had an order for half side rails up both sides when in bed to enable independent repositioning and transfers.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure the food service staff had appropriate competencies to carry out the food service safely and effectively functions whe...
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Based on observation, interview, and record review, the facility failed to ensure the food service staff had appropriate competencies to carry out the food service safely and effectively functions when:
1. A kitchen staff member did not demonstrate the correct technique for testing the sanitation level on the dish machine.
2. A kitchen staff member did not demonstrate thermometer calibration correctly.
3. A kitchen staff member did not demonstrate the correct techniques for testing the sanitizer in the red buckets.
This failure in staff competency had the potential to result in improperly sanitized resident dishes and food contact surfaces and expose residents to food-borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).
Cross reference 812 and CCR-72345(a)
Findings:
1. During a concurrent observation and interview on 1/22/24 at 10:04 am, with the Dietary Aide (DA) J, DA J demonstrated how to test the low temperature dish machine for the correct sanitation level. The DA J placed a stainless steel container through the dish machine, dipped the strip for 13 seconds in the water solution and held it up against the color chart. Then the DA J took another strip and dipped for ten seconds, compared the result to the color chart and dipped the same strip for eight seconds. The DA J discarded the strip, took another strip, and dipped the strip in the same water solution. The DA J stated the water was not hot enough that was why he was not getting the desired result.
On 1/22/24 at 10:17 AM, the DSM acknowledged DA J's sanitizer test demonstration and stated he should know how to test this correctly. The DSM then placed a stainless-steel container upside down and ran it through the dish machine. She dipped a test strip from the chlorine test strip container on top of the stainless-steel container. The test strip was medium gray, which read 50-100 ppm (parts per million). The DSM stated, this is the correct level, it should be between 50-100 ppm.
Review of facility's untitled in-service record, dated 10/30/23, indicated staff are all taught how to use the new test strips for sanitation to show the strength of sanitizer, was attended by DA J.
According to the 2022 Federal Food Code, Section 4-603.16, Rinsing Procedures, indicated Washed utensils and equipment shall be rinsed .use of a distinct, separate water rinse after washing and before sanitizing if using (1) a 3-compartment sink use of a nondistinctive water rinse that is integrated in the hot water sanitization immersion step of a 2-compartment .
2. During a concurrent observation and interview on 1/22/24 at 12:16 pm, with the [NAME] (CK) EE, to demonstrate how to calibrate (making precise measurement) the thermometer. The CK EE filled a glass with ice and water, placed the digital thermometer with the tip touching the bottom of the glass. The CK EE stated he was trained that way two days ago by another staff. The CK EE also stated he was not sure if the thermometer should read 30 or 32 degrees Fahrenheit for calibration.
During a review of facility's policy and procedure (P&P) titled Calibrating and Sanitizing Thermometers, dated 2023, the P&P indicated Thermometers will be calibrated routinely to ensure accurate temperatures are obtained and meet appropriate guidelines for safe food preparation and service. Placing in a cup full of ice water, thermometer should read 32 degrees Fahrenheit.
3. During a concurrent observation and interview on 1/23/24 at 10:18 am, with DA CC, to demonstrate how to test sanitizer in red bucket. The DA CC took a strip and dipped it for 15 seconds and the strip was orange color with a little green at the bottom of the strip. Then DA CC compared the result with the test strip container and stated the strip needed to be dark green or medium green, which was 300-400 ppm. DA CC stated that is a good level. The DSM acknowledged the incorrect sanitizer test demonstration. The DSM stated, the sanitizer in the red bucket should be between 200 ppm, and DA CC should know the correct level.
Review of the manufacturer's label on the sanitizer bottle for the sanitizer used in the red buckets, the effective concentration to sanitize should be at 150-400 PPM. The chem test strips from the vial that the facility used provided a color-coded graph in increments of 100 PPM, 200 PPM, 300 PPM, 400 PPM, and 500 PPM. There was no measurement on the chem strip vial available to determine 150 PPM.
According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-302.14, titled Sanitizing Solutions, Testing Devices, A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided.
During a review of facility's in-service record, dated 10/12/23, indicated sanitizing test strip (how to use) was attended by the DA CC.
According to the manufacturer's guidance for Ammonium sanitizer testing titled Hydrion (QT-10) Quat, indicated Dip the strip into the sanitizing solution for 10 seconds .
During a review of the facility's undated policy and procedure (P&P) titled Dietary Cleaning, the P&P indicated Proper cleaning and sanitation of equipment ensures removal of residual food, chemicals, and bacteria More sanitizer is not better; too much sanitizer can cause chemical poisoning. Use test strips to determine the proper strength of sanitizer .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility did not ensure the facility approved menus were followed as printed.
This failure altered the availability of foods served to resident...
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Based on observation, interview, and record review, the facility did not ensure the facility approved menus were followed as printed.
This failure altered the availability of foods served to residents, which could decrease food intake and compromise the nutritional status 240 of 244 medically vulnerable residents who consumed food from the kitchen.
Findings:
During a review of the facility's Diet Spreadsheet on 1/22/24, Week 1 Day 1, approved by the Registered Dietitian (RD) was ½ cup of cereal, omelet 1 each, ½ cup breakfast potatoes, 1 slice of wheat toast, 1 cup coffee/tea, 1 cup milk, 1 jelly packet, 1 margarine, 1 salt packet, 1 pepper packet, and 1 non-dairy creamer. The nutrition analysis for Week 1 Day 1 was 2177 calories and 91.93 grams of protein.
During a kitchen observation the breakfast meal trayline on 1/22/24 at 9:28 am, the Regular breakfast meal items on the trayline included a large pan of scrambled eggs, pan of potatoes, and a pan of cream of wheat. There was a medium sized meal tray cart with 30 trays and did not have milk on the trays.
During a review of the facility's Diet Spreadsheet, Week 1 Day 2, approved by the RD, the Regular Diet lunch meal was 3 ounces of beef tip au jus, ½ cup butter noodles, ½ cup spinach, 1 wheat roll, 1 cup coffee/tea, ½ cup milk. The nutritional analysis for Day 2 was 2207 calories and 90.47 grams of protein.
During a concurrent observation and interview on 1/23/24 at 11:20 am, with the Dietary Services Manager (DSM) and RD, it was observed that resident meal trays were assembled and prepared without the carton of milk at breakfast for two days and the current lunch. DSM stated milk was for residents that request it. RD stated the menu should be followed but it was okay not to serve milk at meals.
Review of an eight-ounce cup of whole milk indicated it provided 150 calories and 8 grams of protein. Milk is listed at 1 cup for breakfast and ½ cup at lunch and dinner on the facility's 7 Day Menu spreadsheets. A resident receives a diet which is 360-450 fewer calories and 27 fewer grams of protein.
During an interview on 1/26/24 at 10:48 AM with the RD, the RD stated it was important for the Cooks to follow the approved recipes and menus, so the residents receive appropriate nutrition.
During an interview on 1/27/24 at 1:28 pm, with the RD, the RD stated the facility began to use the long-term Alternate Menu for Emergency to feed the residents because the kitchen was closed. The menu had broccoli cheddar soup, egg salad sandwich, and side green salad. The residents received an egg salad sandwich and diced carrots. The RD stated they did not have a substitution for the broccoli cheddar soup on the menu. The RD further stated it was important for residents to receive nutritionally adequate meals.
During a review of the facility's Consultant Dietitian Nutritionist Job Description date 2023, the contract indicated .Responsibilities: .3. Coordinates, implements, and evaluates the facility menus for nutritional adequacy .
Review of the facility's Food Service policy and procedures (P&P) Manual section titled Menu may be substituted with appropriate items as needed, page 305, dated 2023, the section indicated 1. Menus should 'mirror' the facility's regular menu (Title 22-California). The calories and protein content need to be close to the regular menu
Review of the facility's policy and procedure (P&P) titled Menu Planning, dated 2023, indicated Menus are planned at least one week in advance and dated and posted .The menu will provide the following food groups .milk group equal or more than 3 servings per day.
Review of the facility's policy and procedure (P&P) titled Menu Substitution, dated 2023, indicated .to assure the menu is followed and served as planned .menu substitutions be noted on the posted weekly and daily menus throughout the facility, so residents and non-Department of Food and Nutrition Services staff are aware of the substitutions.
During a review of the facility's undated Policy and Procedure (P&P) titled Food Service, the P&P indicated The company provides, and each resident receives food that is: prepared by methods that conserve nutritive value .palatable .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 1/24/24 at 4:05 pm, with Registered Nurse (RN) P, RN P stated resident food ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 1/24/24 at 4:05 pm, with Registered Nurse (RN) P, RN P stated resident food brought in from outside would be stored for three days and it should have a label that indicated the name and date. RN P confirmed the station 5 nourishment refrigerator had four containers of food without a name and date.
During a concurrent observation and interview on 1/27/24 at 10:53 am, with RN W, RN W confirmed that the daily temperature monitoring for the residents' nourishment refrigerator in one of the stations on 1/27/24 was not done. RN stated it should be checked daily by the night shift staff.
During an interview with the DON on 1/30/24 at 1:30 PM, the DON stated it was important for resident's food to be stored safely for up to 48 hours in the nurses' station refrigerators. The DON further stated nurses needed to follow the facility's policy for food brought from the outside.
Review of the facility's undated policy and procedure (P&P) titled Food Brought from Outside the facility, the P&P indicated Containers will be labeled with the resident's name and the use by date. The nursing staff will discard perishable foods (foods likely to spoil, decay or become unsafe to consume if not refrigerated at 40 degrees F or below; ex: meats, fish, dairy) on or before the use by date.
During a review of the facility's P&P titled, Food Brought from Outside the Facility, (undated) the P&P indicated, Perishable must be stored in re-sealable containers with tight fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item, and the 'use by' date.The nursing staff will discard perishable foods on or before the 'use by' date.Potentially hazardous foods [A food of animal origin, e.g., meat, poultry, milk, fish, shellfish, crabs, and lobster, or of plant origin and has been heat treated] that are left out for the resident without a source of heat or refrigeration longer than 2 hours will be discarded.
Based on observation, interview and record review, the facility failed to follow its policy related to resident food brought in from outside the facility which facilitated improper food storage not safe for resident consumption.
This failure had the potential to expose 240 of 244 residents who consumed food orally to harmful bacteria that could result in food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).
Findings:
1. During a concurrent observation and interview on 1/23/24, at 9:15 a.m., with Certified Nursing Assistant (CNA) A, in Resident 222's room, personal food items were noted on Resident 222's bedside table. A Styrofoam container of approximately half a cup of rice, a clear plastic container with approximately 5 pieces of half-eaten fish, a clear plastic container with salted fish with a use by date of [DATE] were noted on the bedside table. CNA A stated, there is rice, fish, and shrimp at the bedside, the rice and fish do not have dates, the shrimp is past the use by date and should have been thrown away. CNA A stated, resident's personal foods should be dated, and old food thrown away.
During an interview on 1/23/24, at 9:25 a.m., with Resident 222, Resident 222 stated, he intended to eat the leftover rice, fish and shrimp left at the bedside. Resident 222 stated, the rice was from yesterday, the fish and shrimp have been here at least a day in my room.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from verbal and physical a...
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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 were free from verbal and physical abuse for two of three residents (Residents 1 and 2) when:
1. Resident 1 sustained facial injuries when Resident 2 scratched her in the face and was transferred to the emergency room (ER).
2. Resident 2 sustained emotional distress by feeling upset when Resident 1 said bad words, and complained of pain on her breast when Resident 1 grabbed her breast.
This failure had caused both emotional and physical harm to Residents 1 and 2.
Findings:
On 9/08/2023, the facility submitted a facsimile (FAX) to the California Department of Public Health (CDPH) about an incident between Residents 1 and 2. The FAX showed Residents 1 and 2 had verbal arguments. Resident 1 grabbed Resident 2's breast, and Resident 2 grabbed Resident 1's hair and scratched her in the face.
During a review of the facility's investigative summary dated 9/13/2023, the summary indicated Resident 1 and 2 were outside of the facility by the front of the building on 9/08/2023 around 10:30 a.m. when they had a verbal argument. Resident 1 and 2 started a verbal argument, Resident 2 wheeled away, but Resident 1 said something bad to Resident 2. Resident 2 spit in Resident 1's direction, then Resident 1 grabbed Resident 2's breast. Resident 2 pulled Resident 1's hair and scratched Resident 1's left side of the face.
Review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including psychotic disorder (a mental disorder characterized by a disconnection from reality) with hallucinations (seeing or hearing things that others do not), depressive episodes (experiences of feeling sad, irritable, and empty), and opioid (a broad range of drugs used to reduce pain, including illegal drugs) dependence. Her Minimum Data Set (MDS, an assessment tool) dated 8/12/2023, indicated a Brief Interview for Mental Status (BIMS) score of 15 (intact cognition).
During a review of Resident 1's Psychiatry Visit Progress Report dated 6/21/2023, the report indicated Resident 1 had a history of psychotic disorder with hallucinations, depressive episodes, and opioid dependence. The report also indicated treatment goals were stabilization of depressed mood, stabilization of irritability/anger and increasing appropriate expression of angry feelings.
During a review of Resident 1's care plan for negative/untoward event resident to resident verbal aggression, created on 8/22/2023, the care plan indicated interventions, including one on one sitter provided for close observation and safety.
During a review of Resident 1's physician order, dated 8/22/2023, the order indicated 1 to 1 sitter (staff that are immediately at hand can help prevent an accident or redirect a patient from engaging in a harmful act).
During a review of Resident 1's situation, background, assessment, and recommendation (SBAR) dated 9/08/2023, the SBAR indicated an altercation with a skin tear: at 11:02 a.m., CNA (Certified Nursing Assistant) met the writer at the front, reporting that the resident gave her debit card to a male resident, and the staff went back to attend the resident. As the writer was walking outside, the writer saw commotion between two residents. Resident 1 was pulling Resident 2's hair, and another resident tried to separate them.
During a review of Resident 1's SBARs, the SBAR dated 9/01/2023 indicated a resident to resident altercation: the resident was arguing with another resident. Sitter began to approach to separate them. Sitter witnessed the other resident placed a nail on Resident 1's right forearm, resulting in a skin tear. The SBAR dated 9/05/2023 indicated a claimed allegedly resident to resident altercation: Resident 1 reported that an alleged altercation happened with another resident on 9/01/2023.
During a review of Resident 1's nurses note dated 9/08/2023, the note indicated that staff called the doctor regarding the resident's multiple altercations with other residents, putting self and others in danger, threatening behavior, verbally aggressive and verbally abusive to staff, not redirectable, and an MD order to send the resident to the ER or psych (psychiatry, unit for residents with mental disorders).
During a review of Resident 1's hospital Discharge summary, dated [DATE], the summary indicated that on 9/08/2023, Resident 1 was brought in due to the patient having repeated physical altercations with staff and other residents of the nursing home, with the last altercation resulting in superficial abrasions to the left jaw.
Review of Resident 2's clinical record indicated she was admitted on [DATE] and had diagnoses including hemiplegia (a condition that involves one-sided paralysis), bipolar disorder (a mental illness), major depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest), and stimulant dependence. Her MDS, dated [DATE], indicated a BIMS score of 13 (intact cognition).
During a review of Resident 2's SBAR dated 9/08/2023, the SBAR indicated an altercation with another resident: per the resident, Resident 1 said something that made her upset, Resident 1 grabbed her right side of the breast, and she grabbed Resident 1's hair and scratched Resident 1's left side of the face.
During an interview on 11/08/2023 at 10:10 a.m. with Resident 2, she was lying in her bed, and her call device was observed within her reach. Resident 2 stated she remembered that day, and Resident 1 was crazy. Resident 2 was outside of the facility, she tried to leave Resident 1 away, but Resident 1 kept saying bad stuff, which was upsetting her. Resident 1 grabbed her breast, and she scratched Resident 1's face. Resident 2 stated that there was no staff with Resident 1. Resident 2 further stated she was upset, and her breast was hurting then.
During an interview on 11/08/2023 at 10:40 a.m. with Licensed Vocational Nurse A (LVN A), she stated she was informed that Residents 1 and 2 were arguing outside of the facility on 9/08/2023. LVN A stated the residents were fighting when she went out to the residents, and staff separated the residents immediately. LVN A further stated that Resident 1 had a history of multiple altercations with other residents and was transferred to the ER for her uncontrollable behavior on 9/08/2023.
During an interview and record review on 11/08/2023 at 3:40 p.m. with LVN B, she confirmed Resident 1's physician's order of a 1:1 sitter and the intervention of a verbal aggression care plan to provide a 1 on 1 sitter. LVN B also confirmed that Resident 1 had an altercation with Resident 2 on 9/08/2023. LVN B stated that a 1:1 sitter was ordered for Resident 1 regarding her multiple altercations with other residents. LVN B further stated she could not locate any documentation indicating a 1:1 sitter was with Resident 1 when Resident 1 had the altercation with Resident 2 on 9/08/2023.
During an interview and record review on 12/08/2023 at 1:30 p.m. with LVN A, she stated she could not locate any documentation indicating a 1:1 sitter for Resident 1 was provided as ordered. LVN A provided the facility's handwritten 1:1 sitter schedule for Resident 1. The schedule indicated that a 1:1 sitter was not provided on 8/22/2023; 8/23/2023; night shift on 8/24/2023; evening and night shift on 8/26/2023 and 8/28/2023; night shift on 8/29/2023, 8/30/2023, 8/31/2023, 9/01/2023, 9/02/2023, 9/03/2023, and 9/04/2023. LVN A confirmed the schedule review and stated the facility did not provide a 1:1 sitter as ordered.
During a phone interview on 12/14/2023 at 12:30 p.m. with LVN C, she stated that she was the charge nurse for Resident 1 on 9/08/2023. LVN C stated the 1:1 sitter for Resident 1 came into the facility, and Resident 1 was alone outside of the facility during the altercation. LVN C confirmed that the 1:1 sitter to Resident 1 was not provided during the altercation. LVN C stated that the 1:1 sitter for Resident 1 should not have left the resident alone.
During a phone interview on 1/19/2024 at 2:10 p.m. with Certified Nursing Assistant D (CNA D), she stated that she was the assigned 1:1 sitter for Resident 1 on 9/08/2023 during the day shift from 7:00 a.m. to 3:00 p.m. CNA D also stated, before the altercation happened, she saw Resident 1 give her ATM card to a male friend. CNA D went inside the facility to report it to her charge nurse and left Resident 1 alone outside of the facility. CNA D further stated when she and LVN C went outside the facility where she left Resident 1, both she and LVN C witnessed Residents 1 and 2 physically fighting. CNA D confirmed that Resident 1 stayed outside of the facility without any staff during the altercation. CNA D acknowledged that she should have stayed with Resident 1 while providing 1:1 sitter care.
During a review of the facility's undated policy and procedure (P&P) titled Abuse, Neglect and Exploitation Prohibition, the P&P indicated, Each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property.
During a review of the facility's undated policy and procedure (P&P) titled Safety Supervision of Residents, the P&P indicated, The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment.
During a review of the facility's undated policy and procedure (P&P) titled Comprehensive Plan of Care, the P&P indicated, The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well being. The comprehensive plan of care must include interventions to prevent avoidable decline in function or functional level.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity when the certified nursing assistant A (CNA A) pull...
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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with respect and dignity when the certified nursing assistant A (CNA A) pulled the standing Resident 1 backward and did not ask for assistance in putting the Resident 1 in bed. This failure resulted in not ensuring Resident 1 ' s right to be treated with respect and dignity and could potentially result in low-self-esteem and self-worth.
Findings:
Review of Resident 1's medical record indicated diagnoses that includes metabolic encephalopathy (a disorder that affects brain function), schizophrenia (a mental illness that affects how a person thinks, feels, and behaves), history of displaced fracture of fifth vertebrae (a series of small bones forming the backbone), lack of coordination, difficulty of walking, and unsteadiness on feet.
Review of Resident 1's minimum data set (MDS, a resident assessment tool) dated 12/14/23 indicated he is non-interviewable and with long- and short-term memory problems. He mostly needed one-person physical assist during transfers.
During an interview with CNA A on 1/3/24 at 3:02 p.m., he stated licensed vocational nurse B (LVN B)asked him to assist in helping Resident 1. CNA A saw Resident 1 standing and holding on to the sink inside the bathroom with feces on the floor, sink, wall including some of his Resident 1 body parts. CNA A stated he held Resident 1's on both under armpits and carried the standing Resident 1 backward and put Resident 1 in bed to better clean him up. CNA A stated he did not ask for assistance or call for help from other facility staff when he pulled the standing Resident 1 backward in putting the Resident 1 in bed. CNA A acknowledged he should have asked for help from another staff in assisting Resident 1 in putting in bed.
During an interview with the director of staff development C (DSD C) on 1/8/24 at 2 p.m., she stated CNA A should have requested help from another facility staff or put on the bathroom call light for the other facility staff to come and help CNA A in assisting Resident 1 in bed in a proper technique by not pulling Resident 1 backward
During an interview with the rehabilitation director D (RD D) on 1/10/24 at 10:36 a.m., she acknowledged the CNA A should have assisted the Resident 1 in putting him in bed in a better way by asking assistance and help from other facility staff rather than pulling the standing Resident 1 backward into Resident 1 ' s bed.
During a review of the undated facility's policy and procedures Resident Dignity & Personal Privacy indicated the facility provides care for residents in a manner that respects and enhances each resident dignity, individuality . Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.
During a review of the undated facility's policy and procedures Resident Transfers indicated, .Assess resident to determine functional ability and type of assist needed. Be sure to obtain assistance, when necessary. If assistance is not immediately available, make the resident comfortable when help arrives .
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision to prevent 1 out of 10 residents (Resident 1) w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision to prevent 1 out of 10 residents (Resident 1) who was at risk for elopement from leaving the facility when Resident 1 went out to smoke outside the facility and did not return the same day. These failures compromised Resident 1's health and safety, as she was found by police officers and was admitted to the acute hospital for treatment and evaluation the next day 12/24/2022
Findings:
A review of Resident 1's medical record indicated she was admitted to the facility on [DATE] with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and unspecified Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). Further review of Resident 1's medical record indicated Resident 1 ' s conservator was her responsible party.
A review of Resident 1's Elopement Risk Assessment, dated 12/02/2022, indicated she was at risk for elopement and had behaviors of wandering without purpose, wanting to go home, or somewhere else, exit seeking, and had a substance abuse/psychiatric history.
During an interview with the Nurse Supervisor (NS) on 1/9/2024 at 4:55 p.m., the NS stated Resident 1 was at risk for elopement and did not have the physician's out-on-pass order. Resident 1 signed the facility out-on-pass log to come out for smoking on 12/23/22 and did not return the same day. The NS further stated that Resident 1 was at risk for elopment and refused to wear the wander guard bracelet.
A review of Resident 1's clinical record dated on 12/24/2022, the Nursing notes indicated Resident 1 was found by police officers and was admitted to the acute hospital for treatment and evaluation on 12/24/2022.
A review of Resident 1's care plan titled Resident is non-compliant, dated 12/03/2022, indicated that Resident 1 refused to have a wander guard bracelet.
A review of Resident 1's medical record indicated no evidence to prove that Resident 1 had signed the out-on-pass log and no documents indicating that the conservator was notified about Resident 1 refusing to wear the wander guard bracelet.
A review of Resident 1's Safe Smoking Assessment/ Evaluation, dated 12/02/2022, indicated the IDT did not complete the assessment that would indicate the degree of supervision required, and if the resident was an independent smoker.
A review of Resident 1's care plan dated 12/2022 did not include care plan to address concerns about her smoking issue along the following areas: where smoking materials would be stored, degree of supervision, and protective devices.
During a phone interview with the Assistant Director of Nursing (ADON) on 1/12/2024 at 1:16 p.m., the ADON confirmed that IDT did not complete the Safe Smoke Assessment related to supervision and that there was no care plan to address the smoking issue associated with the degree of supervision required when Resident 1 would go smoking. The ADON stated the Safe Smoke Assessment should have been completed before the resident was allowed to smoke. the ADON further confirmed that Resident 1 came out of the facility building to smoke without supervision.
A review of the facility's undated policy and procedure, Smoking Policy , indicated, All residents that desire to exercise the privilege to smoke will be assessed to determine their smoking safety awareness. Until this assessment is complete, the patient will only be allowed to smoke under supervision. The IDT will determine if the resident is a safe smoker and the amount of supervision needed. Initial review of the safe smoking assessment will be completed at the next morning meeting, following the admission of the patient. Members of the IDT will then sign and date the assessment at this time. Care Plans will then be developed base on the assessment and findings of the IDT .
A review of the facility's undated policy and procedure, Elopement, indicated that the Elopement Risk Form will be completed for all patients upon admission, readmission, quarterly, and with significant changes. Patients showing to be at Risk for Elopement will have a wander guard placed if applicable to the facility.
Jan 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the doctor or nurse practitioner (NP)/or physician assistant...
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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 doctor or nurse practitioner (NP)/or physician assistant (PA) was promptly promptly informed of any condition change/s for one of three sampled residents (1) when after Resident 1's fall incident on 10/31/23, she complained of severe pain (10 out of 10 ) during morning shift on 11/4/23, and on the next day 11/5/23, she developed bruise (injury appearing as an area of discolored skin on the body, caused by a blow or impact due to rupture of underlying blood vessels.) on her right hip and the vagina area. This failure could jeopardize Resident 1 ' s health and safety due to the delay in Resident 1 receiving appropriate treatment /interventions that included timely transfer to acute hospital for further management and evaluation.
Findings:
Review of Resident 1's face sheet indicated the responsible party (RP, is a person who has been chosen to act or make decisions on behalf of another person for signing consent form ) was her daughter. Her minimum data set (MDS, an assessment tool) dated 10/15/23, indicated a brief interview for mental status (BIMS, an assessment tool for cognition) score of 7, or severely impaired cognition.
Review of Resident 1's SBAR (situation, background, assessment, recommendation, a communication tool), dated 10/31/23 indicated she had an unwitnessed fall on 10/31/23 at 3:00 a.m.
Review of Resident 1 s change of condition notes on 11/5/23, indicated, Right hip, vagina area has light bruise. However, further review of Resident 1's medical record did not include any documented evidence that any doctor's notification was done.
Review of Resident 1's medication administration record from 10/31/23 to 11/10/23, indicated during the morning shift on 11/4/23, Resident 1's a pain score of 10 out of 10 (severe pain), and after taking pain medication, her pain remained 8 out of 10 (severe pain).
However, there was no evidence of doctor's notification done.
During an interview on 11/22/23, at 11 a.m., with the registered nurse A (RN A), she stated, Resident 1 had an incident of fall on 10/31/23 and the x-ray was done on 11/1/23 with the result of no acute fractures. However, because Resident 1 developed discoloration from her right hip and vagina area and had been complaining of severe pain, the physician prescribed second x-ray on the 11/9/23. The x-ray results included, cannot exclude recent fracture and CT recommended. RN A further stated, Resident 1 was transferred to acute hospital on [DATE].
During an interview on 12/4/23, at 1:20 p.m., with Resident's responsible party (RP, is a person who has been chosen to act or make decisions on behalf of another person for signing consent form), she stated, Resident 1 had so much pain after the fall, she cried and cried, could not eat anything, and had to receive IV fluid. She started to have bleeding and was sent to the acute hospital for further evaluation and management.
During an interview and record review on 12/11/23, at 4 p.m., with the director of nursing (DON), she reviewed Resident 1's nurses progress notes from 11/1/23 to 11/8/23. The DON confirmed she could not find any documentation that Resident 1's doctor was notified regarding Resident 1's change in condition (bruise and severe pain).
During an interview on 1/3/24, at 1 p.m., with the DON, she confirmed the nurse should have notified physician about Resident 1's severe pain on 11/4/23, and the presence of discoloration on her right hip and vaginal area.The DON also stated, the nurse should notify the doctor for any new change of condition including pain and presence of bruising.
Review of Resident 1's emergency department notes, dated 11/10/23, indicated she was in pain for groin and pelvic pain. The x-ray revealed that Resident 1 had multiple pelvis fractures and the fractures were beyond the usual pubic rami fractures (is a break in one of these bones to make up part of the pelvis) and were unstable. The lab results revealed that she had low hemoglobin (Hb, is a protein in red blood cells that carries oxygen throughout the body) at 7.6 as the result of anemia (low levels of healthy red blood cells or hemoglobin). She received morphine (is a non-synthetic narcotic used for the treatment of pain) 2 milligrams (mg, unit of measurement) through intravenous (IV, in the vein) at 7:45 p.m. According to Resident 1's last complete blood count (CBC) test results on 11/3/23 which her Hb was 9.5 and the PA's progress notes on 11/9/23 documented Resident 1 was noted vagina bleeding.
Review of Resident 1's hospital Discharge summary, dated [DATE], indicated she had late effect of closed pelvic fracture (is a break of the ring of bones that connect to spine and the hips, and the bone does not break through the skin. commonly with pain in the groin, hip, or lower back). Her pain at the time of discharge was two out of ten (means that pain is under control).
Review of the facility's undated policy and procedure (P&P) titled, Changes in Resident Condition, it indicated, The resident, attending Physician and resident representative (if resident has no capacity to make health care decisions or if resident opts to notify a designated family member) are notified when changes in condition or certain events occur. Communication with the interdisciplinary team and direct care staff is also important to ensure that consistency and continuity of care are maintained.
Changes in the resident status are documented by the Licensed Nurse in the S-B-A-R or progress notes, care plan and risk meeting notes (when indicated). Plan of care will be communicated to the Interdisciplinary staff.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0776
(Tag F0776)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to ensure the timeliness of the radiology services for one of three sampled residents (Resident 1) when the physician ' s order to do a stat ...
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Based on interview, and record review, the facility failed to ensure the timeliness of the radiology services for one of three sampled residents (Resident 1) when the physician ' s order to do a stat (immediately) x-ray (a photographic or digital image of the internal composition of a part of the body) of right hip to rule out fracture was done as ordered.This failure had delayed meeting Resident 1's needed care and treatment.
Findings:
During an observation on 11/22/23, at 10:18 a.m., Resident 1 laid in bed and a long brace (equipment used to mimmobilize the leg) applied to her right leg.
Review of Resident 1's physician's order dated 10/31/23 indicated a radiology (x-ray)order for right hip AP/Lat (anterior posterior/lateral) view.
During an interview on 11/22/23, at 11 a.m., with the registered nurse A (RN A), she stated, Resident 1 had an unwitnessed fall on 10/31/23 when she was found on the floor next to her bed. The x-ray for her right hip to rule out fracture was done on 11/1/23 at around 4:30 p.m.
During an interview on 12/8/23, at 12:35 p.m., with registered nurse B (RN B), she confirmed the x-ray order from the doctor was to perform a stat X-ray of right hip for Resident 1, obtained on 10/31/23. RN B stated stat order should have carried out immediately.
During an interview on 12/11/23, at 4 p.m., with the director of nursing (DON), she stated, for stat X-ray order, it should be done immediately, but the x-ray vendor had short staffing issue, so the x-ray was not be done on 10/31/23 as ordered. The facility had to wait until the next day of 11/1/23 at 4:30 p.m. for the X-ray to be done. The DON concurred that delay in completing the x-ray and knowing the findings could affect Resident 1's care and treatment.
Review of the facility's undated policy and procedure (P&P) titled, Company Contract Management, it indicated, It is the policy of the company to enter into written contracts that comply with all laws governing the provision of health care services with vendors who are eligible to participate in federal health care programs.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the staff report one of two incidents of a resident-to-resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the staff report one of two incidents of a resident-to-resident altercations when certified nursing assistant A (CNA A) reported to the licensed nurse about the altercation between Resident 1 and Resident 2, but the incident was not reported until four days later, when Resident 1 informed the staff about it. This failure had the potential to put the residents at risk for further abuse.
Findings:
Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE].
Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 8/12/23, indicated her cognition was intact.
Review of Resident 2's admission Record indicated she was admitted to the facility on [DATE].
Review of Resident 2's MDS, dated [DATE], indicated her cognition was intact.
Review of Resident 1's Observation Detail List Report, dated 9/5/23, indicated Resident 1 reported to the staff that on 9/1/23, at the nurse station AA (NS AA), she wanted to get by, but Resident 2 was on her way and did not want to move. Resident 2 hit her on the face with a towel, and she struck back by hitting Resident 2's right upper arm with her hand.
During an interview with Resident 2 and with Spanish interpreter B (SI B) on 11/7/23 at 2 p.m., she stated it was at the NS AA, between 3 p.m. and 3:30 p.m., she and Resident 1 were in their wheelchairs. Resident 1 wanted her to move so she could pass through. Since Resident 1 was demanding and said it hostilely, she told Resident 1 to wait. Resident 1 hit her on her right shoulder, and she hit Resident 1 back on her left arm. Resident 2 stated CNA A saw that and separated her and Resident 1.
During an interview with CNA A on 11/10/23 at 1:05 a.m., she stated she was working evening shift on that day. It was at the NS AA, around 3 p.m. or 3:30 p.m. Resident 1 wanted Resident 2 to move, so she could pass by, but Resident 2 did not want to move.
Resident 1 and Resident 2 hit each other. CNA A stated she separated Resident 1 and Resident 2, and she reported the incident to the licensed nurse. However, the incident was not reported to either the Nurse Supervisor, Director of Nursing or Administrator until four days later when Resident 1 told the staff about it on 9/5/23.
Review of the facility's undated policy, Resident-to-Resident Altercations, indicated . Procedure: 1. Company staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator.
Dec 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to provide a copy of resident's medical record upon verbal request for one of three sampled residents (1) when her responsible party (RP, is a...
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Based on interview and record review, the facility failed to provide a copy of resident's medical record upon verbal request for one of three sampled residents (1) when her responsible party (RP, is a person who has been chosen to act or make decisions on behalf of another person) made a verbal request for Resident 1's medical records over months and did not receive any response from the facility. This failure had a potential to limit resident's rights for accessing records.
Findings:
Review of Resident 1's complaint intake information, dated 11/28/23, indicated RP H requested Resident 1's medical records from 8/31/23 and the facility did not make a copy of Resident 1's medical records to her.
During an interview on 12/7/23, at 4 p.m., with the medical record personnel F (MRP F), she stated, Resident 1's RP requested to have a copy of Resident 1's medical records in August 2023 and she forgot her request for making a copy of Resident 1's medical records. She stated, normally she would make a copy of resident's medical records right away after when they made a request.
Review of the facility's undated policy and procedure (P&P) titled, Resident Access to Protected Health Information, it indicated, Medicare regulations for nursing facilities provide that current residents or their legal representatives may access the resident's designated record set upon written or oral request within 24 hours (excluding holidays and weekend).
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide personal hygiene to one of three sampled residents (1) when her adult diapers were not changed as per plan of care an...
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Based on observation, interview, and record review, the facility failed to provide personal hygiene to one of three sampled residents (1) when her adult diapers were not changed as per plan of care and task schedule to keep clean and dry after each incontinent episodes.
This failure had the potential risk for developing complications such as skin rash or urinary tract infection.
Findings:
Review of Resident 1's complaint intake information, dated on 11/28/23, indicated, Resident 1 pointed her diaper was soaking wet to her visitor during visiting on 11/21/23. At 6:35 p.m., the visitor spoke with the nurse on duty to verify the last time of diaper changes for Resident 1 was in the morning.
Review of Resident 1's minimum data set (MDS, is a standardized assessment tool that measures health status in nursing home residents), dated 9/2/23, indicated her brief Interview for Mental Status (BIMS, assessment tool for cognition) score was 3 or severe cognitive impairment, her bladder status was always incontinent and she required extensive assistance for personal hygiene.
Review of Resident 1's plan of care for incontinence, dated 8/2/23, indicated to keep Resident 1 clean and dry after each incontinent episode.
Review of Resident 1's Vital Report for urine output, dated 11/19/23 to 12/8/23, indicated, she received diaper changes at total of three to five times in a day. On 11/21/23, she received diaper changes at 3;06 a.m., 9 :46 a.m., 7:56 p.m. and 10:36 p.m.
During an interview on 12/8/23, at 12:45 p.m., with the director of staff development (DSD), she stated, staff would need to check residents' adult diapers every two hours. Each shift needed to change adult diapers at least two to three times upon receiving resident, before or after meal and before ending their shift. Approximately would have six to nine times of diaper changes in a day.
During an observation on 12/7/23, at 3:10 p.m., Resident was able to point her diaper when to be changed while in bed.
During a telephone interview on 12/11/23, at 12:44 p.m., with the certified nursing assistant C (CNA C), she stated, sometimes the staff had issues with prolong or without changing resident ' s adult diapers
Review of the facility's undated policy and procedure (P&P) titled, Personal Care Needs Policy, it indicated, A patient who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal and oral hygiene.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents when cockroaches were seen by...
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Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents when cockroaches were seen by three of three sampled residents (1, 2 and 3) and 16 randomly selected residents ( (4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,18, 19)in the facility. This failure affected the residents' quality life, and dperived them to live in a healthy and sanitary environment.
Findings:
During a facility tour and concurrent interview on 12/7/23, at 10 a.m., with the housekeeper supervisor (HS), in the nursing station five, room A, Resident 4 stated, he had seen cockroaches in the bathroom. At 10:05 a.m., in the nursing station five, room B, Resident 5 stated, he had seen cockroaches in his room. At 10:10 a.m., in the nursing station five, room C, Resident 6 stated, he had seen cockroaches in the building.
During a facility tour and interview on 12/7/23, at 10:15 a.m., with HS, in the nursing station four, room D, Resident 7 stated, he had seen cockroaches in his room. At 10:18 a.m., Resident 8 was in the station four, room E, he stated, he had seen spider and cockroaches in his room and in the elevator recently. He further stated, the facility told him someone would come to spray but no one came to spray after reporting it to them.
During a facility tour and interview on 12/7/23, at 10: 10:20 a.m., with HS, in the nursing station two, room F, Resident 9 stated, he had seen cockroaches in his room.
During a facillty tour on 12/7/23, at 10: 10:25 a.m., with HS, in the nursing station three, room Q, leftover foods on a plate placed on the resident ' s bed were seen.
During furhter facility rounds and interview on 12/7/23, at 10: 35 a.m., with HS, in the nursing station one, room G, Resident 10 stated, he had seen cockroaches in his room longtime ago, and also recently, can not remember the date. At 10: 36 a.m., in the nursing station one , room H, Resident 11 stated, he had seen cockroaches in his room. At 10: 37 a.m., in the nursing station one, room I, Resident 12 confirmed there is still existing issue on cockroaches at the facility, not resolved, and his roommate, Resident 13 stated, he had seen cockroaches in the bathroom. At 10:40 a.m., in the nursing station one, room J, Resident 14 stated, she had seen cockroaches in the bathroom. At 10: 41 a.m., in the nursing station one of room K, Resident 15 and 16 stated, they had seen cockroaches in the bathroom and one-time cockroaches were found in Resident 16's drawer.
During further facility rounds and interview on 12/7/23, at 11a.m., with HS, in the nursing station six, room L, Resident 17 and 18 stated, they just saw cockroaches in their room recently. At 11:05 a.m., in the nursing station six, room M, Resident 19 stated, he had seen cockroaches weeks ago and facility ' s staff did not take any actions. At 11:15 a.m., in the nursing station six, room N, Resident 3 stated, he just saw cockroaches in the other resident ' s room recently. At 11:30 a.m., in the nursing station six , room O, Resident 2 stated, he had seen cockroaches on his bed board and curtains recently.
During an interview on 12/7/23, at 11:45 a.m., with the HS, the HS confirmed having heard all the residents' statements and claims that they have seen cockraches in the building recently, and the on-going issues/concerns that cockroaches were seen in the rooms, bathrooms and other areas that were not resolved during environmental rounds with her. The HK claimed, the building is big and it was difficult to keep the rooms clean because the residents were non-compliant with keeping food in their rooms, and these could have contributed to the presence of insects and roaches in the facility.
During an interview on 12/8/23, at 12: 45 p.m., with Resident 1, in the nursing station five, room P, Resident 1 claimed he recently reported to staff the presence of cockroaches in his room; however, the facility did not communicate with him any action taken or confirm when the pest control service would come to spray his room.
During an interview on 12/11/23, at 1:30 p.m., with the administrator, he stated, pest control services were provided monthly, and since May 2023, the facility had changed contracts for pest services to another Pest control company. However, based on the residents' statements and claims, and observations during facility rounds with the HS, the monthly pest control services seemed not adequate and effective at this time.
Review of the facility's undated policy and procedure (P&P) titled, Pest Control, it indicated, Routine inspections are conducted at the Company for evidence of pests. Insect or pest sightings should be reported to the Housekeeping/Maintenance supervisor.
Report the following insect or pest related information: type of problem, location, person reporting, and time reported . Train employees on preventive measures, unsanitary conditions, etc . Clean up food spills promptly. Store dry food stuffs in closed containers or bins, including food in resident rooms. Keep facility grounds free of trash and brush .
Oct 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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed submit an investigation summary within 5 working days to the California Department of Public Health (CDPH, state survey agency) regarding an a...
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Based on interview and record review, the facility failed submit an investigation summary within 5 working days to the California Department of Public Health (CDPH, state survey agency) regarding an alleged physical abuse incident that occurred between a certified nursing assistant A (CNA A) and one of two sampled residents (Resident 1). This failure had the potential to delay the facility's recommendation for action to ensure the safety for Resident 1.
Findings:
Review of Resident 1's Change in Condition Narrative Notes, dated 9/5/23, indicated an incident had occurred between her and CNA A. The documentation indicated, Resident 1 accusing CNA A of hitting her right forearm with the bed control. No bruise/swelling noted. It also indicated the medical doctor MD), responsible party (RP), law enforcement agency, and Department of Health Services (DHS) were notified.
Review of the final investigation transmittal report from the facility indicated the report was faxed to CDPH on 9/15/23. It was more than 5 days since from the date of incident of the allegation of physical abuse incident between CNA A and Resident 1 on 9/5/23.
During an interview with the administrator (ADM) on 10/27/23 at 10:44 a.m., he stated he did not find a confirmation of transmittal report that the final report was faxed within 5 days after the incident of allegation of abuse between CNA A and Resident 1 on 9/5/23.
Review of the facility's undated policy and procedures Abuse Investigation & Reporting, indicated the Administrator, and or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of incident.
Oct 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the conservator (a responsible adult who manages the daily l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the conservator (a responsible adult who manages the daily life and/or finances of an adult, who is unable to adequately care for themselves because of a cognitive or physical disability) for one of three residents (Resident 1) when there was an incident that Resident 1 reported Resident 2 punched her underneath the left side of her breast and Resident 2's conservator was not notified of the incident.
This failure resulted in Resident 2's conservator not being informed of the incident and any possible change in Resident 2's condition.
Findings:
Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE].
Review of Resident 2's admission Record indicated he was admitted to the facility on [DATE], and he had a conservator.
Review of Resident 1's Observation Detail List Report, dated 4/26/23, indicated, Resident 1 reported that Resident 2 hit her repeatedly because he stated she was in his way, and she could not move.
During an interview with thre director of nursing (DON) on 9/29/23 at 4 p.m., she reviewed Resident 2's clinical record and confirmed Resident 2's conservator was not notified of the incident. The DON stated Resident 2's conservator should have been notified.ir. Resident 1 swung trying to hit him, and he stopped her from hitting him. However, there was lack of indication that Resident 2's conservator was notified of the incident htat happened on 4/26/23. The report indicated, No to the question if the Resident Representative was notified.
During an interview with the director of nursing (DON) on 9/29/23 at 4 p.m., she reviewed Resident 2's clinical record and confirmed Resident 2's conservator was not notified of the incident that happened on 4/26/23. The DON stated Resident 2's conservator should have been notified.
Review of the facility's undated policy, Resident-to-Resident Altercations, indicated Procedure: . 2. If two residents are involved in an altercation, staff will: . c. Notify each resident's resident representative and Attending Physician of the incident.
Aug 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected multiple residents
Based on observation, interview, and policy review, the facility failed to provide care in a manner that maintained the dignity and respect for four of six residents (1, 2, 3, and 4) when certified nu...
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Based on observation, interview, and policy review, the facility failed to provide care in a manner that maintained the dignity and respect for four of six residents (1, 2, 3, and 4) when certified nursing assistant A (CNA A), CNA B, and CNA C double diapered ( two diapers were used at the same time, one diaper over the other diaper) for Resident 1, Resident 2, Resident 3, and Resident 4. This failure had the potential to cause embarrassment to the residents and negatively affect the residents' self-esteem.
Findings:
During an observation with CNA A on 8/29/23 at 1:45 p.m., Resident 1 was double diapered. CNA A stated other CNAs told her to put on two diapers for Resident 1.
During an interview with CNA A on 8/29/23 at 2:10 p.m., CNA A acknowledged she should put on only one diaper for the residents.
During an observation and interview with CNA B on 8/29/23 at 2:30 p.m., Resident 2 had a rolled-up diaper placed on his genital area; a second diaper was on top of it and wrapped around his hip. CNA B stated other CNAs told him to put on two diapers for Resident 2. CNA B acknowledged he should put on only one diaper for the residents.
During an observation with CNA C on 8/29/23 at 2:45 p.m., Resident 3 was double diapered.
During an observation and interview with CNA C on 8/29/23 at 2:50 p.m., Resident 4 was double diapered. CNA C stated most of the residents were double diapered. CNA C stated she acknowledged she should put on only one diaper for the residents, but other CNAs told her to put on two diapers for the residents.
During an interview with the director of staff development (DSD) on 8/30/23 at 4:35 p.m., the DSD stated CNAs should have put on only one diaper for the residents.
Review of the facility's undated policy, Adult Briefs and Underpads, indicated Purpose: To provide cleanliness, comfort to the resident, and to prevent physiological complications . Procedure: . 3. Remove adult brief or underpad from resident . 5. Reapply a clean adult brief or underpad.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and policy review, the facility failed to observe proper infection control practices when laundry aid D (LA D) transferred soiled linen and clothing from the hamper to...
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Based on observation, interview, and policy review, the facility failed to observe proper infection control practices when laundry aid D (LA D) transferred soiled linen and clothing from the hamper to the yellow laundry bin in the hallway. This failure had the potential to result in transmission of infection and recontamination among residents and staff.
Findings:
During an observation on 8/29/23 at 1:25 p.m., LA D was observed transferring soiled linen and clothing from the hamper to the yellow laundry bin in the hallway in front of the storage room. There were several residents and staff present in the hallway.
During a concurrent interview with LA D, he acknowledged he should have transferred the soiled linen and clothing from the hamper to the yellow laundry bin inside the storage room and not in the hallway.
During an interview with the infection preventionist (IP) on 8/30/23 at 1:30 p.m., she stated the laundry aids should transfer the soiled linen and clothing from the hamper to the yellow laundry bin inside the storage room and not in the hallway.
Review of the facility's undated policy, Laundry Handling Practices, indicated Purpose: Proper handling of linen and laundry will reduce the likelihood of recontamination. Procedure: Use Standard Precautions in the handling of all soiled laundry.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and policy review, the facility failed to ensure Resident 1 had a clean, safe environment when there were dry feces on the floor next to his bed. This failure had the ...
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Based on observation, interview, and policy review, the facility failed to ensure Resident 1 had a clean, safe environment when there were dry feces on the floor next to his bed. This failure had the potential to negatively affect Resident 1 ' s self-esteem and to place the residents at risk of cross contamination.
Findings:
During an observation on 7/26/23 at 2:45 p.m., Resident 1 was lying in bed, and there were two spots of dry feces on the floor next to his bed.
During an interview with licensed vocational nurse A (LVN A) on 7/26/23 at 2:50 p.m., she confirmed the two spots on Resident 1 ' s room floor next to his bed were dry feces. LVN A stated the resident rooms should be kept clean.
Review of the facility ' s undated policy, Maintaining a Clean Environment, indicated, Items that collect dust or secretions may harbor microorganisms that can colonize and infect susceptible residents or be inhaled by employees performing cleaning tasks . Procedure: 1. Establish a routine schedule for cleaning walls, floors, windows, window frames, fixtures, and furniture. Clean obviously soiled items/areas between scheduled times.
Jul 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP, person designated to make decisio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party (RP, person designated to make decisions on behalf of a resident) about the x-ray result for one of three sampled residents (Resident 1). This failure had the potential to affect the ability of the RP to participate in Resident 1's treatment and care.
Findings:
A review of Resident 1's clinical record indicated she was admitted on [DATE] and had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and mental functions), dementia (mental disorder caused by brain disease or injury), hypertension (high blood pressure), and schizoaffective disorder (a mental disorder). The clinical record indicated Resident 1 was not self-responsible but had a designated RP.
During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem)- fall, dated 3/09/23, the SBAR indicated she fell, and the physician ordered left knee X-ray (a type of radiation used in the diagnosis of diseases) for pain.
During a review of Resident 1's physician's order, dated 3/09/23, the order indicated left knee X-ray.
During a review of Resident 1's nurse's note, dated 3/09/23 and signed by licensed vocational nurse A (LVN A), it indicated Resident 1's physician ordered left knee X-ray and that the order was noted and carried out.
During a review of Resident 1's Radiology report, dated 3/09/23, the Radiology report indicated left knee X-ray was done on 3/09/23, and the result indicated No acute abnormality is evident.
During a review of Resident 1's clinical record, it indicated that there was no documentation indicating Resident 1's RP was notified about the X-ray result.
During a concurrent interview and record review on 5/18/23 at 1:20 p.m. with the Director of Nursing (DON), she confirmed that there was no evidence Resident 1's RP was notified about Resident 1's X-ray result. The DON stated that nurses should have notified Resident 1's RP regarding the X-ray result.
During a phone interview on 5/16/23 at 3:07 p.m. with Licensed Vocational Nurse A (LVN A), she stated she carried out the X-ray order, but she could not recall if she notified Resident 1's RP of the X-ray result. LVN A stated the X-ray result should have been notified to Resident 1's RP.
During a review of the facility's undated policy and procedure titled Changes in Resident Condition, indicated, The resident, attending physician and resident representative are notified when changed in condition or certain events occur.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards f...
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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 were free of accidents and hazards for one of three sampled residents (Resident 2) when staff did not accurately complete Resident 2's Safe Smoking Assessment. This failure had the potential to result in serious injury to the Resident 2 in the facility.
Findings:
1. Review of Resident 2's clinical record indicated Resident 2 was admitted on [DATE] and had diagnoses including stress fracture of right tibia (broken leg bone from repetitive stress), multiple fractures of left side ribs (broken rib cage bones), and traumatic hemothorax (a collection of blood in the space between the chest wall and the lung).
During a review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 4/19/23, the MDS indicated he had a brief interview of mental status (BIMS, a structured cognitive test) scoring 15 (cognitively intact).
Review of Resident 2's Safe Smoking Assessment, dated 4/12/23, indicated it was answered as no for the question Does the resident smoke? If no, do not proceed with assessment, and further questions were left blank. The Safe Smoking Assessment was completed and signed by Licensed Vocational Nurse B (LVN B).
Review of Resident 2's Activity Assessment, dated 4/13/23, indicated it was marked, Smokes Cigarettes for the question Does resident use any of the following? . The Activity Assessment was completed and signed by Activity Assistant C (AA C).
Review of Resident 2's Nursing Home admission Note, dated 4/13/23, indicated Smoking: 50 pack/years, Smoking Cessation counseling.
Review of Resident 2's Progress Note, dated 5/01/23, indicated Smoking: smoking1-3 cigarettes a day, Encouraged cession.
Review of Resident 2's Nurses notes, dated 5/14/23, included resident inside the O2 room with a lighter, resident on his wheelchair, holding a lighter, Police officers took resident outside the building, resident left via 911.
During a phone interview on 5/18/23 at 4:42 p.m. with AA C, she stated that Resident 2 was a smoker, and she observed the resident smoking outside of the facility.
During a phone interview on 5/18/23 at 4:53 p.m. with Certified Nursing Assistant D (CNA D), CNA D stated Resident 2 was a smoker, and she had observed the resident smoking in front of the facility.
During an interview and record review with the Director of Nursing (DON) on 5/18/23 at 5:10 p.m., the DON confirmed Resident 2's Safe Smoking Assessment, dated 4/12/23, indicated the resident was not a smoker, and there was no further Safe Smoking Assessment for Resident 2. The DON stated she didn't know Resident 2 was a smoker or how the resident acquired a lighter. The DON acknowledged that Resident 2's Safe Smoking Assessment was an incorrect and should ahve reflected Resident 2 was a smoker.
During an interview and record review with the Assistant Director of Nursing (ADON) on 7/11/23 at 10 a.m., the ADON confirmed Resident 2's Safe Smoking Assessment, dated 4/12/23, indicated the resident was not a smoker, and the assessment was an inaccurate The ADON stated there should have been a further Safe Smoking Assessment for Resident 2 to correct his smoking status.
During a review of the facility's undated policy and procedure titled Smoking Policy, the policy indicated A safe Smoking Assessment is going to be completed to ensure safety of residents who may smoke and residents other than smokers. The purpose of the smoking safety assessment is to identify risk factors indicating the resident's ability to smoke safely.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and record review, the facility staff failed to check the placement and functioning of one of 2 sampled residents (Resident 2) wanderguard bracelet (a device applied ...
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Based on observation, interviews, and record review, the facility staff failed to check the placement and functioning of one of 2 sampled residents (Resident 2) wanderguard bracelet (a device applied on a resident and will activate an alarm system when the resident tries to leave the facility.) This failure had the potential to affect the safety and well-being of Resident 2, who was identified as an elopement risk.
Findings:
During a review of Resident 2's clinical record, indicated, resident had diagnoses including difficulty in walking, altered mental status (change in mental function that stems from illnesses, disorders and injuries affecting the brain), homelessness, and alcohol abuse.
During a review of Resident 2's Elopement Risk Assessment, dated 1/4/2023, the Elopement Risk Assessment indicated, Resident 2 was at risk of elopement. The observation details including ambulatory and wandering without purpose.
During a review of Resident 2's Care Plan, dated 3/6/2023, the Care Plan indicated, Resident 2 was at risk for elopement and wandering out of the facility due to diagnosis of Alcohol Abuse, ALOC (altered level of consciousness). Resident 2's interventions included to provide activities that will divert resident's attention from wandering, check resident's whereabouts, wander-guard bracelet and check alarm for functioning.
During a review of Resident 2's Medication Administration Record (MAR), dated 4/16/2023, the MAR indicated, Licensed Vocational Nurse (LVN) documented during the 7:00 a.m.- 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shift that Resident 2 had a wander guard, and LVN documented the device was monitored for proper placement and battery function.
During a review of Resident 2's Elopement Risk Identification Form, located in the Elopement Risk Binder on the receptionist desk, the Elopement Risk Identification Form indicated, Resident 2 had a wander guard.
During a review of Resident 2's Progress Note, dated 4/16/2023, the Progress Note indicated, Resident 2 was not in the room at 9:00 p.m. Resident 2 was last seen by the lobby at 6:00 p.m. Searched around the building and neighboring areas. Resident 2 signed out on pass by the receptionist.
During an interview on 4/19/2023, at 1:14 p.m., with Certified Nursing Assistant (CNA), the CNA assigned to the front desk on 4/16/2023 stated that she witnessed Resident 2 signing out but did not hear the alarm go off. The CNA also admitted to not checking the Elopement binder that was on the receptionist desk.
During an interview on 4/19/2023, at 2:30 p.m., with the LVN, she acknowledged not checking the placement and functioning of the wander guard device on Resident 2, despite documenting in the MAR that it was checked during her shift.
During an interview on 6/6/2023 at 3:30 p.m., with the Director of Nursing (DON), she stated Resident 2's wander guard should have been monitored for placement and functioning as indicated on resident's MAR and plan of care.
During a review of the facility's undated policy and procedure (P&P) titled, Wander Elopement Alarm System Testing, the P&P indicated, Document verification of placement and test for all signaling devices (wristbands) daily. Many find it most convenient to do this during medication passes and to record the test results on the medication administration record.
During a review of the facility's undated policy and procedure (P&P) titled, Resident Elopement, the P&P indicated, The company will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for Elopement.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow their policy and procedure for investigating and reporting allegations of abuse for three of four sampled residents (R...
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Based on observation, interview, and record review, the facility failed to follow their policy and procedure for investigating and reporting allegations of abuse for three of four sampled residents (Resident 1, Resident 2, and Resident 3) when:
1. The facility determined Resident 2 was verbally abusive towards Resident 1 and did not separate Resident 2 from Resident 1 in a shared room;
2. Resident 2 complained of feeling threatened and the facility did not report to any state agency;
3. Resident 3 complained of being fed too quickly and the facility failed to conduct a thorough investigation.
These failures had the potential for the residents not to be protected from any potential physical, mental, and psychological abuse.
Findings:
1. Record review of Resident 1's face sheet, undated, indicated Resident 1 had Alzheimer's disease (a progressive disease that destroys memory and other mental functions), reduced mobility (weakness and loss of ability to move freely) , and glaucoma (eye condition that can cause blindness).
Record review of Resident 1's Brief Interview for Mental Status (BIMS; mandatory assessment tool used to screen and identify the cognitive condition of the resident), dated 11/12/2022, indicated Resident 1's BIM's score was 3 which indicated severe impairment.
Record review of Resident 2's face sheet, undated, indicated Resident 2 had type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar) and pancreatic cancer (cancer in the organ lying behind the lower part of the stomach).
Record review of Resident 2's BIMS assessment, dated 12/4/2022, indicated Resident 2's BIM's score was 14 which indicated Resident 2 was cognitively intact.
During an observation and interview with Resident 2, on 1/19/2023 at 4:26 p.m., Resident 2 was sitting at her bedside in a chair. Resident 2 stated she did not like Resident 1 and stated Resident 1 has Alzheimer's and forgets everything. She stated she called Resident 1 .stupid and stated was annoyed by her because she is confused, doesn't make sense, and will ask for her mother who is no longer living. Resident 2 stated she also asked her if she was stupid. During this interview, Resident 1 asked why the closet door would not shut, and Resident 2 stated .see what I mean? She is an idiot Resident 2 stated the facility investigated if she called Resident 1 any derogatory names, and she stated she told staff she did. Resident 2 stated she was offered a room change but chose not to move because she liked having her bed near the window.
During an interview with the Administrator (ADM), who was also the facility's abuse coordinator, on 1/19/2023 at 1:40p.m., the ADM indicated Resident 1's family reported Resident 2 called Resident 1 .stupid. The ADM indicated Resident 2 admitted she called Resident 1 .stupid. He said neither Resident 1 nor Resident 2 wanted to move rooms, so they did not separate Resident 1 or Resident 2. He confirmed family of Resident 1 wanted Resident 2 moved from the shared room.
During an interview with the ADM, on 1/30/2023 at 10:00 a.m., he indicated he considered Resident 2 calling Resident 1 a derogatory name like .stupid was verbal abuse. He stated he spoke with Resident 2 and asked her to not talk to Resident 1 in this manner and he told her one of them should move out of the shared room. He stated Resident 2 declined to move to another room.
During an interview with the Social Services Assistant (SSA), on 1/19/2023 at 2:47 p.m., the SSA indicated Resident 2 calling Resident 1 .stupid was verbal abuse.
During an interview with the Ombudsman, on 1/19/2023 at 2:17 p.m., the Ombudsman indicated she was unsure why Resident 2 had a choice on being moved and confirmed she considered the name calling to be verbal abuse and that to prevent any potential future abuse the residents should be separated.
Review of facility policy Abuse, Neglect, & Exploitation, undated, indicated each resident had the right to be free from abuse and indicated this included verbal abuse which was defined as language that willfully includes disparaging and derogatory terms to residents. The Policy indicated the facility would protect residents from future harm.
2. During an interview with the Social Services Assistant (SSA), on 1/19/2023 at 2:47 p.m., the SSA indicated Resident 2 wrote a letter to the social services department stating she felt threatened by Resident 1's family. She indicated this was not reported to any state agency nor was any investigation by the facility conducted. The SSA confirmed if a resident reported feeling threatened this was considered an allegation of abuse and should be reported to state agencies. She further acknowledged an investigation should have been conducted.
During an observation and interview with Resident 2, on 1/19/2023 at 4:26 p.m., Resident 2 was observed sitting at the bedside in a chair. Resident 2 stated she reported feeling threatened by Resident 1's family. She stated the family member told her .I don't want you talking about or to my mom. If you say anything to my mom, you'll hear from me. Resident 2 indicated she wrote a letter detailing the concerns and gave it to the SSA and Social Services Director (SSD).
Record review of the letter Resident 2 wrote and submitted to the Social Services SSA and SSD, dated 1/9/2023, indicated on 1/8/2023 at around 3:30 p.m., Resident 1's daughter came to her side of the room and stated she did not want Resident 2 to talk to Resident 1 or she would hear from her. The note further indicated she felt the encounter was .threatening.
During an interview with the ADM, on 1/30/2023 at 10:00 a.m., the ADM indicated he did not report the letter Resident 2 wrote to any state agency and confirmed he did not conduct any investigation into the abuse allegations. He indicated it should have been reported if Resident 2 felt threatened.
Review of facility policy Abuse, Neglect, & Exploitation, undated, indicated each resident has the right to be free from abuse. The Policy further indicated the facility will report all allegations to the state as per the state regulation, and the facility will investigate any allegation of abuse. The Policy indicated the facility would protect residents from harm.
Review of facility policy Abuse & Neglect Prohibition California Addendum, undated, indicated the facility staff were all mandated reporters and were required to report any allegations of abuse to state agencies.
3. Record review of Resident 3's face sheet, undated, indicated Resident 3 had a history of type 2 Diabetes Mellitus and a stroke (disrupted brain flow to the brain causing damage), and dysphagia (difficulty swallowing).
Record review of Resident 3's diet order, dated 3/3/2023, indicated he was on a mechanical soft diet with extra moistened food and nectar thickened liquids. Resident 3 was on a one-to-one feeding program and dependent on staff for feeding and required prompts to swallow.
Review of the facility's final report of the allegation of abuse, dated 1/10/2023, indicated the facility investigated an allegation of Resident 3 being fed too quickly.
During an interview with the Nursing Supervisor (NS), on 3/23/2023 at 11:25, the NS indicated he recalled the incident where Resident 1 was being fed too fast and that Resident 3 requested to slow down were ignored. He added I gathered he did not like it. He said he did not recall which day it was or which certified nursing assistant (CNA) was feeding Resident 3. The NS stated he assessed Resident 3's mouth for swelling after being fed too fast.
During an interview with the Director of Staff Development, on 3/23/2023 at 11:41 a.m., she indicated she conducted the abuse investigation and stated the allegation occurred between 12/30/2022 to 1/1/2023, but was unable to determine which day or shift. She stated she interviewed one CNA who assisted with feeding Resident 3. She confirmed five other CNA's worked and fed Resident 3 were not interviewed.
During an interview with the ADM, on 3/23/2023 at 10:51 a.m., he stated he could not find the investigation report that was conducted regarding Resident 3 and the allegation of abuse.
Review of facility policy Abuse, Neglect, & Exploitation, undated, indicated each resident has the right to be free from abuse. Policy further indicated the facility will report all allegations to the state as per the state regulation, and the facility will investigate of any allegation of abuse. The Policy indicated the facility would protect residents from harm.
May 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) a safe and effective transition of care when Resident 1 was:
1. discharged ...
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Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) a safe and effective transition of care when Resident 1 was:
1. discharged home without a concrete start date for home health services to begin upon discharge and without following up post discharge;
2. discharged home without physician ordered long-acting insulin (medication to lower blood sugar).
These failures resulted in Resident 1 being discharged on 12/20/2022 with a delay in initiation of post-discharge follow up by a home health care agency. These failures also had the potential to result in Resident 1 and family member to feel anxious and overwhelmed with the discharge process.
Findings:
1. During an observation and concurrent interview with Resident 1, on 1/17/2023 at 11:58 a.m., Resident 1 was resting in bed. Resident 1 indicated she had been readmitted to the skilled nursing facility from the local acute care hospital after a hospitalization from a pressure ulcer on her sacral area, a urinary tract infection (UTI; bladder infection), and a cough. Resident 1 stated .I was home about 4 days. I was coughing. I got some new sores on my bottom. My bladder bag (urinary bag) began to leak a lot. My thighs were red and raw. Home health never came. I had to go to the hospital. There was no one to take care of me. My sister couldn't do it. She was just in town to visit.
During record review of Resident 1's facility discharge note, dated 12/20/2022, the note indicated Resident 1 was discharged home to an apartment in the community on 12/20/2022. The Discharge note further indicated a local home health care would provide care to Resident 1. The Discharge note did not indicate when services would begin.
During a concurrent interview and record review with the social services director (SSD), on 1/12/2023 at 10:30 a.m., the SSD confirmed Resident 1's discharge care plan, dated 12/20/2022, did not indicate any scheduled time or date for home health services to start.
During an interview with the Social Services Director (SSD), on 1/11/2023 at 1:35 p.m., the SSD confirmed the facility was responsible for planning and safely discharging residents. She confirmed she did not know when the home health was to start providing care on discharge and confirmed Resident 1 would have required care the day of discharge. The SSD confirmed she did not follow up regarding home health, caregiver, or with the family after Resident 1 was discharged . The SSD stated she did not know home health's schedule and stated she did not confirm when they would start providing care for Resident 1. The SSD stated she .should have had more concrete discharge planning given the high dependency for care.
During an interview with the administrator (ADM), on 1/17/2023 at 11:45 a.m., the ADM confirmed the facility was responsible for safe discharge plans.
During a record review of Resident 1's acute care facility's history and physical notes, dated 12/26/2022, the note indicated Resident 1 was discharged from the skilled nursing facility without having established home health, physical therapy, and occupational therapy care for Resident 1. Notes indicated family was in from out of town and they were unable to care for Resident 1 due to Resident 1 being total care (another person(s) is responsible for meeting nearly all needs and must perform nearly all personal care). The notes indicated Resident 1 and Resident 1's family were unable to transfer patient or manage her wounds on their own. The notes indicated the acute care hospital's plan was to seek placement in a skilled nursing facility, to control blood sugars with insulins, resolve the leaking urinary catheter which was causing skin maceration on the skin of the inner thighs, to treat likely viral bronchitis with medications and breathing treatments, and to treat sacral decubitus ulcers on the coccyx.
Record review of facility policy Post Discharge Plan of Care, undated, indicated pre and post discharge planning would be coordinated by the social services department to ensure the resident's needs are met before and after discharge from the facility into the community. The policy further indicated the SSD in conjunction with the care team determined the individual needs, resources, and services required upon discharge and will arrange for post discharge services.
Record review of facility policy Social Service Documentation, undated, indicated the social services staff will provide documentation of accurate resident information including referrals to the community and discharge planning.
Record review of facility job description for Social Service Director, dated 10/1/2003, indicated the SSD was responsible for the coordination of discharge planning for the residents.
Record review of facility policy Referral to Outside Agency, undated, indicated .referrals that will meet the concrete needs of a resident. The policy further indicated the social services staff would make an appointment for the resident with appropriate outside agencies.
2. During an observation and interview with Resident 1, on 1/17/2023 at 11:58 a.m., Resident 1 was resting in bed. Resident 1 indicated she was discharged home without her insulin. Resident 1 stated the skilled nursing facility said they did not have it. Resident 1 further indicated she was discharged without physician ordered prescriptions for the insulin.
During an interview with Resident 1's family member (FM), on 1/11/2023 at 12:07 p.m., she indicated the facility did not provide any long-acting insulin upon discharge. The FM indicated she asked Resident 1's primary nurse about the parameters used to determine if she should always administer the long-acting insulin and how to administer an injection. The FM stated the nurse told her she was not sure what the parameters were, and she did not provide any education or demonstration on administering the injection. FM stated she had to take Resident 1 to the local acute care hospital to get an insulin order.
Record review of Resident 1's physician orders, dated 10/26/2022, indicated 34 units of insulin glargine via the insulin pen was to be administered at bedtime at 9:00 p.m. daily.
During an interview with Licensed Vocational Nurse (LVN) A, on 1/11/2023 at 1:43 p.m., LVN A indicated she discharged Resident 1 from the skilled nursing facility. She indicated .I told the family we didn ' t have the insulin. I said to follow up with her regular doctor.
During an interview with the ADON, on 1/11/2023 at 1:14 p.m., the ADON confirmed there was no documentation of the long-acting insulin sent home with Resident 1 on discharge. The ADON indicated a prescription should have been called into the pharmacy or a prescription or a paper copy should have been provided to Resident 1 at discharge. The ADON confirmed neither was done on the day of discharge.
During an interview with Resident 1's Facility Physician (MD), on 1/11/2023 at 1:53 p.m., the MD indicated the staff should have notified her the facility did not have insulin to discharge with the patient. She indicated she would have either called a local pharmacy and given a telephone order for the insulin or stated the facility could have called in an order for Resident 1 with the MD authorization. The MD confirmed there was no change to the medication order and indicated she intended for Resident 1 to continue the medication upon discharge. The MD confirmed the physician order of 34 units of insulin glargine via the insulin pen to be administered at bedtime at 9:00 p.m. daily.
During an interview with the Social Services Assistant (SSA), on 1/11/2023 at 11:51 a.m., the SSA indicated the facility either discharges a resident home with a month supply of medication or will call in the physician ordered medication to a local pharmacy.
Record review of facility policy Referral to Outside Agency, undated, indicated the social services staff would document in the resident's medical record any physician's orders or telephone orders for discharge to ensure continuity of care.
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two residents (1) receive the necessary...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two residents (1) receive the necessary care and services to attain or maintain the skin integrity when certified nursing assistant A (CNA A) identified an open skin and two scratches on Resident 1's left lower leg but did not report them to the licensed nurse to initiate the treatment. This failure had the potential to result in Resident 1's wounds getting worse and infected.
Findings:
Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including diabetes (a chronic disease characterized by elevated levels of blood sugar), and rash and other nonspecific skin eruption.
Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 2/16/23, indicated his cognition was intact.
During an observation and interview on 3/10/23 at 11:50 a.m., Resident 1 was noted with an open skin and two scratches with dry blood on his left lower leg. Resident 1 stated he had the open skin and scratches about a week ago. However, review of Resident 1's clinical record indicated the lack of documentation, assessment, and treatment for his open skin and scratches.
During an interview with CNA A on 3/10/23 at 1:40 p.m., CNA A stated he worked with Resident 1 yesterday. He saw the open skin and two scratches on Resident 1's left lower leg, but he did not report them to the licensed nurse. CNA A stated he should have reported the open skin and two scratches on Resident 1's left lower leg to the licensed nurse.
Review of the facility's 2011 Interact Tool, Stop and Watch Early Warning Tool, indicated If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can: . Change in skin color or condition .
Based on observation, interview, and record review, the facility failed to ensure one of two residents (1) receive the necessary care and services to attain or maintain the skin integrity when certified nursing assistant A (CNA A) identified an open skin and two scratches on Resident 1's left lower leg but did not report them to the licensed nurse to initiate the treatment. This failure had the potential to result in Resident 1's wounds getting worse and infected.
Findings:
Review of Resident 1's admission Record indicated he was admitted to the facility on [DATE] with diagnoses including diabetes (a chronic disease characterized by elevated levels of blood sugar), and rash and other nonspecific skin eruption.
Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 2/16/23, indicated his cognition was intact.
During an observation and interview on 3/10/23 at 11:50 a.m., Resident 1 was noted with an open skin and two scratches with dry blood on his left lower leg. Resident 1 stated he had the open skin and scratches about a week ago. However, review of Resident 1's clinical record indicated the lack of documentation, assessment, and treatment for his open skin and scratches.
During an interview with CNA A on 3/10/23 at 1:40 p.m., CNA A stated he worked with Resident 1 yesterday. He saw the open skin and two scratches on Resident 1's left lower leg, but he did not report them to the licensed nurse. CNA A stated he should have reported the open skin and two scratches on Resident 1's left lower leg to the licensed nurse.
Review of the facility's 2011 Interact Tool, Stop and Watch Early Warning Tool, indicated If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can: . Change in skin color or condition .
Mar 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three residents (1) receive the necessa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three residents (1) receive the necessary care and services to attain or maintain the skin integrity when Resident 1's bruises were not documented, assessed, and care planned. This failure had the potential to result in Resident 1's bruises getting worse and leading to open wounds for the resident.
Findings:
Review of Resident 1's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including dementia (a condition characterized by loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), lack of coordination, abnormalities of gait and mobility, muscle weakness, reduced mobility, and disorder of muscle.
Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 11/12/22, indicated her cognition was severely impaired.
During an observation on 3/1/23 at 12:35 p.m., Resident 1 was noted with one bruise on her right elbow, one bruise on her right forearm, two bruises on her left upper arm, one bruise on her left forearm, two bruises on her left thigh, and two bruises on her right knee. However, review of Resident 1's clinical record indicated the lack of documentation, assessment, and care plan for her bruises.
During an observation with the director of nursing (DON) on 3/3/23 at 2:50 p.m., the DON confirmed Resident 1 had one bruise on her right elbow, one bruise on her right forearm, two bruises on her left upper arm, one bruise on her left forearm, two bruises on her left thigh, and two bruises on her right knee.
During a concurrent interview with certified nursing assistant A (CNA A), she stated Resident 1 had those bruises since 3/1/23 when she first worked with Resident 1, and the CNA who worked with Resident 1 in 2/2023 endorsed to her that Resident 1 had already had the bruises since 2/2023, and they were reported to the licensed nurse.
During an interview with the DON on 3/3/23 at 3:20 p.m., the DON stated she had already reviewed Resident 1's clinical record and confirmed that there were no documentation, assessment, and care plan found for Resident 1's bruises. The DON stated Resident 1's bruises should be documented, assessed, monitored, and care planned.
Review of the facility's undated policy, Pressure Ulcer and Skin Care Management, indicated . Procedure: 1. A licensed nurse checks the resident's body for the presence of pressure ulcers, wounds, and other skin conditions: . c. weekly on all residents, . 2. The licensed nurse documents that the body check was completed on the resident's medication and treatment administration record. 3. The presence of any pressure ulcer, wound, or other skin condition is documented weekly on pressure ulcer or skin report forms, in the progress notes, and care plan . 10. A licensed nurse completes a pressure ulcer or skin report when a pressure ulcer, wound, or other skin condition is identified, and weekly until healed .
Jan 2023
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition when:
1. The dishmachine has not been function...
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Based on observation, interview, and record review the facility failed to ensure essential kitchen equipment was maintained in a safe operating condition when:
1. The dishmachine has not been functioning properly since July 2022,
2. The right-hand side of the three-compartment sink in the dishwashing room was leaking onto the floor, and
3. The mixing valve for the sanitizer at the three-compartment sink was not mixing properly.
These failures resulted in the facility using disposable containers to serve every meal for approximately six months (cross reference F804), had the potential to result in a safety hazard of a wet floor in the dishroom, and had the potential to result in improper strength of the sanitizing solution (used for sanitizing food service and preparation equipment and surfaces) which could result in foodborne illness among residents receiving food from the kitchen.
Findings:
1. During an observation on 1/18/23 starting at 11:46 am of the lunch meal service, all meals were being served on disposable foam clamshell containers. During a concurrent interview at that time, Foodservice Worker E (FSW E) confirmed the observation stating the dish machine is not reaching the right temperature.
During an interview on 1/18/23 at 12:02 pm, Foodservice Worker B (FSW B) stated the kitchen has been using disposable foam trays for a long time to serve all resident meals because the dish machine is not up to the right temperature. During a concurrent interview at that time, Dietary Manager (DM) confirmed that since last year, about last June or July 2022, they have been using disposable containers to serve all meals to residents. She stated the dish machine is a high temperature dish machine and the part needed to fix the dish machine is on back order and the dish machine does not get hot enough to sanitize the dishes. She further stated they run the pots and pans and any other equipment (meal trays, serving utensils etc) used to prepare or serve food through the dish machine then put them into the sanitizer solution in the three-compartment sink to sanitize them.
During an interview on 1/18/23 at 4:05 pm, the Administrator (Admin) stated the booster that heats the water is broken on the dish machine. At first, they thought it could be repaired but then it has to be replaced. The part that needs replacement is not available. Now they are thinking they will need to change the dish machine to a low temperature machine (one that sanitizes with chemicals instead of heat), but he is unsure if that means changing the whole dish machine out. He further stated he has been spending alot of money on foam containers to serve meals and confirmed it has been since July 2022 that they have been using disposable containers for all meals for residents because the dish machine is not functioning properly.
During an observation and concurrent interview on 1/18/23 at 4:34 pm, Admin was in the kitchen with Maintenance Assistant (MA) and DM at the dish machine. Admin stated he was seeing if the dish machine would reach the proper temperature. He said he was looking for it to reach 180°F (degrees Fahrenheit) and was holding a food thermometer in the edge of the dish machine as it ran. He stated the temperature gauges are not working on the machine and do not move when the dish machine is running. We then ran surveyor's thermometer through the dish machine and the highest temperature registered was 151°F. Admin and DM confirmed the dish machine is still not working properly. Admin stated the company that fixes the machine will be here first thing tomorrow.
During an observation and concurrent interview on 1/18/23 at 11:16 am, Food Service Worker A (FSW A) in presence of DM was calibrating thermometers in ice water (checking that thermometers are reading temperatures correctly and adjusted as needed). FSW A confirmed surveyor's thermometer was reading 31.8°F (ice water is 32°F) and was properly calibrated.
During a phone interview on 1/20/23 at 10:50 am, Maintenance Director (MD) stated he was aware of the dish machine's booster water heater not working and stated an outside company is responsible to maintain the machine and they have already tried to fix the booster. He stated there was a miscommunication with the company regarding the booster because sometimes it is working. He could not remember the exact date the dish machine stopped working properly but stated it has been awhile. He also stated the Admin plans to replace the vendor for the dish machine but has not done so yet.
Review of facility policy titled, Warewashing by hand, undated, indicated the purpose was to define a temporary procedure to be used if the dish machine is inoperable, under procedure indicated Follow the facility's preventative maintenance procedures for equipment repairs. Ensure prompt repair of the machine. Use disposable dishes until machine is operational. If the machine will be out of service for the remainder of the day, continue using disposable dishes and follow procedure for cleaning and sanitizing dishes in the pot and pan sink. Once the dish machine is repaired, wash and sanitize dishes.
2. During an observation on 1/18/23 at 11:02 am, the right-hand side of the three-compartment sink was full of soapy water and was leaking from the bottom of the drain onto the floor. The floor was wet all around the sink and there was a puddle of water on the floor near the sink in the dish room.
During a concurrent interview at that time, DM confirmed the observation and stated the sink should not be leaking and she would report it to maintenance.
During a phone interview on 1/20/23 at 10:50 am, Maintenance Director (MD) stated he was told about the leak at the sink on 1/18/23 and told staff to empty the sink when they leave so he could put sealant underneath to fix it. The sink needs to be dry in order to put the sealant on it so the work has to be done after work when the sink is not being used. He stated he had fixed the leak three months ago but it started leaking again. He stated the sink is still leaking now and has not been fixed.
3. During an observation and concurrent interview on 1/18/23 at 3:42 pm, DM was at the three-compartment sink demonstrating how to get sanitizer solution. DM put sanitizer from the mixing valve into a bucket then dipped the test strip for ten seconds into the solution. DM stated the chemical test strip should change to green, but was not changing color which meant there was no sanitizer. DM checked if the sanitizer was connected and changed to a fuller sanitizer container. Then tried again, getting the same result of no sanitizer detected by the test strip.
During an interview on 1/18/23 at 4:34 pm, Admin stated the company that fixes the mixer would be here first thing tomorrow.
During a phone interview on 1/20/23 at 10:50 am, Maintenance Director (MD) stated an outside company is responsible for fixing the sanitizer mixing valve not the maintenance department, and he did not know if they came yesterday to fix it.
During phone interview on 1/20/23 at 2:03 pm, DM stated the company responsible for fixing the mixing valve has not been out yet to fix it.
Review of facility policy titled Equipment Repair or Replacement, dated 11/1/18, indicated Equipment is repaired or replaced as necessary to ensure the safety and welfare of residents and employees, and Non-critical equipment is equipment whose failure would interrupt standard operational services. Examples include the following .dietary equipment, and Report needed repairs on the Repair Requisition form.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide food that is palatable and at an a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide food that is palatable and at an appetizing temperature. This failure had the potential to result in decreased intake thus further compromising the nutritional status of the 239 residents receiving food from the kitchen.
Findings:
During an interview on 1/18/23 at 12:18 pm, Resident #1 stated the food is ok taste wise, but it could be better, sometimes the food is too dry. Review of Resident #1's Minimum Data Set (MDS) Assessment Section C Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact).
During an interview on 1/18/23 at 12:22 pm, Resident #2 was eating lunch and when asked how the lunch is, he stated, it stinks, and the flavor is not there especially the meat, the mechanical meat is ground to a pulp. Review of Resident #2's Minimum Data Set (MDS) Assessment Section C Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 9 (moderately impaired).
During an interview on 1/18/23 at 12:25 pm, Resident #3 stated the food is alright but sometimes the hot food is cold when he gets it. He stated the microwave is too far away so if the food is warmed up, it is cold again by the time he gets it back. He further stated he adds tabasco and spices to it since it comes plain, and that the beverages sometimes are not cold enough. Review of Resident #3's Minimum Data Set (MDS) Assessment Section C Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 9 (moderately impaired).
During an interview on 1/18/23 at 12:25 pm, Resident #4 said the drinks are sometimes not cold enough and the vegetables are mushy and overcooked. Review of Resident #4's Minimum Data Set (MDS) Assessment Section C Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact).
During an observation on 1/18/23 starting at 11:46 am of the lunch meal service, all meals were being served on disposable foam clamshell containers. During a concurrent interview at that time, Foodservice Worker E (FSW E) confirmed the observation stating the dish machine is not reaching the right temperature.
During an interview on 1/18/23 at 12:02 pm, Foodservice Worker B (FSW B) stated the kitchen has been using disposable foam trays for a long time to serve all resident meals because the dish machine is not up to the right temperature. During a concurrent interview at that time, Dietary Manager (DM) confirmed that since last year, about last June or July 2022, they have been using disposable containers to serve all meals to residents. She stated the dish machine is a high temperature dish machine and the part needed to fix the dish machine is on back order and the dish machine does not get hot enough to sanitize the dishes.
Review of facility menu titled Fall/Winter 2022 on 1/18/23 at 11:14 am, posted in the kitchen indicated for lunch on 1/18/23 King Ranch Turkey, Mexican Rice, Cauliflower, Carrot Cake, margarine, coffee or tea, milk, Garnish of choice.
A test tray of regular and puree diets was requested on 1/18/23 at 1:52 pm.
On 1/18/23 starting at 2:31 pm after the last resident was served, an evaluation of the test tray was conducted with Dietary Manager (DM). There were two foam food containers one with regular foods: sliced turkey with gravy, cooked carrots, and plain rice; the other with puree turkey, puree cauliflower, and puree rice. No garnish was present. DM took temperatures of the foods on the test tray with a facility thermometer:
Regular Turkey with gravy 97.2°F (degrees Fahrenheit a unit of temperature measurement),
Regular [NAME] 97.3°F,
Carrots 107.2°F,
Puree Turkey 107.4°F,
Puree [NAME] 105.4°F,
Puree Cauliflower 103.8°F,
Reduced fat milk 54°F, and
Apple Juice 64.4°F,
The regular turkey and regular rice tasted cold with no warmth. The rice was chewy with some hard bits in it and tasted like plain rice with no seasoning. The turkey with gravy was very salty. The carrots were cool with taste of carrots but no seasoning. The puree turkey was cool had some flavor of plain turkey but was mushy and [NAME] texture. The puree rice was cool and had little flavor and a gluey texture. The puree cauliflower was cool but had good flavor of buttery cauliflower. The milk and apple juice were an ok temperature but not cold.
During an interview with DM at that time, DM stated the desired temperatures at service depend on resident preference and there are microwaves in each station where Certified Nursing Assistants can heat up the food if requested. She further stated her expectation for temperatures of hot foods at service is she would like to see at least 100°F. She stated the saltiness is the gravy, you have to add the gravy to the turkey and the rice to give them flavor - the saltiness balances out the blandness of the turkey and rice. She agreed the hot foods were cool, but said they are not cold like a cold drink. She stated before the dish machine broke, they used a plate warmer, regular plates, insulated bases, and insulated dome covers to serve all meals to residents which kept the food extra warm. They have been using foam disposable containers for a long time and she does not like the disposables because they are bulky and do not maintain heat as well. At the point of delivery of food to the residents, the food was hotter with the heated plates, insulated bases and domes.
Review of facility policy titled Serving Foods, undated, indicated the following:
Serve food at the proper temperature, attractively, and under sanitary conditions.
Serve on a regular dinner plate.
Garnish plates attractively.
Match china and other serviceware.
Garnish plates according to menu or production notes.
Although there are no specific state and federal requirements concerning point of delivery food temperatures, the [name of association] has guidelines that are acceptable for health care. These guidelines are: hot foods 110°F or above, cold liquids/milk based foods 50°F or below.
CONCERN
(F)
📢 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
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and facility document review, the facility failed to ensure food was prepared and served in accordance with professional standards for food safety when:
1. Trays used ...
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Based on observation, interview, and facility document review, the facility failed to ensure food was prepared and served in accordance with professional standards for food safety when:
1. Trays used to serve resident meals had cracks, and/or were not clean,
2. Staff did not perform proper hand hygiene, and
3. Staff did not wear a hairnet while working around food.
These failures had the potential to cause cross contamination of food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness), the growth of microorganisms, and foodborne illness for the 239 residents receiving food from the kitchen at the facility.
Findings
1. During a concurrent observation and interview on 1/18/23 at 11:38 am, approximately 120 resident ' s meal trays were stacked near the meal service trayline (food service equipment holding hot foods ready to serve for meals). Some trays were discolored with a whitish haze on tops and bottoms, some had broken rough corners, and some had tape and/or stickers on them that were sticky and gummy to touch. Foodservice Worker C and D (FSW C and FSW D) confirmed the observation and stated sometimes staff put paper labels on the trays with tape and the tape is hard to remove. FSW C further confirmed the trays were ready to be used for lunch.
During a concurrent observation and interview on 1/18/23 at 3:58 pm, while looking at a stack of resident meal service trays that had already been cleaned, Dietary Manager (DM) confirmed some of the trays have white marks, cracks at the edges, and tape or stickers on them. She stated the heat from dishwashing makes the tape and stickers hard to remove. She stated the white marks are from the hard water and showed a newer tray which she said is the color they should all be, a cranberry color. She stated they replace them as they go and stated they can ' t throw them all away at the same time, they have over 200 trays in the kitchen.
During an observation on 1/26/23 at 11:05 am, approximately 120 resident meal trays were stacked near the meal service trayline as FSW D was putting napkins and utensils on trays for meal service. Almost all the trays had either cracked rough edges, whitish build-up, tape stuck to the edges, or had gummy sticky material on the edges. During a concurrent interview at that time, FSW D confirmed the observation stating some of the trays should be thrown out, the trays with sticky material were not clean, the trays have been in this condition for a long time, and he has told DM the trays need to be replaced a couple of months ago.
During a concurrent observation and interview on 1/26/23 at 11:20 am, Registered Dietitian (RD) and DM confirmed these trays will
be used today for lunch. Twenty of the trays were closely examined. 19 out of the 20 trays had either cracked rough edges, whitish build-up on tops and bottom, food particles, tape on the edges, or gummy material. The whitish material on the tray was able to be scraped off with a fingernail. The observation was confirmed by RD and DM.
During an interview on 1/26/23 at 11:40 am, Resident #5 stated the meal trays are in bad shape, they have white haze on them and have cracks all over them and his meals are served on the trays in his room. He stated he has told staff about the trays and they have not been changed. Review of Resident #5 ' s Minimum Data Set (MDS) Assessment Section C Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact).
During an interview on 1/26/23 at 12:34 pm, Resident #6 stated the meal trays are dirty when they are served to him in his room. Review of Resident #6 ' s Minimum Data Set (MDS) Assessment Section C Cognitive Patterns indicated a Brief Interview for Mental Status (BIMS) score of 14 (cognitively intact).
Review of facility policy titled Food Service, undated, indicated the company stores, prepares, distributes and served food under sanitary conditions.
According to the 2022 FDA Food Code, non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and shall be free of unnecessary ledges, projections, and crevices. Non-food contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material and shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
The 2022 FDA Food Code Annex further explains that hard-to-clean areas could allow the growth of foodborne pathogenic microorganisms and the objective of cleaning is to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food.
2. During an observation in the kitchen on 1/18/23 at 11:16 am, the Food Service Worker A (FSW A) was setting up foods for meal service and was calibrating thermometers (ensuring thermometers are measuring temperatures correctly) in a cup of ice water, the water was leaking so he went to the janitor ' s closet and picked up a mop head with gloved hands. He cleaned up the water from the floor with the mop head, then removed his gloves and put new gloves on without washing his hands.
During a concurrent interview at the same time, FSW A confirmed he did not wash his hands before putting on new gloves and that he should have washed his hands before putting on new gloves.
During an observation in the kitchen on 1/18/23 at 1:52 pm, Food Service Worker B (FSW B) was serving meals when she went to get something from the walk-in refrigerator, when she returned to serving meals, she removed her gloves and put on a new pair of gloves without washing her hands.
During a concurrent interview at that time, FSW B confirmed she did not wash her hands before putting on new gloves and that she should have washed her hands before putting on new gloves.
Review of facility policy titled Sanitation and Infection control Handwashing, dated 2018, indicated when to wash hands was before and after cleaning procedure and before and after handling foods.
According to the 2022 U.S. Food and Drug Administration (FDA) Food Code food employees shall clean their hands and exposed portions of their arms immediately before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands.
3. During an observation in the kitchen on 1/18/23 at 10:43 am, the Dietary Manager (DM) entered the kitchen, put a scarf over her hair, and started walking around the kitchen in food production areas. She did not have a hairnet on and hair was hanging down out of the scarf in the back.
During an observation on 1/18/23 at 11:28 am, the DM was taking temperatures of uncovered foods on the trayline (equipment used to keep foods hot while serving), she still had a scarf covering her hair and no hairnet and hair was hanging down out of the scarf in the back.
During an interview on 1/18/23 at 12:02 pm, the DM stated she usually wears a hairnet and confirmed she should always wear a hairnet while in the kitchen.
Review of facility policy titled Sanitation and Infection Control Personal Hygiene, dated 2012, indicated a hair net and/or head covering which completely covers all hair should be worn during meal preparation and service.
According to the 2022 U.S. Food and Drug Administration (FDA) Food code section 2-402 Hair Restraints, 2-402.11 Effectiveness, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.
The 2022 FDA Food Code Annex section 2-402.11 further explains Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Resident 1's responsible party (RP) access to medical recor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Resident 1's responsible party (RP) access to medical records upon written request and within the timeframe specified in their policy. This deficient practice violated RP 's rights to access Resident 1's medical records.
Findings:
Review of Resident 1's clinical record indicated resident was admitted on [DATE] and expired on [DATE].
During an interview with the RP on [DATE] at 09:00 a.m., the RP stated he requested and signed a form to access Resident 1's medical records on [DATE] but have not received any records from the facility since then.
During an interview and concurrent record review with the Medical Records Director (MRD) on [DATE] at 2:30 p.m., MRD stated Resident 1's RP requested access to medical records on [DATE]. Reviewed Authorization Form for Release of Information, signed and dated on [DATE] by RP, indicated I authorize the use and disclosure of my health information. Description of information being used or disclosed: All records. MRD confirmed the RP's request was not processed within 48 hours as indicated on the Medical Records department guidelines. MRD further stated that they will provide the medical records to RP.
During a phone interview with the DON (Director of Nursing) [DATE], at 2:30 p.m., DON stated residents or RP can access medical records within 48 hours from the time it was requested. DON stated it should have been processed right away.
Review of the undated facility's policy, Resident Access to Protected Health Information, indicated Medicare regulations for nursing facilities provide that current resident or their legal representatives may access the resident's designated record set upon written or oral within 24 hours (excluding holidays and weekends).
Dec 2022
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain a clean, safe, orderly, and sanitary homelike environment for two facility shower rooms. These failures had potentia...
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Based on observation, interview, and record review, the facility failed to maintain a clean, safe, orderly, and sanitary homelike environment for two facility shower rooms. These failures had potential to compromise residents' health and safety.
Findings:
During a concurrent observation and interview with the assistant director of nursing (ADON) on 12/20/22 at 10:55 a.m. in station 6, shower room walls had blackish substances, the metal shower curtain holders were rusty, and the shower room door frames had multiple rusty spots with chipped bottom parts.
The ADON confirmed the above observations. The ADON stated the shower rooms were not clean and the chipped door frames may cause injuries to the residents. The ADON stated the facility should maintain the shower rooms clean and safe.
A review of the facility maintenance log in station 6 indicated no repair work had been done on station 6 shower rooms in December.
During an observation and interview with maintenance personnel A (MP A) on 12/20/22 at 11:45 a.m., he confirmed the observations. He stated he didn ' t get a request for the repair. He stated the rusty metal shower curtain holders needed to be replaced, and the door frames needed to be repaired. He further stated housekeeper needed to clean the walls.
During an interview with the ADON on 12/20/22 at 3:40 p.m., she stated she could not find the shower room cleaning log. The ADON further stated housekeepers didn ' t have the cleaning schedule for the shower rooms. The ADON stated the facility should follow the cleaning schedule by the facility ' s policy.
Review of facility's policy Shower & Tub room Cleaning released on 4/15/2001, indicated Shower and tub rooms are cleaned daily to remove soap scum, dirt, and debris and provide residents with a safe and sanitary place to bathe. Each month, use a scrub brush and diluted all-purpose cleaner, or tub/tile cleaner, on walls to remove residue from grout and corners. The policy also indicated Report or repair missing or damaged fixtures or tiles to maintenance.
Jul 2022
23 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision to prevent one of 14 residents (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision to prevent one of 14 residents (Resident 27) who were at risk for elopement from leaving the facility without staff's knowledge and permission when:
1. Staff did not provide Resident 27 with supervision and one staff physical assistance for locomotion on unit (how resident moves between locations in her room and adjacent corridor in the same floor), and locomotion off unit (how resident moves to and returns from off-unit locations [i.e., hallways, dining, or how resident moves to and from distant areas on the floor]).
2. Four out of five charge nurses (licensed vocational nurse B [LVN B], LVN C, LVN F, and registered nurse G [RN G]) did not know how to check the functionality of the wander guard (a device applied to the resident's body that triggers an alarm if the resident tries to exit the facility); and
3. Licensed Nurse did not complete the quarterly Elopement Risk Assessment and did not develop an elopement risk care plan in a timely manner.
These failures compromised Resident 27's health and safety, as she was found by paramedics (persons trained to give emergency medical care to people who are injured or ill) on the street eating dirt and rocks. Resident 27 sustained scrapes and scratches on the bridge of her nose and on both knees. She was admitted to the acute hospital for treatment and evaluation.
Findings:
1. Review of Resident 27's medical record indicated she was admitted to the facility on [DATE] with diagnoses of dementia (general term describing problems with reasoning, planning, judgment, memory and other thought processes) with behavioral disturbance, generalized muscle weakness, difficulty walking, psychotic disorder (severe mental disorder that causes abnormal thinking and perceptions), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and hypertension (abnormally high blood pressure).
Review of Resident 27's Minimum Data Set (MDS, an assessment tool) dated 6/16/22, indicated she had short-term and long-term memory problems, with severely impaired daily decision making. The MDS indicated Resident 27 rarely or never understood others and was rarely or never able to make herself understood. The MDS further indicated Resident 27 required supervision (oversight, encouragement, or cueing) and one staff physical assistance for eating, transfers, walking in room and corridor, and locomotion on and off unit.
Review of Resident 27's Elopement Risk Assessment, dated 7/15/22, indicated she was at risk for elopement, was ambulatory (able to walk), had behaviors of wandering without purpose, and had a substance abuse/psychiatric history.
Review of Resident 27's care plan titled Risk for elopement and wandering out of the facility, dated 7/15/22, indicated the resident was to have a wander guard bracelet and staff was to check the alarm for functioning.
During an observation and concurrent interview with certified nursing assistant A (CNA A) on 7/13/22 at 2:28 p.m., Resident 27 was ambulating (walking) independently in the hallway near her room. CNA A stated Resident 27 was confused, wandered around, and walked independently.
During an interview with CNA D on 7/14/22 at 8:54 a.m., CNA D stated Resident 27 walks around all the time. CNA D stated staff need to watch and supervise her, sometimes she wants to go out and wanted go home, we need to follow her around. CNA D also stated, If busy, the supervisor needs to follow her when she's up because she could go out.
On 7/15/22 at 2:41 p.m., two surveyors (Pharmacy Consultant and a nurse surveyor) reported having heard the facility's exit door alarm sound off and witnessed Resident 27 trying to get out of the facility at 1:17 p.m. The facility's consultant/Vice President ran after Resident 27 and brought her back inside.
Review of Resident 27's SBAR (Situation, Background, Assessment, Recommendation; a communication tool), dated 7/16/22 indicated, Writer received a call from paramedics that resident was found outside the facility on Forest Avenue near the corner stop light and when assessed by the paramedics resident noted with an elevated temperature and tachycardia (fast heart rate over 100 beats a minute) Resident 27 was sent to the emergency room for further evaluation and treatment.
During an interview and concurrent record review with RN R on 7/18/22 at 10:23 a.m., RN R stated she was the nurse supervisor on duty when Resident 27 eloped on 7/16/22. RN R confirmed having received a call from the paramedics that Resident 27 was found near the stoplight on Forest Avenue (about a two-minute walk from the facility). RN R stated Resident 27 was wearing a wander guard bracelet and she had no idea how the resident got out of the facility. RN R also stated she interviewed the receptionist on duty at the time of incident, who claimed the door did not alarm or sound off when Resident 27 got out of the facility. RN R also reviewed Resident 27's physician's order, dated 3/14/22, that indicated wander guard to prevent elopement RN R stated charge nurses were responsible for checking the functionality of the wander guard alarm.
During an interview with the receptionist staff (RS) on 7/18/22 at 12:46 p.m., he confirmed he worked as receptionist on 7/16/22 from 7:00 a.m. to 4:00 p.m. The RS confirmed he received a call from the paramedics, then transferred the call to the nurse supervisor on duty. The RS confirmed he and the facility staff were aware that Resident 27 was an elopement risk. The RS also stated Resident 27 had a history of pulling out doors and trying to get out. The RS stated the main door and other exit doors did not sound off and he did not know how Resident 27 was able to get out of the facility without the alarm sounding off.
Review of Resident 27's History and Physical from the acute hospital, dated 7/17/22, indicated she was brought in by ambulance on 7/16/22 after bystanders noted the resident to be face down in a planter attempting to eat rocks, and the facility did not know she left the facility. Resident 27 presented to the ED (emergency department) after being found by EMS [emergency medical services] altered [physical and/or mental condition were not normal]. The ED notes also indicated, found by EMS altered, on the floor by a street trying to eat rocks and dirt. Patient was found to be a conserved [under the protection of a guardian or custodian] resident of and they were unaware she was missing. Patient was brought to the ED and work up for fall and infection was done.
Resident 27 was admitted to the hospital's emergency room on 7/16/22. On physical examination it indicated the resident was disheveled [untidy, messy or unkempt], dirt all over face. Patient presenting with PMH [previous medical history] for dementia, major neurocognitive disorder with behavioral and psychotic disorder, depression, and anxiety, being admitted for AMS [altered mental status]. In the ED, Resident 27 had a heart rate of 134 beats per minute (normal heart rate is 60 to 100 beats per minute). On admission she appeared disheveled, had dry mucous membranes, and had scrapes and scratches on the bridge of her nose and both knees. She presented in the ED with lactic acidosis (lactic acid build up in the bloodstream caused by impaired/decreased tissue oxygenation; a potential medical emergency). She was administered 3 L (liters, unit of measurement) of IV (intravenous- given by vein) fluids, and IV Vancomycin and Zosyn (antibiotics, medications to treat infection).
2. Review of resident 27's physician's order, dated 3/14/22 indicated, Wander guard to prevent elopement twice a day at 0900 A.M., 0500 P.M
During an interview with LVN B on 7/18/22 at 10:50 a.m., LVN B confirmed having been assigned to Resident 27 and another resident who had a wander guard. LVN B admitted he had never used any device to check if his residents' wander guards were functioning properly. He stated, Never used it before, and does not have the machine.
During an interview with LVN C on 7/18/22 at 10:52 a.m., LVN C stated she had been assigned in Station 3 before. LVN C admitted she was not taught or instructed on how to check the functionality of the wander guard.
During an interview with housekeeping/maintenance (HKM) and housekeeping maintenance staff (HKS) on 7/18/22 at 11:02 a.m., both staff stated they had not checked any wander guards used by residents.
During an interview with LVN E on 7/18/22 at 11:08 a.m., LVN E stated the machine to check the functionality of the wander guards was kept in Station 4.
During an observation and concurrent interview with LVN F on 7/18/22 at 11:15 a.m., LVN F and RN R both searched for the wander guard checking device from the Station 4 medication cart but could not find it. LVN F claimed nobody oriented her on how to check the functionality of the wander guard and she did not know how to use such device. LVN F also stated she would have the director of staff development (DSD) teach her. RN R heard and confirmed LVN F's claim.
During an interview and concurrent record review with the DSD on 7/18/22 11:30 a.m., the DSD confirmed she had not done any in-service (training) with the registry nurses (nurses from a staffing agency who come to work temporarily in the facility) and other nurses on how to check the functionality of the wander guard. The DSD, upon review of her in-service log with her assistant, confirmed the Elopement In-service conducted did not include the procedure on how to check the wander guard.
During an interview with RN G on 7/18/22 at 11:40 a.m., RN G stated, I don't know how to check, don't' know how to use the device.
3. During a record review and concurrent interview with the minimum data set coordinator (MDSC) on 7/15/22 at 2:02 p.m., the MDSC stated the Elopement Risk Assessment should be completed every quarter. The MDSC confirmed she knew Resident 27 because she is the one wandering around and she was at risk for elopement.
During the concurrent record review, the MDSC confirmed Resident 27's Elopement Risk Assessment was done only upon admission on [DATE] and was not completed in June 2022. The MDSC also confirmed the elopement risk care plan was not developed. The facility completed the Elopement Risk Assessment and developed the elopement risk care plan on 7/15/22, after this record review and concurrent interview.
Review of the facility's 12/1/2005 policy and procedure, Elopement, indicated Elopement Risk Form will be completed for all patients upon admission, readmission, quarterly, and with significant changes. Patients showing to be at Risk for Elopement will have a wander guard placed if applicable to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure for two of seven sampled residents (Resident 110 and 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 for two of seven sampled residents (Resident 110 and Resident 175) advance directive instructions were clear.
This had the potential for staff to not honor the wishes of the resident in the event of an emergency.
Findings:
Record review of Resident 110's face sheet, undated, indicated the resident had a history of dementia (loss of cognitive functioning to an extent that it interferes with a person's daily life and functioning), major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest), and received hospice services (care focused on comfort and quality of life of a person who is approaching the end of life).
Record review of Resident 175's face sheet, undated, indicated the resident had a history of heart failure a chronic condition in which the heart doesn't pump as well as it should), Type 2 Diabetes (an impairment in the way the body regulates and uses sugar), and dependence on renal dialysis (treatment to filter the blood the way the kidneys should).
Record review of Resident 110's Physician Orders for Life-Sustaining Treatment (POLST, end of life planning which, if any, medical interventions to prolong life), dated [DATE], signed by the physician and the Resident 110's Representative Party (RP; person responsible for making medical decisions for the resident) indicated the resident, in the event of an emergency wished for the facility to Do Not Attempt Resuscitation, (DNR; allow natural death and without cardiopulmonary resuscitation (CPR; chest compressions combined with breaths to restore spontaneous blood circulation).
Record review of Resident 175's POLST, dated [DATE], signed by the physician and the Resident 110's RP indicated DNR in the event of an emergency.
Record review of physician orders for both Resident 110 and Resident 175, dated [DATE], indicated both residents had physician orders for CPR.
During interview with Registered Nurse R (RN R), on [DATE] at 11:52 a.m., RN R confirmed both Resident 110 and Resident 175 have physician orders for CPR and confirmed both residents have DNR selected on their POLST. RN R stated the CPR orders for both residents should be discontinued and the facility should honor the POLST. RN R confirmed there could be confusion and there was the potential end of life treatment would not be honored.
Record review of facility policy Advance Directives, dated 3/2004, indicated the resident has the right to accept or refused medical treatment and the facility will honor the wishes of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a comprehensive, Minimum Data Set (MDS, a standardized asse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a comprehensive, Minimum Data Set (MDS, a standardized assessment tool) for one of 35 sampled residents (Resident 27), within 14 days of a significant change in the resident's condition.
This failure had the potential for inadequate information to be gathered for the timely development of an appropriate plan of care, and the required modification of appropriate care and services for Resident 27.
Findings:
A review of Resident 27's MDS dated [DATE] indicated she required extensive assistance with two persons physical assistance with bed mobility, dressing, toilet use and personal hygiene; and to all dependence with one person physical assistance with bathing.
During a record review and concurrent interview with the minimum data set coordinator (MDSC) on 7/15/22 at 2:02 p.m., she confirmed Resident 27 had improvement in her functional abilities on two or more areas but did not complete an MDS on significant change. The MDSC acknowledged having thought an MDS reassessment would only be done if there was a decline in resident's status.
During an interview with the minimum data set nurse (MDSN) on 7/15/22 at 2:25 p.m., she stated the significant change MDS was required for either a decline or improvement in any resident's functional status.
During a follow up interview on 7/18/22 at 2:15 p.m., the MDSC stated she reviewed Resident 27's clinical record and would complete a significant change in the MDS.
According to the Resident Assessment Instrument (RAI) version 3.0, page 2-20, gives clear instructions for the completion of the MDS. A Significant Change of Status Assessment must be completed, within 14 days, when the Interdisciplinary Team (IDT, a team of health care professionals who work in a coordinated fashion toward a common goal for the patient) has determined that a resident meets the significant change guidelines. A significant change in condition is defined as an improvement or decline in a resident's condition, from his or her baseline, in two or more areas, as indicated by a comparison of the resident's current status with the most recent assessment. A significant change is defined as any decline in physical function where a resident is newly coded as extensive assistance, a change in incontinence pattern, the emergence of a pressure ulcer, or unplanned weight loss greater than 5% in 30 days or 10% in 180 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to submit the PASRR (Preadmission Screening and Resident Review, a fed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to submit the PASRR (Preadmission Screening and Resident Review, a federally required document to ensure residents are appropriately placed) when one of five sampled residents (Resident 110), received mental illness diagnoses and did not receive a level two screening to ensure they received the services needed.
The deficient practice could potentially result in Resident 110 not receiving specialized care and services appropriate for her condition.
Findings:
Review of Resident 110's face sheet, undated, indicated the resident had a history of dementia (loss of cognitive functioning to an extent that it interferes with a person's daily life and functioning), major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest), and received hospice services (care focused on comfort and quality of life of a person who is approaching the end of life). The face sheet indicated Resident 110 was admitted on 10/19
Record review of the Nurse Practitioner (NP) Progress Notes, dated 6/8/2022 and recorded as a late entry on 6/10/2022, indicated Resident 110 had Schizoaffective disorder and later in the note under assessment/plan Schizophrenia and Depression were noted to be assessment areas for Resident 110.
During interview and concurrent record review with Registered Nurse R (RN R), on 7/14/2022 at 8:22 a.m., RN R confirmed Resident 110 was admitted on [DATE] and PASRR 1 indicated no requirement to complete a level two PASRR. RN R confirmed Resident 110 was diagnosed with depression and schizoaffective disorder on 6/9/2022. RN R confirmed the medication Seroquel was started around this time for the treatment of schizoaffective disorder. RN R stated the facility would be required to do a PASRR again and confirmed no change of condition or PASRR 2 was completed RN R stated the facility should have done both and that the facility is required to do so in order to ensure proper services are being provided to residents.
According to the Medicaid.gov, Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care .PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings .
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 149's clinical record indicated she was admitted on [DATE] and had diagnoses of traumatic hemorrhage of ce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 149's clinical record indicated she was admitted on [DATE] and had diagnoses of traumatic hemorrhage of cerebrum (a collection of blood within the skull), history of falling, hypertension (high blood pressure), depression (a mood disorder that causes a feeling of sadness and loss of interest), difficulty in walking, and muscle weakness.
Review of Resident 149's fall care plan indicated it was not updated with plan of care and recommendations from Risk meeting notes initial week one dated 6/06/22 for the resident's fall on 5/31/22. The plan of care and recommendations indicated write in Korean to 'set breaks before sitting on the rollator (walker with wheels)' or 'after use.'
During an observation on 7/12/22 at 10:52 a.m. in resident 149's room, the resident's rollator was located near the resident bed and there was no sign of set breaks before sitting on the rollator anywhere in the room.
During an interview and observation with the assistant director of nursing (ADON) on 7/13/22 at 3:22 p.m., she confirmed Resident 149 did not have the sign of set breaks before sitting on the rollator.
During an interview and record review with the ADON on 7/13/22 at 3:22 p.m., she confirmed Resident 149's fall care plan was not updated with write in Korean to 'set breaks before sitting on the rollator' or 'after use' as recommended from Risk meeting notes initial week one dated 6/06/22. The ADON stated the fall care plan should have been updated.
During an interview with the director of nursing (DON) on 7/14/22 at 9:10 a.m., she stated the fall care plan should be updated with the plan of care and recommendations.
Review of the facility fall Prevention dated 12/01/2015, indicated all patients admitted to the facility with potential for fall will have a care plan for falls initiated first 24 hours. This care plan will then be modified as needed .
Review of the facility comprehensive Plan of Care dated 11/15/2001, indicated Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur.
Based on observation, interview and record review, the facility failed to develop and implement care plans for four of 32 sampled residents when:
1. Resident 41's Fall Risk Evaluation was not completed and Fall risk care plan was not developed.
2. Resident 117's smoking assessment was not accurately completed and smoking care plan was not developed; and fall care plan was not implemented.
3. Resident 535's smoking reassessment and care plan were not developed when he started to smoke in the facility.
4. Resident 149's fall care plan was not updated and implemented.
These failures had the potential for inaccurate development and implementation of a personalized and resident-centered care plans that would address the residents' identified concerns and needs.
Findings:
1. During a record review and concurrent interview with registered nurse H (RN H) on 7/12/22 at 10:10 a.m., RN H reviewed Resident 41's clinical record and stated the charge nurse or nurse supervisor should have completed another Fall Risk Evaluation after the last assessment that was completed on 4/2/22. RN H could not find documented evidence that a fall care plan was developed when Resident 41's Fall Risk Evaluation done on 4/2/22.
2. A review of Resident 117's clinical record indicated he had two unwitnessed fall incidents on 4/23/22 and 7/5/22. His fall care plan dated 7/5/22 included an intervention to put him on a Falling Star.
During an observation and concurrent interview with registered nurse I (RN I ) and certified nursing assistant J (CNA J) on 7/14/22 at 12:50 p.m., both staff confirmed Resident 117's door did not have the Falling Star sticker placed next to his door name tag. RN I stated if the resident was placed on Falling Star Program, there should be a sticker placed next to his name by the door on his room.
A review of Resident 117 face sheet included diagnoses of alcohol abuse and dependence with withdrawal delirium, alcohol use with intoxication, and subarachnoid hemorrhage (burst or rupture of a blood vessel in the brain that caused bleeding), and radiculopathy conditions that causes pain, numbness, and tingling in the arms or legs).
During a record review and concurrent interview with the minimum data set nurse (MDSN) on 7/14/22 at 1:29 p.m., she reviewed Resident 117's Safe Smoking Assessment Evaluation done on 4/22/22 and she confirmed the assessment did not reflect the diagnoses that were related to seizure activity which could potentially affect his ability to safely smoke. The MDSN confirmed the assessment was not accurate and a smoking care plan was not developed.
3. A review of Resident 535's clinical record indicated he was admitted on [DATE] with Safe Smoking Assessment done on 6/29/22 that indicated he was not a smoker.
During an observation and concurrent interview on 7/12/22 at 9:38 a.m., Resident 535 had three pieces of cigarettes and a lighter on top of his tray table.
During an interview with Resident 535 on 7/12/22 at 12:26 p.m., he claimed he had been smoking twice daily (in the morning and afternoon), and staff had allowed him to smoke in front of the facility's main lobby.
During an observation on 7/12/22 at 5:04 p.m., Resident 535 was sitting on his bed and certified nursing assistant J (CNA J) confirmed the presence of two cigarettes and a lighter on top of resident's table.
During an interview and concurrent record review with the social services director (SSD) and registered nurse H (RN H) on 7/12/22 at 5:24 p.m., both staff concurred that a Safe Smoking Assessment should have been completed. The SSD stated she would talk to Resident 535 about his smoking. RN H stated she would request the director of staff development (DSD) to in-service the staff regarding safekeeping of smoking paraphernalia (lighter) .
A review of the facility's 11/15/2001 policy and procedure, Comprehensive Plan of Care, indicated each resident will have a comprehensive care plan developed that . to meet their medical, nursing, mental and psychological needs identified during the comprehensive assessment. A comprehensive care plan must address the resident's individual needs, strengths, and preferences.
A review of the 10/2020 policy and procedure, Smoking, indicated all residents who desire to exercise the privilege to smoke will be assessed to determine their smoking safety awareness. The IDT will determine if the resident is a safe smoker and the amount of supervision needed. The facility will develop a care plan for those residents identified as having a potential safety concern in relation to smoking or handling of smoking materials when smoking. Safe Smoking Assessment will be repeated quarterly .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary care and services to ensure prev...
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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 the necessary care and services to ensure prevention of development or worsening of an existing pressure ulcer (injury to the skin and underlying tissue) for one out of three sampled residents (Resident 116) observed for pressure ulcers when:
1. There was no treatment for a pressure ulcer on the sacral area (portion of spine between lower back and tailbone) that was identified on admission;
2. There was no staging of the pressure ulcer on the sacral area on admission;
3. When the physician prescribed treatment, there was no documentation that treatment orders were followed consistently;
4. There was no consistent skin assessment of the pressure ulcer;
These failures resulted in Resident 116 developed into an unstageable pressure ulcer (full thickness tissue loss that was difficult to assess) with eschar (dead tissue that is dark in color) on the sacral area.
Findings:
Review of Resident 116's face sheet, dated 1/25/2022, indicated resident was admitted on [DATE] with a history of arthritis (swelling of joints), type II diabetes (the way the human body produces and regulates insulin), chronic urinary tract infection (UTI; ongoing or recurring infection of the urinary tract).
1. Record review of Resident 116's admission nursing assessment, dated 1/25/2022, indicated a pressure ulcer on the sacral area which measured 0.3 centimeters (cm) x 0.3 cm x 0.1 cm. The Braden score (assessment tool used to identify residents at risk for pressure ulcer or sore development) was assessed to be 18, which is high risk for pressure ulcer development.
Record review of Resident 116's admission orders, dated 1/25/2022, indicated no orders for sacral pressure ulcer wound care.
During an interview and concurrent record review with the minimum data set coordinator (MDSC), on 7/15/2022 at 11:35 a.m., the MDSC confirmed the admission minimum data set, MDS (an assessment tool), dated 1/25/2022, for Resident 116 there was no documentation in MDS section M there was a sacral pressure ulcer upon admission. The MDSC confirmed there was no wound care orders for a pressure ulcer on the sacral area wound care until 1/30/22. The MDSC indicated the MDS was inaccurate and should have included the pressure ulcer on the sacral area which measured 0.3 centimeters (cm) x 0.3 cm x 0.1 cm.
Review of facility policy titled MDS Accuracy, dated 11/15/2001, indicated the initial assessment provided baseline data for ongoing assessment of resident progress. The policy further indicated the assessment accurately reflects the resident's health status.
2. Record review of Resident 116's admission nursing assessment, dated 1/25/2022, had no documentation of staging of the pressure ulcer.
During an interview and concurrent record review with the MDSC, on 7/15/2022 at 11:35 am, the MDSC confirmed there was no staging of the sacral pressure ulcer on admission and confirmed the pressure ulcer should have been staged with the initial nursing assessment.
Review of facility policy Policy for Ulcer Monitoring, dated 12/1/2005, indicated the facility would measure the wound according to National Pressure Injury Advisory Panel (NPUAP) guidelines and would then stage the wound using the NPUAP staging system.
Review of facility policy, Skin Care Management, dated 12/1/2005, indicated when a pressure ulcer is identified the nurse will document the stage.
3. Record review of the physician's order, dated 1/30/2022, indicated an order to clean the sacral pressure ulcer with normal saline (sterile fluid to cleanse wounds), pat dry, and apply Hydrogel (medication used to heal pressure ulcers) once daily from 1/30/2022 to 2/10/2022.
Record review of weekly nursing documentation, dated 2/8/2022, indicated there was no sacral pressure ulcer care documented and the facility was unable to provide documentation of pressure ulcer care for Resident 116 for 2/8/2022.
Record review of the physician orders, dated 2/10/2022 to 3/9/2022, changed pressure ulcer care instructions to cleanse sacral pressure ulcer with normal saline, pat dry, and apply Calmoseptine (medication to heal pressure ulcers) with each brief change and as needed.
Record review of weekly nursing documentation from 2/11/2022 to 3/8/2022, indicated there was no nursing documentation of sacral pressure ulcer wound care completed. The facility was unable to provide documentation of sacral pressure ulcer wound care from 2/11/2022 to 3/8/2022, which was a total of 26 days without any documentation that pressure ulcer care was provided.
Record review of the physician's order dated 3/9/2022, Physician wound care orders from 3/9/2022 to 3/25/2022 for daily wound care.
Review of physician's wound care orders dated 3/9/2022, states from 3/25/22 to 4/12/22, cleanse wound with normal saline, pat dry, apply Medihoney (medication used to heal pressure ulcers) and cover with calcium alginate (medication used to heal pressure ulcers) and dry dressing every other day and as needed.
Record review of the physician order, dated 3/26/2022 to 4/11/2022, indicated to cleanse the sacral wound with normal saline, pat dry, apply Medihoney to wound bed, cover with calcium alginate and cover with dry dressing every other day dressing and as needed. The facility was unable to provide nursing documentation of wound care completed from 3/26/2022 to 4/11/2022 which was a total of 17 days without any sacral pressure ulcer would care.
During an interview and concurrent record review with the MDSC, on 7/15/2022 at 11:35 am, the MDSC confirmed from 3/26/2022 to 4/11/2022 there was no documentation of wound care being performed for Resident 116.
During an interview and concurrent record review with the director of nursing (DON), on 7/15/2022 at 1:30 p.m., she confirmed that between 3/26/2022 to 4/11/2022, there was no nursing documentation of sacral pressure ulcer wound care done. She confirmed there should have been sacral pressure ulcer wound cares documented for the time frame 3/26/2022 to 4/11/2022. The DON confirmed for 43 days there was no documented pressure ulcer wound care provided to Resident 116. The DON confirmed daily wound care was documented beginning 4/12/2022.
During interview with Registered Nurse I (RN I), on at 7/15/2022 at 8:47 a.m., she confirmed on 6/29/2022 Resident 116's sacral pressure ulcer was unstageable and with eschar.
Review of policy Ulcer Monitoring dated 12/1/2005, indicated that nursing should complete a weekly wound record based on the daily assessments. The policy further stated that this would be reviewed by the IDT on a weekly basis.
Review of facility policy, Skin Care Management, dated 12/1/2005, indicated the nurse will document daily the monitoring of all pressure ulcers to include status of the dressing, surrounding skin, presence of complications, and pain.
4. Record review of weekly nursing documentation for 2/8/22, 2/15/22, 2/22,22, 3/1/22, 3/8/22, 3/16/22, and 3/26/22 indicated there was no skin assessment documented for Resident 116. The facility was unable to provide documentation skin assessments for Resident 116 were completed on those days.
Review of facility policy, Skin Care Management, dated 12/1/2005, indicated the nurse will document daily the monitoring of all pressure ulcers to include status of the dressing, surrounding skin, presence of complications, and pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record Review of Resident 2's undated face sheet indicated history included arthritis (joint swelling), reduced mobility, and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record Review of Resident 2's undated face sheet indicated history included arthritis (joint swelling), reduced mobility, and hypertension (high blood pressure). Review of Resident 2's Brief Interview for Mental Status (BIMS; assessment tool to determine cognition), dated 6/11/2022, of 15 and he was able to make his own decisions regarding his finances and his medical care and treatment.
During observation and concurrent interview with Resident 2, on 7/11/2022, Resident 2 showed unkempt long toe nails and stated he is embarrassed by his toe nails, he cannot trim them himself, and stated staff will not tell him when he will be seen by podiatry. He also stated they hurt when they snag fabric.
During record review of Resident 2's Minimum Data Set (MDS; tool used for clinical assessment), dated 6/11/2022, indicated the resident required extensive assistance with one person assisting with personal hygiene.
During record review and concurrent interview with registered nurse R (RN R), on 7/14/2022 at 8:47 a.m., RN R confirmed Resident 2 had a physician's order for podiatry, dated 9/23/2021, for hypertrophied toenails (when nails are abnormally thick). RN R confirmed Resident 2 was last seen by podiatry on 10/19/2021.
During interview with the social services director (SSD), on 7/15/2022 at 12:17 p.m., the SSD indicated the resident was seen on 10/19/2021 by podiatry. She indicated residents should be seen around every 60 days and that there had been roughly 9 months between services. She indicated Resident 2 had a toe nail fungus along with some other toe nail issues.
Record review of facility policy Physician Orders, dated 11/15/2002, indicated physician orders are obtained to provide clear direction in the care of the resident.
Based on observation, interview and record review, the facility failed to ensure proper foot care was provided to three of five sampled residents (Resident 2, 117 and Resident 155 ) when:
1. Resident 117's long, thick toenails were not trimmed by podiatrist (medical specialists who help with problems that affect your feet or lower legs) ;
2. Resident 155's long, thick and curled toenails were not cut and trimmed by podiatrist;
3. Resident 2's long, thick toenails were not cut or trimmed by podiatrist.
These failures had the potential to increase the risk for the development of foot ulcer and infection.
Findings:
1. A review of Resident 117's facesheet indicated diagnoses of diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar (glucose) levels to be high), human immunodeficiency virus (HIV) disease.
During an observation on 7/11/22 at 10:53 a.m., Resident 117 claimed he had pain on his feet and showed his long, curled with sharp edges toenails touching his feet. His both feet had yellow callus (buildup of hard, thick areas of skin usually seen on feet) and was painful. Resident 117 stated, he had to cut his nails because staff don't do it .
During a follow up visit on 7/12/22 at 2:02 p.m., Resident 117 stated he already cut his toenails when he got the nail clippers from staff.
During an interview and concurrent interview with SSD on 7/13/22 at 9:20 a.m., SSD confirmed that Resident 117 was not referred and seen by podiatrist since admission on [DATE]. SSD stated Resident 117 was diabetic and staff could not trim his toenails and required podiatry referral.
During an interview with the director of nursing (DON) on 7/18/22 at 9:18 a.m., she stated certified nursing assistants could cut the fingernails of residents who were not diabetic and nurses would cut the nails of diabetic residents, podiatrist cut the toenails of diabetic residents.
2. During an observation on 7/12/22 at 1:37 p.m., Resident 155 complained of pain when certified nursing assistant U (CNA U) removed his socks from his left foot. He stated his sock got stuck in his big toenail. CNA U confirmed resident's toenails were long and thick and one toenail was poking the sole of his foot.
During an interview and record review with the social services director (SSD) on 7/13/22 at 9:38 a.m.,
SSD confirmed Resident 155 was diabetic and needed an urgent podiatry referral after looking at the pictures of resident's toenails. Resident 155 was last seen by podiatrist on 4/27/22 and SSD stated I don't know why he was not seen by podiatrist again. SSD also stated once a resident was seen by podiatrist, he should be followed up every 61 days.
Review of the facility's June 2008's policy and procedure, Referral to Outside Agencies, indicated referrals for Professional Concrete Services ( vision, hearing, dental, podiatry, and other ancillary services) can be made by the Social Services Director, licensed nurse, or a member of the IDT based on a resident's individualized, specific needs identified through interviews, evaluations, and assessments. The Social Services Director or designee makes an appointment for the resident with the appropriate outside agency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide care according to professional standards of p...
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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 care according to professional standards of practice and facility policy and procedures for two of 32 sampled residents (Residents 46 and 68) when:
1. Certified nurse assistant (CNA) and restorative nurse assistant (RNA) controlled the enteral feeding pump (a device used to deliver nutrition to the stomach using a tube);
2. Medications and feeding formula given via the gastrotomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) was not appropriately done for Resident 68.
These failures had the potential for complications related to the enteral feeding and to cause harm to the residents.
Findings:
1. Review of Resident 46's clinical record indicated she was admitted on [DATE] and had diagnoses of gastrostomy status (a surgical opening into the stomach to deliver nutrition), depression (a mood disorder that causes a feeling of sadness and loss of interest), dementia (a group of symptoms affecting thinking and social abilities interfering with daily functioning), and dysphagia (difficulty swallowing foods).
Review of Resident 46's Physician order dated 6/30/22, indicated Jevity 1.2 (feeding formula) via enteral pump at 65 milliliters (ml, a metric of volume) per hour for 21 hours, ON at 12 p.m. OFF at 9 a.m. or until feeding ordered is consumed. May stop feeding for activities and ADLs (activities of daily livings).
During an observation and concurrent interview with CNA L and RNA DD on 7/11/22 at 10:42 a.m., RNA DD was observed stopping Resident 46's enteral feeding pump before the resident care and CNA L was observed starting the enteral feeding pump after the care. RNA DD confirmed she stopped the enteral feeding pump. CNA L confirmed she started the enteral feeding pump. CNA L stated she could control the enteral feeding pump and there was no need to call a licensed nurse.
During an interview with director of nursing (DON) on 7/13/22 at 10:30 a.m., she confirmed a licensed nurse should control the enteral feeding pump not the CNA/RNA. The DON stated the CNA/RNA should asked their nurse to control the enteral feeding pump.
Review of the facility Charge nurse job description dated 1/2012, indicated Performs or supervises the administration and documentation of medications, enteral nutrition and treatments per the physician's order .
2. Resident 68 was admitted to the facilities with diagnoses including pneumonitis (inflammation of the lung tissue) due to inhalation of food and vomit, and gastrostomy status.
During the medication administration observation with licensed vocational nurse (LVN) Q on 7/12/22 at 8:09 a.m., she was observed preparing 7 medications, including 5 solid tablets, for Resident 68. She placed each tablet in a small plastic bag and crushed each medication individually by using a crushing device. She brought the medications along with one-237 milliliters (mL, unit of measurement) carton of Glucerna (a nutritional formula) to the resident's room.
On 7/12/22 at 8:27 a.m., Resident 68 was observed on the wheelchair at the foot of his bed, in the reclining position, with his eyes closed as if sleeping. LVN Q explained to the resident that she would be administering his medications but the resident did not open his eyes nor respond to the nurse. LVN Q stated the resident was non-verbal and unable to make his needs known. There at the bedside, LVN Q diluted each crushed medication with some water. Before the medication administration, she withdrew about 50 mLs of water into the 60-mL syringe, attached the syringe to the resident's G-tube, and pushed the water by pushing the plunger rapidly (over about 3 to 5 seconds) to empty the contents into the G-tube. The resident was observed squirming his upper body and making a hissing noise in response. After pushing the water, LVN Q did the same by withdrawing a syringe-full of Glucerna and pushed it down the G-tube rapidly; and repeated the process until the Glucerna carton was empty. Each time she pushed the liquid contents, the resident squirmed his upper body and made a hissing noise. After finished with the Glucerna, LVN Q started the medication administration by drawing up the liquid contents from the medication cup and pushing it into the resident's G-tube. She flushed the tubing with some water, pushed it quickly, and repeated with another medication. She flushed the tubing with about 50 mLs of water after the last medication was administered.
During an interview on 7/12/22 at 08:50 a.m., when asked if she would normally push the medications and enteral formula that way for G-tube administration, LVN Q stated if she did not, it would take forever for the contents to go down the G-tube. She confirmed the resident appeared in discomfort by the rapid pushing of the water, the enteral formula, and the medications.
A review of Resident 68's medical record indicated a physician's order for: Glucerna 1.5 cal(ories), 1 can via gravity/bolus feeding via enteral tube every 4 hours, dated 3/17/22.
During an interview with the director of nursing (DON) on 7/12/22 at 4:16 p.m., she stated the nurse was supposed to administer the water, Glucerna, and medications by pouring the liquid into the syringe and let it go down by gravity. She said it was okay to push but very slowly to prevent stomach pain or discomfort for the resident.
A review of the facility's policy and procedures titled Medication Administration Enteral Tubes, dated 9/2018, indicated, The nursing care center assures the safe and effective administration of enteral formulas and medications and Flush the tube with at least 15 mL of water . Allow medication to flow down tube via gravity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 32's clinical record indicated she was admitted on [DATE] and had diagnoses of history of traumatic brain ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 32's clinical record indicated she was admitted on [DATE] and had diagnoses of history of traumatic brain injury, sepsis (a life-threatening complication of an infection), epilepsy (an abnormal activity in the brain causing uncontrollable jerking movements of the arms and legs, and loss of consciousness), and aneurysm of carotid artery (a ballooning in the wall of the blood vessel in the neck).
Review of Resident 32's Physician order dated 4/01/21, indicated Oxygen at 2 liter per minute via nasal cannula continuously for SOB (shortness of breath).
During an observation on 7/11/22 at 12:04 p.m. in Resident 32's room, the resident had the NC on his nostrils, but the NC was not connected to the oxygen concentrator.
During an interview and concurrent observation with registered nurse Z (RN Z) on 7/11/22 at 12:14 p.m., she confirmed Resident 32's NC was not connected to the oxygen concentrator.
During an interview and concurrent record review with RN Z on 7/11/22 at 12:19 p.m., she reviewed Resident 32's physician order and confirmed Resident 32 should have the oxygen continuously as ordered.
Review of facility Oxygen administration via concentrator dated 8/15/2002, indicated Turn to proper flow rate as ordered by the physician. Check the concentrator to assess the maximum flow rate. If the correct flow rate is not being maintained, check tubing for kinks or obstructions and check all connectors.
Review of facility Oxygen administration dated 8/15/2002, indicated Assemble the oxygen unit and flow meter, making sure all connections are secure. Attach the oxygen delivery device to the oxygen unit.
Based on observation, interview and record review, the facility failed to ensure that proper care and treatment services for oxygen (O2) were provided for two of five sampled residents (Resident 53 and Resident 32) when:
1. Physician orders for oxygen administration for Resident 53 were not followed;
2. Resident 32's nasal cannula (NC, a device used to deliver oxygen) was not connected to the oxygen concentrator (a medical device that gives extra oxygen).
These deficient practices had the potential for the residents to have complications related to improper treatment while receiving O2 therapy.
Findings:
1. Record review of Resident 53's face sheet, undated, indicated Resident 53 has a history of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), emphysema (a condition in which the lungs are damaged causing breathlessness), and hypertension (high blood pressure).
During observation and record review with LVN S, on 7/14/2022 at 10:07 a.m., LVN S confirmed the observation that Resident 53 was receiving 2.5 liters (L, a metric unit of volume)/minute (min) of oxygen via nasal canula. LVN S confirmed the physician order for Resident 53 is 4L/min.
Record review of physician orders for Resident 53, dated 3/31/2022, indicated a physician order of oxygen at 4 liters per minute and check with oxygen saturation (measurement of how much oxygen is in the blood) to be checked three times a day. Review of Resident 53's Vitals Report, on from 7/1/2022 to 7/12/2022, indicated numerous times throughout this time frame the resident had anywhere from no oxygen being administered to 3L of oxygen being administered for a total of 24 of 44 times the oxygen saturation was checked the oxygen being administered was less than the physician order of 4L/min.
During interview with LVN S, on 7/14/2022 at 10:07 a.m., LVN S stated nurses should alert the health care provider of her oxygen saturation and the varying oxygen needs. He stated they need parameters of oxygen saturation with instructions on how much oxygen they should administer. LVN S stated with chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems) physicians often give a range of oxygen and goals for oxygen saturation.
During observation and concurrent interview with RN R, on 7/15/2022, RN R confirmed Resident 53's physician order for four liters of oxygen, and confirmed the resident was on 2 L/min. RN R indicated the facility needed to contact the physician regarding the change in oxygen needs and get a new order for oxygen and stated they need a range of how much oxygen to provide along with oxygen saturation parameters.
Record review of the facility's policy Oxygen Administration, dated 8/15/2002, indicated staff should monitor the response to oxygen therapy and should follow the physician's orders, and clarify as needed.
Record review of the facility's policy, Changes in Resident Condition, dated 2/4/2008, indicated the communication regarding care and changes were important for consistency and care management. The policy indicated changes in resident status should be communicated with the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to provide adequate pain management based on professional standards to one of five residents (Resident 234) when:
1. Licensed nur...
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Based on observation, interview and record review, the facility failed to provide adequate pain management based on professional standards to one of five residents (Resident 234) when:
1. Licensed nurse did not notify the attending physician to get an order for PRN (as needed) medication for breakthrough pain (a flare of pain that might happen even though you are taking pain medicine regularly for chronic pain)
2. Licensed nurse did not follow the care plan to call MD (doctor of medicine) when pain relief measures failed to provide adequate relief.
3. Licensed nurse did not assess resident's pain when needed and did not document the pain medication when given.
These deficient practices had the potential to effectively manage pain to help the resident attain or maintain the highest practicable level of well-being.
Findings:
A review of Resident 234's admission Record indicated diagnoses of chronic pain syndrome, gout (swelling and tenderness of one or more joints characterized by severe pain, redness, and tenderness), cellulitis (common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) of right and left lower limb, neuralgia (a stabbing, burning, and often severe pain due to an irritated or damaged nerve) and neuritis (inflamed peripheral nerves); and osteoarthritis (the wearing down of the protective tissue at the ends of bones (cartilage) of hip.
During an observation and concurrent interview on 7/12/22 at 11:47 a.m., Resident 234 claimed there's a pain on my back. Resident also stated, nobody gives me pain medications after that one they gave this morning.
During an record review and concurrent interview with registered nurse R (RN R) on 7/15/22 at 10:00 a.m., RN R stated Resident 234 was on Methadone (pain medication) 10 mg. (milligrams, unit of measurement) 1 tablet daily and scheduled at 9:00 a.m. daily, and Gabapentin (for nerve pain) 100 mg. at bedtime (9:00 p.m.) as prescribed. RN R verified there was no PRN medication for breakthrough pain.
RN R also reviewed the medication administration record (MAR) from July 1-15, 2022 that indicated Resident 234 had 6/10 level of pain twice which were not relieved by non-pharmacological interventions. RN R stated the nurse should have called the doctor to get an order for PRN pain medications.
Review of Resident 234's care plan for pain dated 10/14/2020 included interventions to administer pain medications as ordered, provide non-pharmacological measures for pain relief (position change, restful environment diversional activity, etc) and to consult MD if the above measures fail to provide adequate pain relief.
During an observation and concurrent interview with Resident 234 on 7/15/22 at 11:55 a.m., resident was in bed and wanted the nurse because of pain. Resident 234 claimed her pain was on her back, feet, hands. She stated staff don't listen, and she will be told by staff that she already had the medications in the morning whenever she complained of pain. Certified nursing assistant EE (CNA EE) who came at bedside reported resident's pain to the charge nurse.
During a follow up visit with Resident 234 on 7/15/22 at 1:10 p.m. she claimed her pain level was still 9/10 and this was validated by the director of staff development (DSD) who came at resident's bedside. Resident claimed the nurse did not give her any pain medication nor had asked her about her pain. Licensed vocational nurse FF stated she had already given the Methadone in the morning at 9:00 a.m. LVN FF admitted she had not assessed Resident 234's pain since CNA EE had notified her, and that resident needed a PRN medication.
A review of Resident 234's progress notes dated 7/15/22 indicated, resident concerned about pain, no PRN for pain so MD was contacted and notified. MD gave order for Advil 400 mg every 8 hours PRN.
During a record review and concurrent interview with the minimum data set nurse (MDSN) and minimum data set coordinator (MDSC) on 7/15/22 at 3:35 p.m., both staff reviewed Resident 234's MAR and did not find any documented evidence that the PRN Advil was administered after it was ordered at 1:24 p.m.
During an interview and concurrent record review with the director of nursing (DON) on 7/18/22 9:06 a.m., the DON reviewed the MAR that indicated the nurse administered the Advil 400 mg but documented late ( hours after it was administered). The DON stated nurse should document the medications right away when given, if not documented not given.
A review of the facility's 12/1/2005 policy and procedure, Pain Management, indicated the purpose of pain management is to identify patients experiencing pain, develop, implement, and evaluate care plans for the management of pain, monitor and document the patient's response to pain management interventions. The pain experience is very subjective, pain is whatever the patient says it is. Care plan should include both pharmacological and non-pharmacological interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of 12 residents (27, 56, and 206) were free from unnec...
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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 three of 12 residents (27, 56, and 206) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when:
1. Resident 56 received Zoloft (used to treat persistent feeling of sadness, loss of interest, and panic attacks) without attempts of gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) since 7/3/21;
2. Resident 206 received olanzapine (used to treat extreme mood swings that include emotional highs and lows) without attempts of GDR since 8/7/21; and
3. Resident 27 received trazodone (an antidepressant medication) without monitoring for the effectiveness by monitoring number of hours of sleep.
These failures resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include, but not limited to, sedation, respiratory depression, falls, constipation, anxiety, agitation, abnormal involuntary movements, and memory loss.
Findings:
1. Review of Resident 56's admission Record indicated he was admitted to the facility on [DATE] with depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) diagnosis.
Review of Resident 56's physician order indicated he had been administered Zoloft 25 milligrams (mg, a metric unit of mass) every day for depression since 7/3/21, but there was no GDR attempts found for Resident 56's Zoloft 25 mg.
During an interview with the director of nursing (DON) on 7/18/22 at 2:28 p.m., she reviewed Resident 56's clinical record and confirmed there had been no GDR attempts for Resident 56's Zoloft 25 mg since 7/3/21.
2. Review of Resident 206's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including depression and bipolar disorder (a mood disorder that can cause intense mood swings).
Review of Resident 206's physician order indicated she had been administered olanzapine 5 mg at bedtime for bipolar disorder since 8/7/21, but there was no GDR attempts found for Resident 206's olanzapine 5 mg.
During an interview with the DON on 7/18/22 at 2:30 p.m., she reviewed Resident 206's clinical record and confirmed there had been no GDR attempts for Resident 206's olanzapine 5 mg since 8/7/21.
Review of the facility's policy, Medication Monitoring - Medication Management, dated 1/2022, indicated Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.
3. Resident 27 was admitted to the facility with diagnoses including insomnia due to other mental disorder and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 27's medical record indicated she had a physician's order, dated 6/10/2022, for trazodone 50 mg, 1 tablet at bedtime for insomnia M/B [manifested by] inability to sleep.
Resident 27's medical record also had a physician's order to monitor # [number] hours of sleep twice a day, from 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m., dated 3/9/22.
A review of the June and July 2022 medication administration records (MAR) indicated there was no # hours of sleep (such as how many hours the resident slept during the shift) documented, just the nurses' initials in the entries.
During a concurrent interview and record review with the DON on 7/15/22 at 2:06 p.m., she stated the nursing staff monitored the effectiveness of trazodone by monitoring the number hours of sleep. She reviewed the MAR and confirmed the staff put their initials in the # hours of sleep entries, and not the actual number (quantity) hours of sleep. She stated there should be the number of hours (such as 6 hours, 7 hours, etc.) to see if the medication was effective for the condition.
During a follow-up interview on 7/15/22 at 2:53 p.m., the DON stated whoever did the order since March did not put the space for staff to input the number of hours of sleep.
A review of the facility's policy and procedures titled Medication Monitoring Medication Management, dated 1/2022, indicated: When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications . and The clinical record must reflect the following: .Whether there is adequate monitoring for effectiveness of the medication in treating the specific condition .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure Resident 195 was free of a significant medication error when he received citalopram (a medication for depression) twic...
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Based on observation, interview, and record review, the facility failed to ensure Resident 195 was free of a significant medication error when he received citalopram (a medication for depression) twice the ordered dose. This failure resulted in the medication not given as ordered by the physician, and had the potential for increased risk of side effects (such as fatigue, dizziness, insomnia, etc.) for the resident.
Findings:
During a medication pass observation on 7/11/22 at 8:27 a.m., licensed vocational nurse (LVN) M was observed preparing and administering 3 medications to Resident 195. The medications included one tablet of citalopram 20 milligrams (mg, unit of measurement).
On 7/11/22, a review of Resident 195's medical record indicated he was admitted to the facility with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). It indicated he had a physician's order for citalopram 20 mg once daily for depression starting on 2/30/20. On 3/30/22, the order was reduced to 10 mg. The latest order was: citalopram 10 mg once daily, dated 4/7/22.
During a concurrent interview and record review with LVN M on 7/11/22 at 2:20 p.m., she reviewed Resident 195's physician's order for citalopram and confirmed it was for 10 mg, not 20 mg. LVN M provided Resident 195's citalopram blister card (a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered). The pharmacy label on the medication card indicated Citalopram 20 mg tablet and Give 1 tablet by mouth daily. There was no other stickers, such as the direction-change sticker on the card. LVN M stated there should be a direction-change sticker on the card to alert the nursing staff of the dose change. She stated she had been giving 20 mg (one whole tablet) on the days she worked.
On 7/11/22, a review of the July 2022 MAR indicated, in an 11-day period from 7/1 to 7/11/22, LVN M administered the citalopram 7 times, and LVN O administered the other 4 times.
During an interview with LVN O on 7/12/22 at 11:00 a.m., he stated he was a floater (staff without assigned specific area, who move from one unit to another depending on needs) so he was not familiar with Resident 195's medications, and did not recall giving half a tablet or whole tablet of the citalopram for him last week.
During an interview with the director of nursing (DON) on 7/12/22 at 4:20 p.m., she stated she was informed about the citalopram medication error for Resident 195. She said the medication card should have a direction change sticker whenever there was a dose change.
During a telephone interview with the pharmacist on 7/12/22 at 1:59 p.m., he stated the pharmacy had been sending monthly supply of citalopram 20 mg for Resident 195, and they only sent 10 mg on 3/30/22 (the day of the order change) and on 7/11/22 (the day the error was identified).
Resident 195's medical record included a physician's order to monitor for the potential side effects related to citalopram use. They included: fatigue, headache, tremor, somnolence, dizziness, agitation, insomnia, irregular heart rhythms, and confusion.
A review of the facility's Medication Pass Guidelines, dated 3/2000, indicated: To assure the most complete and accurate implementation of physician's medications orders Medications are administered in accordance with written orders of the attending physician Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.
A review of the facility's policy and procedures titled Medication Administration Orals, dated 11/2017, indicated: Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 95's clinical record, indicated he was admitted to the facility on [DATE] with diagnoses including lack of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 95's clinical record, indicated he was admitted to the facility on [DATE] with diagnoses including lack of coordination and reduced mobility.
During an interview with Resident 95 on 7/11/22 at 10:27 a.m., he stated he wants his finger nails to be clipped, they can't seem to find clippers.
During an observation on 7/18/22 at 7:41 a.m., Resident 95's finger nails on both hands were long with yellowish color.
During a concurrent interview with Resident 95, he stated my nails were long for about a month and many times I talked to certified nursing assistants (CNA) and others.
During an interview with CNA GG on 7/18/22 at 10:40 a.m., CNA GG stated CNA's were responsible in clipping residents finger nails. CNA GG further stated, if resident's finger nails were long CNAs report it to the charge nurse.
During a concurrent interview and record review with the infection preventionist (IP) on 7/18/22 at 12:29 p.m., the IP confirmed the above observation and confirmed Resident 95's cognition was intact. Further review of Resident 95's clinical record did not indicate he had non-compliance issues.
During an interview with the director of staff and development (DSD) on 7/18/22 at 1:29 p.m., the DSD stated CNA's were responsible in clipping residents finger nails and stated staff should provide hygiene to promote quality of life.
Review of Resident 95's point of care history indicated Resident 95 needed assistance with in performing his personal hygiene.
Review of Resident 95's Shower Day Skin Inspection form indicated finger nails clipping were not done on 4/7/22, 4/11/22, 4/18/22, 4/21/22, 4/25/22, 5/1/22, 5/9/22, 5/15/22, 6/6/22.
5. During an observation on 7/11/22 at 12:06 p.m., meal cart was delivered in station UVW and certified nursing assistant's started to deliver meal trays to residents room. There was no licensed nurse who checked the meal trays before they were distributed to the residents.
During an interview with the director of staff development (DSD) on 7/11/22 at 12:16 p.m., the DSD stated if the meal cart was already delivered, the staff should start passing the meal tray.
During an observation on 7/11/22, in station UVW, meal cart #2 was delivered in the station's hallway and there was no LN to check the meal tray before being distributed to the residents.
During an interview with certified nursing assistant X (CNA X) on 7/11/22 at 12:25 p.m., CNA X confirmed LN did not check the meal tray. CNA X further stated she had not observed the LN checking the meal trays.
During an observation on 7/11/22 at 12:52 a.m., meal cart was delivered in station XYZ and certified nursing assistant Y (CNA Y) distributed the meal trays. There was no LN who checked the meal trays before being distributed to the residents.
During an interview with CNA Y on 7/11/22 at 12:54 p.m., CNA Y stated LNs does not check the meal trays.
During an interview with the director of nursing (DON) on 7/11/22 at 5:01 p.m., the DON stated LNs should check the meal trays before CNAs distribute them to the residents. The DON further stated, LNs should check the diet card in the meal tray to make sure the diet order is right to the resident.
Review of the facility's policy, Meal Service dated 2018 indicated, Nursing is responsible for the delivery of the correct tray and checking that the appropriate diet was delivered.
2a. During the initial tour on 7/11/22 at 2:10 p.m., Resident 26 was noted to have long with yellowish and blackish particles nails. Certified nursing assistant D (CNA D) validated the observation and stated the resident's nails are thick and should be trimmed and cleaned.
2b. During an observation on 7/11/22 at 11:19 with certified nursing assistant D at bedside, CNA confirmed Resident 27's fingernails were long and dirty. CNA D stated she would need to cut Resident 27's nails.
During an interview with certified nursing assistant L (CNA L) on 7/15/22 at 9:04 a.m., nurses were responsible to cut the nails of residents who were diabetic and CNAs would cut the nails of non-diabetic residents.
2c. During the initial tour on 7/11/22 at 1:57 p.m., Resident 58 was noted with black sticky particles inside her fingernails. Resident 58 stated I don't' like it long and dirty. She informed CNA K that she needed her nails to be trimmed.
2d. During the initial tour on 7/11/22 at 9:19 a.m., Resident 155 showed his long nails to the surveyor and stated he wanted the staff to trim the nails.
3. During an observation on 7/12/22 at 11:39 a.m., Resident 234 stated her food was not good and wanted to have regular food. She requested to talk to a dietician (board certified expert in food and nutrition).
A record review of Resident 234's diet order indicated mechanical soft texture.
On 7/14/22 at 1:01 p.m., a dietary staff talked to Resident 234 and then obtained an order for speech therapy (ST) evaluation. The ST evaluation was done on the same day and indicated Resident 234 could have solid foods (regular foods) and thin liquids.
During a follow up visit with Resident 234 on 7/15/22 at 11:48 a.m., Resident 234 stated the staff had not been listening to her request to have regular foods.
During an observation on 7/15/22 at 1:10 p.m., Resident 234 was eating her lunch and stated, she's happy and glad to eat regular food .
Based on observation, interview, and record review, the facility failed to ensure 7 of 35 residents (36, 26, 27, 58, 155, 234, and 95) received the necessary care, services, and correct diets when:
1. Resident 36 did not receive the assessment and treatment for her wound timely;
2. The fingernails of Resident 26, Resident 27, Resident 58, and Resident 155 were long, dirty and were not trimmed;
3. Resident 234's request for a diet changed was not addressed promptly;
4. Resident 95 had long yellowish finger nails; and
5. Licensed Nurse (LN) did not check food trays for correct diets before serving the residents in two of 6 stations (Station UVW and Station XYZ).
These failures had the potential to affect the residents' care, health and well-being.
Findings:
1. Review of Resident 36's admission Record indicated she was admitted to the facility on [DATE] with diagnosis of dementia (the loss of the ability to think, remember, and reason to levels that affect daily life and activities).
During observations on 7/11/22 at 11:45 a.m. and on 7/14/22 at 11:02 a.m., Resident 36 had two wounds on her right cheek and one wound on her right lower arm.
During an observation with registered nurse I (RN I) on 7/15/22 at 9:45 a.m., Resident 36 still had two wounds on her right cheek and one wound on her right lower arm.
During a concurrent interview with RN I, she reviewed Resident 36's clinical record and confirmed there was no assessment and treatment order for the wounds. RN I stated she would call the physician to obtain treatment orders.
Review of the facility's policy, Skin Care Management, dated 12/1/05, indicated Each patient receives the care and services necessary to retain or regain optimal skin integrity.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 77's clinical record indicated she was admitted on [DATE] and had diagnoses of osteomyelitis (bone infecti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 77's clinical record indicated she was admitted on [DATE] and had diagnoses of osteomyelitis (bone infection), depression (a mood disorder that causes a feeling of sadness and loss of interest), acquired absence (amputation) of left leg above knee, acquired absence of right leg below knee, muscle weakness, difficulty in walking, and lack of coordination.
Review of Resident 77's Minimum Data Set (MDS, an assessment tool) dated 4/05/22, indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 15 (cognitively intact).
Review of Resident 77's Physician order dated 5/13/22, indicated RNA program for active assist range of motion (AAROM) to both upper extremities (BUE) two times per week for 90 days. and RNA program for sitting balance at edge of bed two times per week for 90 days. The orders were discontinued on 7/14/22.
During an interview with Resident 77 on 7/15/22 at 1:06 p.m. in her room, she stated the RNA program was not provided to her.
During an interview and concurrent record review with assistant director of nursing (ADON) on 7/18/22 at 10:08 a.m., she reviewed Resident 77's physician orders and confirmed the RNA program should have provided as ordered. The ADON confirmed there was no documentation RNA program was done in May, June and July.
3. Record Review of undated Resident 2's face sheet, indicated Resident 2's history included arthritis (joint swelling), reduced mobility, and hypertension (high blood pressure). Review of Resident 2's Brief Interview for Mental Status (BIMS; assessment tool to determine cognition), dated 6/11/2022, of 15 and he was able to make his own decisions regarding his finances and his medical care and treatment.
Record review of Resident 2's Progress Notes, dated 7/7/2022, indicated that Resident 2 stated he did not receive seven sessions of the RNA program, and that it was explained to Resident 2 that the RNA who was assigned to provide services was on vacation. The note further indicated that any days missed will be compensated by adding on additional sessions.
Record review of Resident 2's physician orders, dated 4/13/2022, indicated Resident 2 should receive RNA services for range of motion twice a week for 90 days and would end 7/13/2022. Record review of Resident 2's physician orders, dated 6/7/2022, indicated the end date of RNA services was extended to 9/7/2022.
During interview with Resident 2, on 7/14/2022 at 11:07 a.m., Resident 2 stated The facility did not provide RNA services seven times. It is nonsense. I am here and my insurance and tax payers are paying and I am not getting the services. We had an interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their clients) and they said they would make up the time. What happens if my nurse goes on vacation. Will I wait two weeks or more for my medications?
During interview with the Assistant Director of Nursing (ADON), on 7/15/2022 at 10:26 a.m., the ADON stated she supervises the RNA program. The ADON confirmed Resident 2 has a physician order for RNA services and states it is for maintaining strength and lower extremity range of motion. The ADON stated Resident 2 is at risk for bilateral lower extremity contractures and confirmed a care plan for this. The ADON confirmed the resident did not receive RNA services twice because Resident 2's primary RNA was on vacation. She stated Resident 2 did not receive the physician ordered services the last week of June or first week of July. The ADON confirmed missing days will be made up. She confirmed his end date has been extended and they will do more sessions per week to make up for any missing sessions.
Review of the facility's untitled and undated policy indicated, It is the Facility's philosophy that all residents receive care and services that promote their ability to adapt and adjust to living as independently as possible. The policy further indicated, restorative care program is a vial part of the residents care.
Based on interview and record review, the facility failed to ensure appropriate treatment and services were provided for five of seven residents (Resident 125, 228, 234, 77 and 2) 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 125's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including other sequelae of cerebral infarction (other consequences of stroke).
Review of Resident 125's physician order dated 6/7/22 indicated RNA program for ambulation with front wheeled worker two times per week for 90 days and RNA program for transfer from wheelchair to bed two times per week for 90 days
During an interview with restorative nursing assistant CC (RNA CC) on 7/14/22 at 1:35 p.m., RNA CC stated I was not sure when Resident 125 was referred to RNA program. RNA CC further stated Resident 125 always refused his exercise but she did not document his episodes of refusal.
During an interview and concurrent record review with the director of nursing (DON) on 7/14/22 at 4:15 p.m., the DON confirmed Resident 125 had the above physician orders for RNA and confirmed there was only one documented episode of RNA program done in June 2022.
During an interview with the assistant director of nursing (ADON) on 7/14/22 at 4:25 p.m., the ADON stated RNA CC told her, Resident 125 had episode of refusal. The ADON further stated if resident refuses three times the facility should conduct RNA meeting and discussed what is the reason resident was refusing. The ADON confirmed RNA meeting for Resident 125's refusal of RNA program did not happen because it was not brought out.
2. Review of Resident 228's clinical record indicated he was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of muscle function).
Review of Resident 228's physician order dated 3/15/22 indicated RNA program for active assistive range of motion (AAROM) to both upper extremities (BUE) two times per week for 90 days and RNA for passive range of motion both lower extremities (BLE) two times per week for 90 days.
During an interview with RNA DD on 7/15/22 at 8:35 a.m., RNA DD stated she did not work with Resident 228 last March 2022. RNA DD confirmed there was no RNA documentation in March and there were only two RNA documentation in April and there was no documentation RNA was done in May and June.
During an interview with the ADON on 7/15/22 at 9:31 a.m., the ADON stated she was in-charged for the RNA program. The ADON reviewed Resident 228's clinical record and confirmed there was only one documentation for passive and active range of motion exercises. The ADON confirmed RNA program was not documented that it was done in the month of May and June. The ADON acknowledged if resident refuses RNA program three times, residents should be referred back to the rehab department.
During an interview with minimum data set nurse (MDSN) on 7/15/22 9:39 a.m., the MDSN reviewed Resident 228's care plan and stated RNA program started 3/15/22 and next update is 9/30/22/
At 9:55 a.m., the MDSN reviewed Resident 228's minimum data set (MDS, an assessment tool) dated 6/6/22 and confirmed Resident 228 was no longer in RNA program. The MDSN further confirmed Resident 228's care plan did not reflect his status.
Review of the facility's policy, Comprehensive Plan of Care dated 11/15/2001 indicated, residents goal should be evaluated.
3. A review of Resident 234's admission Record indicated diagnoses of gout (swelling and tenderness of one or more joints characterized by severe pain, redness, and tenderness), osteoarthritis (the wearing down of the protective tissue at the ends of bones (cartilage) of hip. Her minimum data set (MDS, an assessment tool) dated 6/7/22 indicated, she had functional limitation in range of motion (ROM) on both lower extremities.
During an observation on 7/12/22 at 11:44 a.m., Resident 234 was in bed. She stated they leave me in bed all the time. Resident also stated she wanted to sit and get up.
During an observation on 7/15/22 at 11:58 a.m., Resident 234 denied refusing any restorative nursing assistant (RNA) or any exercises. Resident 234 claimed nobody performed any exercise on her legs and she stated I really wanted to have exercises of my feet, it helps right?
During an observation on 7/15/22 at 1:09 p.m., the director of staff development (DSD) confirmed Resident 234 had contractures on both feet and had foot drop.
During a record review and concurrent interview on 7/15/22 at 10:02 a.m., registered nurse R (RN R) confirmed there was no documented evidence that the physician was notified of Resident 234's RNA refusal.
During an interview with the minimum data set nurse (MDSN) on 7/15/22 at 11:02 a.m., confirmed Resident 234 had limited ROM on both lower extremities. The MDSN stated RNA referral should be done to prevent further decline.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility had a medication error rate of 18.75% when six (6) medication errors occurred out of 32 opportunities during the medication administrat...
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Based on observation, interview, and record review, the facility had a medication error rate of 18.75% when six (6) medication errors occurred out of 32 opportunities during the medication administration for five out of nine residents (Resident 68, 96, 115, 152, and 195). The failure resulted in medications not given according to the physician's orders, and had the potential for residents not receiving the full therapeutic effects of medications.
Findings:
1. During a medication pass observation on 7/11/22 at 8:27 a.m., licensed vocational nurse (LVN) M was observed preparing and administering 3 medications to Resident 195. The medications included one tablet of citalopram (an anti-depressant medication) 20 milligrams (mg, unit of measurement).
On 7/11/22, a review of Resident 195's medical record indicated: Citalopram 10 mg 1 tablet once daily for depression, dated 4/7/22.
During a concurrent interview and record review with LVN M on 7/11/22 at 2:20 p.m., she reviewed Resident 195's physician's order for citalopram and confirmed it was for 10 mg, not 20 mg. She stated she had been giving citalopram 20 mg on the days she worked.
2. During a medication pass observation on 7/11/22 at 8:38 a.m., LVN M was observed administering two tablets of medications to Resident 115. Included in the medications was one tablet of vitamin B-12 (a supplemental nutrient that keeps the nerve cells and blood cells healthy) 500 micrograms (mcg, unit of measurement).
On 7/11/22, a review of Resident 115's medical record indicated a physician's order for cyanocobalamin (vitamin B-12) 2,000 mcg once daily, dated 6/7/22.
During a concurrent interview and record review with LVN M on 7/11/22 at 2:27 p.m., she reviewed Resident 115's medical record and confirmed she gave only 1 tablet of vitamin B-12 500 mcg, and stated she should have given four tablets to make 2,000 mcg.
3. During a medication pass observation on 7/11/22 at 9:26 a.m., LVN O was observed preparing 6 medications for Resident 96. Included in the medications was a tablet of vitamin D3 (a supplement 1,000 international units (IU, unit of measurement).
On 07/11/22 at 9:28 a.m., at the resident's bedside, LVN O stated he needed to come back with the translator as the resident did not speak English and could not understand him.
On 7/11/22 at 10:15 a.m., LVN O stated he needed to pull the medications again as he already disposed of the those he had prepared earlier. Again this time he prepared 6 medications including one tablet of vitamin D3 1,000 IU and one tablet of vitamin D3 5,000 IU. On 7/11/22 at 10:23 a.m., LVN O administered the medications to Resident 96 with the assistance and translation of another nurse.
On 7/11/22, a review of Resident 96's medical record indicated the physician's orders:
a. Vitamin D3 5,000 IU, once daily, dated 12/9/2021; and
b. Calcium 600 mg plus vitamin D3 200 IU, one tablet twice daily, dated 6/27/2020.
During a concurrent interview and record review with LVN O on 7/12/22 at 10:04 a.m., he verified Resident 96 did not have an order for vitamin D 1,000 IU, only the 5,000 IU. He stated he probably saw the order for calcium 600 mg plus vitamin D and thought that was it.
4. During a medication pass observation on 7/11/22 at 9:51 a.m., LVN P was observed preparing and administering 4 medications, including a tablet of aspirin enteric coated (EC, a coating formation that allows aspirin to pass through the stomach to the small intestine before dissolving) 81 mg, to Resident 152.
On 7/11/22, a review of Resident 152's medical record indicated a physician's order, dated 5/16/22, for aspirin, chewable, 81 mg once daily for stroke prevention.
During a concurrent interview and record review with LVN P on 7/11/22 at 3:51 p.m., she looked up the physician's order, and confirmed she administered the EC aspirin, not the chewable type. She verified they were not the same.
5. During a medication pass observation on 7/12/22 at 8:19 a.m., LVN Q was observed preparing and administering 7 medications, including a tablet of senna (to treat constipation) 8.6 mg, to Resident 68.
On 7/12/22, a review of resident 68's medical record indicated the following physician's orders:
a. Senna tablet; 8.6 mg; amount: 2 tablet (8.6 mg) via gastric tube twice a day for bowel regimen, dated 10/13/21; and
b. Restasis (cyclosporine, medication to help stimulate tear production in people with chronic dry eyes) 0.05%, 1 drop in each eye twice daily at 9 a.m. and 5 p.m. for dry eyes, dated 10/13/21
There was no Restasis eye drop given during the medication administration observation as mentioned above.
During a concurrent interview and record review with LVN Q on 7/12/22 at 10:21 a.m., she looked up Resident 96's physician's orders and verified it indicated to give 2 tablets of senna. She stated, I will give another tablet now. Regarding the Restasis, LVN Q stated it was due at 9 a.m., but she did not give it because she did not have it in stock. With the surveyor present, LVN Q searched through the medication cart and stated she did not have it.
During an interview with the director of nursing (DON) on 7/13/22 at 10:10 a.m., she reviewed Resident 86's physician's order for senna, which indicated 2 tablet (8.6 mg). She verified the order indicated to give 2 tablets; and senna only came in 8.6 mg and not 4.3 mg tablets.
A review of the facility's Medication Pass Guidelines, dated 3/2000, indicated: To assure the most complete and accurate implementation of physician's medications orders Medications are administered in accordance with written orders of the attending physician Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route.
A review of the facility's policy and procedures titled Medication Administration Orals, dated 11/2017, indicated: Review and confirm medication orders for each individual resident on the Medication Administration Record PRIOR to administering medication.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when:
1. Nine (9) insulin (medication to lower blood sugar) pens did not have patient-specific labeling on each pen to prevent mix-up errors;
2. Temperature (temp) monitoring was missing and/or not consistently documented twice daily on the temp log sheets for two of three observed medication refrigerators;
3. Expired or discontinued medications were not put away to prevent medication errors;
4. An eye drop medication was not kept in the refrigerator until opened; and
5. A heparin (an injectable medication to prevent blood clot) vial was not dated with an open date.
The deficient practices had a potential for residents to receive medications with unsafe and reduced potency from being used past their discard date; medication errors due to medications not being labeled or removed from active stock; and inadequately monitored medications, which could lead to unsafe and ineffective medications for the residents.
Findings:
1. During a visit to the Station 4 Medication Room with registered nurse (RN) T on [DATE] at 11:09 a.m., inspection of the medication refrigerator identified eight (8) insulin pens (such as Trulicity and Lantus pens) without patient-specific labeling on them. RN T confirmed the pen would be removed from the refrigerator and left in the medication cart for multiple administrations, and stated they should be labeled to prevent mix-up with other residents' pens who had the same insulin orders.
During a visit to the Station 3 Medication Room with licensed vocation nurse (LVN) KK on [DATE] at 12:28 p.m., inspection of the medication refrigerator identified one of one Trulicity pen without the patient-specific labeling on the body of the pen. LVN KK stated it should be labeled with the resident's information.
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, If an institution chooses to use insulin pen devices, each should contain a patient-specific label and be stored in a patient-specific bin/drawer . to prevent contamination from inadvertent misuse on another patient.
A review of the facility's policy and procedures (P&P) titled Medication Ordering and Receiving From Pharmacy Provider Medications and Medication Labels, dated 1/2022, indicated: The provider pharmacy permanently affixes label to the outside of prescription containers . For medications designed for multiple administration . a label is affixed to product to assure proper resident identification.
2. During a visit to the Station 4 Medication Room with registered nurse (RN) T on [DATE] at 11:09 a.m., a review of the medication refrigerator temp log indicated the staff had been monitoring only once daily from 7/1 to [DATE]. The instructions on the log indicated to Record temps twice each workday. RN T verified this finding and stated it should be monitored twice daily. The medication refrigerator was observed to contain many insulin products, a refrigerated emergency kit (medications for use in the emergency), eye drops, and other refrigerated medications.
On [DATE] at 11:20 a.m., further review of the past five months' temp logs, from February to [DATE], with RN T, indicated they were incomplete, as follows. She verified they were incomplete and not consistently monitored twice daily.
- For February 2022, there were 20 missing temp recordings; there were 5 days without any recording
- For [DATE], there were 23 missing temp recordings
- For [DATE], there were 6 missing temp recordings
- For [DATE], there were 8 missing temp recordings; there was 1 day without any recording
- For [DATE], there were 5 missing temp recordings; there was 1 day without any recording
During a visit to the Station 3 Medication Room with LVN KK on [DATE] at 12:28 p.m., a review of the past four months' medication refrigerator temp logs, from April to [DATE], with LVN KK reflected the following:
- For [DATE], there were 31 missing temp recordings
- For [DATE], there were 30 missing temp recordings; there were 2 days without any recording
- For [DATE], there were 33 missing temp recordings; there were 2 days without any recording
- For [DATE], there were 35 missing temp recordings; there were 3 days without any recording
During the review, LVN KK stated the temp log should be documented twice daily according to the temp log's directions. The medication refrigerator was observed to contain many refrigerated medications including insulin pens, insulin vials, and the refrigerated E-kit.
A review of the facility's P&P titled Storage of Medications, dated 1/2021, indicated: The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily.
During an interview with the infection preventionist (IP) on [DATE] at 8:53 a.m., she stated the facility stored vaccines (such as flu vaccine, vaccine to prevent pneumonia, hepatitis, etc.) throughout the year in each of the medication refrigerator at each nursing station for the resident administration. There was no separate refrigerator for just vaccines.
3. During a visit to the Station 1 Medication Room with RN G on [DATE] at 11:43 a.m., an opened vial of Lantus (long acting insulin) and an opened vial of Admelog (fast-acting insulin) were identified in the medication refrigerator without any open date. They were together with many other insulin vials. RN G stated they were discontinued medications and should have been put away.
During a visit to the Station 3 Medication Room with LVN KK on [DATE] at 12:28 p.m., an opened tuberculin vial (used in the diagnosis of tuberculosis) was identified with the opened date of [DATE]. The manufacturer's label indicated to Discard opened product after 30 days. LVN KK confirmed this product had expired and should have been discarded.
The facility's P&P titled Storage of Medications, dated 1/2021, indicated, Outdated . discontinued medications are immediately removed from stock .
4. During an inspection of Station 2's medication cart with LVN KK on [DATE] at 11:42 a.m., an unopened latanoprost eye drop (medication for glaucoma) for a resident was identified in the medication cart, stored at room temperature. The pharmacy label indicated: Refrigerate until opened. Discard 42 days after opening. An auxiliary label on the carton indicated: Refrigerate until opened then store at room temperature. LVN KK verified this finding.
The facility's P&P titled Storage of Medications, dated 1/2021, indicated, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration.
5. During an inspection of the Station 5A Medication Cart on [DATE] at 2:22 p.m. with LVN S, one of one heparin multi-dose vial was identified opened without the open date. LVN S verified this finding and stated it was good for 28 days after opened.
A review of the facility's P&P titled Medication Ordering and Receiving From Pharmacy Provider Medications and Medication Labels, dated 1/2022, indicated: Multi-dose vials shall be labeled to assure product integrity, considering the manufacturer's specifications . Nursing staff should document the date opened on multi-dose vials .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to prepare food that conserved nutritive value and flavor when pureed food was prepared hours before serving. This failure had t...
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Based on observation, interview, and record review, the facility failed to prepare food that conserved nutritive value and flavor when pureed food was prepared hours before serving. This failure had the potential for 50 out 232 residents who received pureed diet with reduced nutrients or flavor.
Findings:
During an interview with the dietary manager (DM) on 7/12/22 at 8:58 a.m., the DM confirmed the puree food preparation starts at 10:00 a.m.
During an observation on 7/11/22 at 10:08 a.m., dietary cook MM (DC MM) pureed the cooked frozen green beans.
At 10:29 a.m., surveyors asked when will the cook prepare to puree the proteins. Dietary cook NN (DC NN) stated he already pureed the proteins at 9:30 a.m., and placed them at the steam table around 9:45 a.m.
At 11:55 a.m., tray line (food preparation/assembly) started.
At 1:33 p.m., tray line was still ongoing and meal cart for station XYZ was out in the kitchen.
During an interview with the registered dietitian (RD) on 7/12/22 at 3:45 p.m., the RD was asked about the puree preparation. The RD stated I will get back about the puree preparation.
Review of the facility's policy, Meal Service dated 2018 indicated, Food shall not be held on steam table for more than two hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain essential equipment in good and safe operating condition when:
1. Two out of two walk-in freezers had icicle build-u...
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Based on observation, interview, and record review, the facility failed to maintain essential equipment in good and safe operating condition when:
1. Two out of two walk-in freezers had icicle build-up;
2. Two out of five-unit refrigerators had broken parts.
These failures had the potential to cause the freezers and refrigerators to be ineffective for keeping food frozen and refrigerated for 223 residents who received food from the kitchen out of 232 residents.
Findings:
1a. During an initial kitchen tour observation on 7/11/22 at 8:51 a.m., the walk-in freezer in the kitchen had icicle build up in the storage racks and the significant ice buildup was observed around a pipe.
During a concurrent interview, the dietary manager (DM) confirmed the above observation and stated she will get the maintenance staff.
During an observation in the kitchen on 7/12/22 at 9:26 a.m., the walk-in freezer's pipe had ice buildup.
1b. During an observation on 7/11/22 at 11:02 a.m., walk-in freezer outside the kitchen had significant ice buildup on the wall and on the floor.
During a concurrent interview, the DM confirmed the above observation and stated it was delivery day.
During an interview with the dietary staff (DS) on 7/12/22 at 9:03 a.m., the DS stated, no delivery today.
During an observation with the DS on 7/12/22 at 9:09 a.m., the walk-in freezer outside the kitchen had icicles on the wall and on the floor.
During a concurrent interview with the DS, he confirmed the above observation and stated, not ok to see the ice buildup.
During an interview with the registered dietitian (RD) on 7/12/22 at 3:35 p.m., the RD stated walk-in freezer should not have icicle buildup.
2a. During an observation in station UVW's storage room on 7/12/22 at 4:36 p.m., the refrigerator's door gasket was broken and the refrigerator's behind kickplate had orange-brown color.
During a concurrent interview with licensed vocational nurse KK (LVN KK), she confirmed the above observation.
During an interview with the RD on 7/12/22 at 4:38 p.m., the RD stated the broken gasket was not ok.
2b. During an observation in station XYZ's storage room on 7/12/22 at 5:08 p.m., the refrigerator's storage bin had a cracked.
During a concurrent interview with LVN KK, she confirmed the above observation.
2017 Food Code Section 4-501.11 states that equipment must be maintained in a state of repair and condition that meets the requirements specified by the food code.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation interview, and record review, the facility failed to provide a safe and comfortable environment for residents and visitors when:
1. A housekeeping cart with cleaning chemicals was...
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Based on observation interview, and record review, the facility failed to provide a safe and comfortable environment for residents and visitors when:
1. A housekeeping cart with cleaning chemicals was left unattended on the resident hallway;
2. A resident's room (Resident 2) had damaged walls and a hole in the wall.
This had the potential to adversely affect the health and safety of residents and any visitors.
Findings:
1. During observation on hall five, on 7/11/2022 at 12:12 p.m., a housekeeping cart was left unattended with a container of bleach wipes on top of the cart and mop bucket with liquid in it.
During interview with laundry aide (LA), on 7/11/2022 12:12 p.m., LA confirmed the unattended cart with bleach and indicated the mop water was for the janitor. She stated she did not know where the janitor was and confirmed leaving the housekeeping cart unattended was a safety risk to residents and visitors. LA confirmed the residents would have access to the chemicals and confirmed the observation of three residents in wheelchairs passing by the unattended cart while two more residents walked by with their walkers.
During interview with Housekeeping Aide (HKA), on 7/11/2022 at 12:20 p.m., HKA confirmed the chemical in the mop bucket on the housekeeping cart was a germicidal and disinfectant chemical called pH7Q. HKA confirmed the instructions indicated poison control may need to be contacted if in the eyes, on the skin, if swallowed, and if inhaled. HKA confirmed bleach wipes were also on the top of the cart. HKA confirmed chemicals should not be stored unattended in the hall for safety reasons and confirmed any visitors and residents could access the chemicals on the cart.
Record Review of facility policy Housekeeping Equipment Guide, dated 4/15/2001, indicated the cart should never be left unattended with chemicals exposed for safety reasons. The policy further indicated chemicals should be kept with the housekeeper or locked up.
2. Record Review of Resident 2's face sheet, undated, indicated Resident 2, history included arthritis (joint swelling), reduced mobility, and hypertension (high blood pressure). Review of Resident 2's Brief Interview for Mental Status (BIMS; assessment tool to determine cognition), dated 6/11/2022, of 15 and he was able to make his own decisions regarding his finances and his medical care and treatment.
During observation and concurrent interview with Resident 2, on 7/14/2022 at 11:16 a.m., Resident 2 indicated a baseball sized hole along with other small holes and wall damage around the larger hole. The hole and other smaller holes were on the wall across from the foot of his bed and under a clock on the wall. He stated he reported it to staff when he was moved to the room. He stated the facility did not repair the hole and instead taped a calendar over it. He pointed out numerous other holes in wall and stated he asked for repair and no changes were made. He stated .I hate how it looks. I am ashamed and embarrassed and I worry it is also dirty because you can see the drywall broken and into the wall.
During observation and interview with registered nurse R (RN R), on 7/15/2022 at 12:05 p.m., RN R stated taping a calendar over a hole in the wall is not homelike nor was it an adequate repair. RN R stated the wall needed to be repaired.
Record Review of facility policy Resident Rights, dated 12/18/2002, indicated the resident has the right to a dignified existence along with freedom of choice about how they wish to live their every day life.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4b. Review of Resident 14's clinical record indicated she was admitted on [DATE] and had diagnoses of sepsis (a life-threatening...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4b. Review of Resident 14's clinical record indicated she was admitted on [DATE] and had diagnoses of sepsis (a life-threatening complication of an infection), depressive disorder (a mood disorder that causes a feeling of sadness and loss of interest), anxiety disorder (a mental disorder by feeling worried and/or fear), lack of coordination, altered mental status and hypertension (high blood pressure).
Review of Resident 14's Minimum Data Set (MDS, an assessment tool) dated 6/17/22, indicated she had a brief interview of mental status (BIMS, a structured cognitive test) scoring 12 (moderately impaired).
During an observation and concurrent interview with Resident 14 on 7/11/22 at 10:17 a.m. in her room, three white pills in a medication cup on the over-the-bed table were observed. Resident 14 stated her nurse left the medication there and went out to check another resident.
During an interview and concurrent observation with LVN Q on 7/11/22 at 10:22 a.m., she confirmed she left Resident 14 unattended while the resident took the medications. LVN Q stated she should have remained with Resident 14 while the resident took the medications.
During an interview with Resident 14 on 7/15/22 at 11:36 a.m., she stated her nurse did not remain with her while she took her morning medications.
During an interview with RN I on 7/15/22 at 1:50 p.m., she stated she left Resident 14 unattended while the resident took her medication. RN I stated she should have remained with Resident 14 while the resident took the medication.
During an interview with director of nursing on 7/18/22 at 10:33 a.m., she acknowledged the licensed nurse should remain with the residents while administering medication.
The facility's policy and procedures titled Medication Administration, dated 11/2017, indicated: Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so . Use caution with residents who have difficulty with swallowing.
Based on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction); and safe and effective use and administration of medications when:
1. Random controlled medication use audits 9 out of 9 residents (Residents 11, 18, 23, 37, 116, 118, 133, 139, and 163) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. There was a total of 47 controlled medications unaccounted for. This failure had the potential for misuse or abuse of controlled medications;
2. Medications for residents were not given or given late for two of 35 sampled residents (Resident 68 and 77) and Resident 133. This had the potential for residents not meeting the resident's therapeutic needs;
3. Two of 14 observed emergency kits (E-kit, a kit/box containing medications and supplies for immediate use during a medical emergency or urgent situations) were opened and not replaced timely as per the facility policy and procedures. This had the potential for unavailability of emergency medications to administer to residents during urgent situations; and
4. Three nursing staff left the medications at the residents' bedside without ensuring they swallowed the medications. This had the potential for residents not taking the medications or having swallowing difficulty or choking without the nurse present for immediate help.
Findings:
1. The Controlled Drug Records (CDRs) for nine (9) random residents receiving PRN (meaning as-needed) controlled medications were requested for review during the survey.
During an interview with the director of nursing (DON) on 7/13/22 at 3:07 p.m., she stated any time a resident requested for a PRN controlled medication, the nurse was to assess the resident's condition, remove the medication from the locked controlled drug compartment, sign out of the narcotic book (on the CDR), administer to the resident, document the administration on the MAR, then re-assess the resident for effectiveness after 45 to 60 minutes.
a. Resident 23 had a physician's order, dated 7/1/21, for oxycodone (a potent controlled medication for moderate to severe pain) 10 milligrams (mg, unit of measurement), 1 tablet every 6 hours PRN moderate pain.
During a concurrent interview and record review with the DON on 7/13/22 at 3:09 p.m.,
a review of Resident 23's CDR for oxycodone and the 7/2022 MAR reflected the nursing staff signed out of the CDR (meaning they removed the medication from the locked controlled medication compartment in the medication cart) but did not document the respective administration on the MAR: on 7/6/22 at 9 a.m., 7/8/22 at 9 a.m., and on 7/12/22 at 12 p.m. The DON verified this finding and acknowledged three (3) oxycodone tablets were not accounted.
b. Resident 118 had a physician's order, dated 6/1/22, for tramadol (a controlled medication for pain) 100 mg, 1 tablet every 8 hours PRN pain.
On 7/13/22 at 3:16 p.m., a review of Resident 118's CDR for tramadol and the July 2022 MAR with the DON indicated, on 7/4/22 at 11 a.m., the nursing staff removed a tablet of tramadol without documenting the administration on the MAR. She verified one tramadol tablet was unaccounted.
c. Resident 37 had a physician's order, dated 3/11/22, for tramadol 50 mg 1 tablet every 4 hours PRN.
On 7/13/22 at 3:19 p.m., a review of resident 37's CDR for tramadol 50 mg and the June 2022 MAR with the DON indicated the staff removed 1 tablet of tramadol on 6/11/22 at 5 a.m. but did not document the administration on the MAR. The DON verified one tramadol tablet was unaccounted.
d. Resident 11 had a physician's order, dated 4/2/22, for oxycodone-acetaminophen (Percocet, potent controlled medication for moderate to severe pain), 5-325 mg 1 tablet every 6 hours PRN pain.
On 7/13/22 at 3:24 p.m., a review of Resident 11's CDR for Percocet 5/325 mg and the April 2022 MAR with the DON indicated the nursing staff signed out 4 tablets on: 4/3/22 at 3 p.m. and 10 p.m.; 4/4/22 at illegible time; and 4/11/22 at 4 a.m. However, none of these was documented on the MAR to indicate they were administered to the resident. The DON acknowledged 4 Percocet tablets were not accounted.
e. Resident 133 had a physician's order, dated 5/7/22, for tramadol 50 mg 1 tablet every 6 hours PRN moderate pain.
On 7/13/22 at 4:46 p.m., a review of Resident 133's CDR for tramadol and the June and July 2022 MARs with the DON indicated the nursing staff removed 10 tablets on: 6/25 at 10 p.m., 6/26 at 5 a.m., 6/27 at 5 a.m., 6/29 at 6 a.m., 6/30 at 5 a.m., 7/1 at 5 a.m., 7/5 at 2 p.m., 7/6 at 6 a.m., 7/7 at 6 a.m., and 7/8/22 at 11 a.m. However, none of these was documented on the MAR to indicate they were administered to the resident. The DON acknowledged 10 tramadol tablets for the resident was not accounted.
f. Resident 116 had a physician's order, dated 1/25/22, for hydrocodone-acetaminophen (Norco, controlled medication for moderate to severe pain) 5-325 mg, 1 tablet every 6 hours PRN moderate to severe pain
On 7/13/22 at 4:55 p.m., a review of Resident 116's CDR for Norco and the June and July 2022 MARs with the DON indicated the staff removed 13 tablets of Norco on: 6/15 at 8:30 a.m.; 6/24 at 9 a.m. and 6 p.m.; on 6/25 at 5 (no am or pm written); 6/26 at 8 p.m.; 6/28 at 9:18 a.m., at illegible time, 3:30, and 8:00(no am or pm written); 6/29 at 2 a.m.; 7/1 at 3 p.m., 7/8 at 11 a.m.; and 7/9/22 at 9 a.m. None of these was documented on the MAR to indicate they were administered to the resident. The DON verified this finding and acknowledged 13 Norco tablets were not accounted for.
During an interview with Resident 116 on 7/14/22 at 12:30 p.m., he stated he had pain on his knees, and the pain level was usually 9 out of 10 (severe pain).
g. Resident 139 had a physician's order, dated 4/28/21, for Percocet 5-325 mg, 1 tablet every 4 hours PRN moderate to severe pain.
On 7/13/22 at 4:59 p.m., a review of Resident 139's CDR for Percocet and the June and July MARs with the DON indicated the staff removed the following: On 6/28 at 12:45 a.m., 6/29 at 1 a.m., 6/30 at 12:12 a.m., 7/1 at 12 a.m., 7/2 at 2 a.m., 7/3 at 12 a.m., 7/4/24 at 12 a.m., 7/5 at 12:15 a.m., 7/6 at 12 a.m., and 7/7/22 at 1:30 (no a.m. or p.m. written). None of these was documented on the MAR to indicate they were given to the resident. The DON confirmed 10 Norco tablets for Resident 139 were unaccounted for. The CDR indicated these were removed by licensed vocational nurse (LVN) V.
During an interview with Resident 139 on 7/14/22 at 9:14 a.m., she stated she had rheumatoid arthritis (chronic inflammatory disorder affecting many joints, including those in the hands and feet) but did not like to ask for pain medications often. She stated, Sometimes it helps, and sometimes not after the medication given to her.
h. Resident 18 had a physician's order on 5/26/22 for lorazepam (Ativan, an anti-anxiety medication) 0.5 mg, 1 tablet at bedtime as needed for anxiety. On 7/2/22, the order was changed to 0.5 mg, 1 tablet every 8 hours PRN anxiety.
On 7/13/22 at 5:03 p.m., a review of Resident 18's CDR for Ativan and the June and July MARs with the DON indicated the nursing removed 3 tablets without documenting the administration on the MAR. They were on: 6/14 at 9 p.m., 6/19 at 9 p.m., and 7/5 at 6:41 p.m. The DON confirmed 3 Ativan tablets for Resident 18 were not accounted for. The CDR indicated they were also removed by LVN V.
i. Resident 163 had a physician's order, dated 6/7/22, for Norco 5-325 mg, 1 tablet every 6 hours PRN moderate to severe pain.
On 7/13/22 at 5:08 p.m., a review of Resident 163's CDR for Norco and the July 2022 MAR with the DON indicated the nursing staff removed 2 tablets: on 7/7 at 12 a.m. and 7/10/22 at 3:30 a.m., without documenting these administrations on the MAR. The DON confirmed 2 Norco tablets for Resident 163 were not accounted for.
During an interview on 7/13/22 at 5:14 p.m., the DON confirmed there was a total of 47 controlled medications removed from the medication carts but not documented as given for 9 out of 9 residents. She stated, The nurse removes med but not documenting on the MAR, but they were supposed to. She was asked to provide supporting evidence, such as in nursing progress notes, to demonstrate they were administered to the residents.
During a follow-up interview on 7/14/22 at 11:40 a.m., the DON stated she looked into the nurses who failed to document the administrations and most of them were from the agency except registered nurse (RN) T, LVN V, the infection preventionist (IP) and a few staff who worked night shift.
During an interview and record review with RN T on 7/14/22 at 11:45 a.m., she reviewed Resident 133's CDR and confirmed she removed the tramadol on 7/6 at 6 a.m. and 7/7 at 6 a.m She stated, I admit I didn't document. She stated she was busy tending to many residents and forgot to document. She confirmed she was supposed to document each medication administration on the MAR.
During a concurrent interview and record review with the IP on 7/14/22 at 11:55 a.m., she confirmed she did not document the administration of Resident 11's Percocet on 4/4/22 at around 1 p.m. She stated she must have forgotten to document, and she was supposed to document on the MAR to account for the medication.
During an interview with LVN V on 7/14/22 at 4:28 p.m., she stated every time a controlled medication was removed from the medication cart, the nurse was to document the administration on the MAR to indicate it was given to the resident. She reviewed Resident 139's CDR and verified she did not document the Percocet administration ten days in a row; and 3 tablets of Ativan for Resident 18. She stated most of the time she was busy, distracted, and I forget to document.
A review of the facility's policy and procedures (P&P) titled Medication Administration Orals dated 11/2017, indicated: Chart medication administration on Medication Administration Record immediately following each resident's medication administration.
The facility's guidelines titled Medication Pass Guidelines, dated 3/2000, indicated: Record the name, dose, route, and time of medication on the Medication Administration Record.
2a. Resident 68 was admitted to the facility with diagnoses including hip and back pain. His physician's orders included: Lidocaine (a topical pain reliever) patch 4%, apply 2 patches topically once a day, at 9 a.m., for pain management, dated 10/13/21.
During an observation on 7/13/22 at 11:33 a.m., LVN Q was observed applying a cream to the resident's hips with the assistance of a certified nursing assistant. LVN Q stated the resident had pain on the hips and lower back. When asked whether the lidocaine was applied, LVN Q stated she did not have the medication in stock so she did not apply it this morning. She went to the medication cart, looked through it, and again stated she did not have the medication.
A review of the resident's July 2022 MAR reflected LVN Q documented not administered, drug/item unavailable for lidocaine patch administration on 7/13/22 at 9:19 a.m.
2b. Resident 77 was admitted to the facility with diagnoses including high blood pressure, neuropathy (nerve pain), and diabetes. A review of the 4/5/22 Minimum Data Set (a care area assessment and screening tool) indicated she had a Brief Interview for Mental Status (BIMS- a test given by medical professionals that helps determine a patient's cognitive understanding that can be scored from 1 to 15) score of 15, indicating she had intact cognition.
During an interview on 7/14/22 at 11:34 a.m., Resident 77 stated, yesterday on 7/13/22, the nurse came in to give her the morning medications but because she had an episode of vomiting, the nurse told her she would come back later to give her the medications; however, she never did. Resident 77 stated she did not get her medications all day until later that night, during the evening shift.
Resident 77's medical record included the following physician's orders:
- Carvedilol 3.125 mg twice daily, at 9 a.m. and 5 p.m., dated 3/29/22
- Gabapentin 300 mg three times daily, at 9 a.m., 1 p.m., and 5 p.m., dated 3/29/22
- Basaglar (insulin glargine, long-acting insulin to lower blood sugar), 24 units; by injection once a day at 9 a.m., dated 6/28/22
- Vitamin D3 (a supplement) 5,000 units, one capsule once daily, dated 4/2/22.
A review of Resident 77's July 2022 MAR indicated the following were left blank, meaning not given:
- Basaglar, the 7/12/22 9 a.m. administration was blank
- Carvedilol, the 7/13/22 9 a.m. administration was left blank
- Vitamin D3, the 7/13/22 9 a.m. administration was blank
- Gabapentin, the 7/13/22 1 p.m. administration was blank.
The MAR indicated LVN AA was the morning nurse on 7/12/22 and 7/13/22.
During a concurrent interview and record review with RN R on 7/15/22 at 8:47 a.m., she confirmed the above undocumented administration. She stated the nursing staff was to document the reasons (such as refusal, resident absence, etc.) for not administering the medications on MAR and should not leave the entries blank.
During a telephone interview with LVN AA on 7/8/22 at 1:19 p.m., she stated 7/12/22 was her first day working on the floor, and worked both AM and PM shifts on 7/13/22. She stated, on the morning of 7/13/22 (her second day), she remembered Resident 77 had an episode of vomiting, so the resident did not want to take the morning medications right away. She stated she came back a few hours later, but did not remember exactly when, to give the medications. She stated she was in a rush and did not document.
During another interview with Resident 77 on 7/18/22 at 2:35 p.m., she confirmed she received all her medications, including the morning and noon medications, all at once later that evening on 7/13/22. During this interview, Resident 77 indicated she did not get her insulin injection along with the gabapentin at noon time the day prior, on 7/17/22, by the same nurse (LVN AA)
On 7/18/22 at 3:44 p.m. a review of Resident 77's July 2022 MAR with RN R indicated, on 7/17/22, LVN AA initialed on the MAR indicating she administered the Basaglar at 9 a.m., but left the gabapentin 1 p.m. administration blank. RN R verified the finding.
2c. Resident 133 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD, chronic inflammatory lung disease that causes obstructed airflow from the lungs) and asthma. The 5/11/22 MDS indicated she had a BIMS score of 15, indicating she had intact cognition.
Her medical record indicated she received multiple medications, including albuterol inhaler, budesenide suspision for nebulization, Daliresp oral tablet, montelukast, and Spiriva for COPD.
During an interview on 7/14/22 at 12:35 p.m., Resident 133 indicated she did not receive some of her breathing treatment medications, but she could not name them. She stated the nurse told her that she ran out of the medications.
During an interview with RN I on 7/14/22 at 2:02 p.m., she stated she just found the budesonide solution and administered it to Resident 133 about about 30 minutes ago, and had not administered the Spiriva yet as she just found it in the medication room. RN I stated they were due at 9 a.m. that morning and acknowledged they were given late.
A review of her physician's orders indicated:
- Budesonide suspension for nebulization, 0.5 mg/2 mL, administer twice daily at 9 a.m. and 5 p.m. for COPD, dated 5/7/22; and
- Spiriva 18 micrograms (unit of measurement), inhale 1 capsule once a day at 9 a.m. for COPD, dated 5/7/2022.
During a follow-up interview with Resident 133, on 7/15/22 at 9:55 a.m., she confirmed the nurse came back and gave the breathing medications in the afternoon the day before. She stated she needed the medications for her COPD and asthma.
A review of the facility's Medication Pass Guidelines, dated 3/2000, indicated: Medications are administered in accordance with written orders of the attending physician . Administer medications within 60 minutes of the scheduled time.
3. During a visit to the Station 4 Medication Room with RN T on 7/11/22 at 10:53 a.m., the injectable E-kit (one containing injectable medications) was observed not sealed. RN T stated she did not know when it was opened. RN T looked around in the medication room but could not find the log book. Inspection of the contents inside the E-kit with RN T identified one of one Glucagen Kit (medication to treat severely low blood sugar) was missing from the kit. Another E-kit, the C3-C5 Ekit (one containing Schedule III to V controlled medications) was identified with the red seals, indicating it had been opened by the facility staff. A review of the E-kit log inside the kit indicated it was opened on 6/23/22 (18 days ago). RN T stated the staff was to call the pharmacy and get a replacement anytime they opened an E-kit.
During an interview with the DON on 7/12/22 at 4:16 p.m., she stated the E-kits should be replaced within 72 hours after opening.
The facility's P&P titled Emergency Pharmacy Service and Emergency Kits (E-Kits), dated 5/2016, indicated: Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit log. One copy of this information should be immediately faxed to the pharmacy . and placed within the sealed emergency kit until it is scheduled for exchange.
4a. On 7/11/22 at 5:00 p.m., LVN BB was observed at her medication cart, with prepared medications in a small medication cup. Then she walked to Resident 117's bedside, put the medication cup on his over-bed table, and said, Here's your medications. Then she walked away and returned to the medication cart in the hallway. Resident 117 was overheard asking what the medications were for, but LVN BB did not respond.
During an interview with LVN BB on 7/11/22 at 5:02 p.m., she stated she gave the resident propranolol (medication for high blood pressure) and divalproex acid (medication for seizure or mood disorder). When asked whether she should check to ensure the resident took the medications, LVN BB walked back to the resident's door and asked him, Did you take it yet? Resident 117 nodded as a response.
During an interview with Resident 117 on 7/11/22 at 5:15 p.m., he confirmed the nurse just left the medications on his table and walked away. He stated, Today she brought in 4 pills of the same med and I am not sure what they are.
During an interview with the DON on 7/12/22 at 4:20 p.m., she stated, Nurses are to make sure they [the residents] are getting their medications before leaving the room, not leaving them with the residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when:
1. Four wire rack shelves had yellowish to gold...
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Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when:
1. Four wire rack shelves had yellowish to golden brown color;
2. Two spatulas had cracked/chipped;
3. Grater (used to shred cheese and other soft food) had yellowish substance;
4. The quaternary bucket was stored near juice boxes/juice machine;
5. Two of four ice machines had black particles;
6. Scoop was inside the ice cooler;
7. Kitchen staff did not demonstrate the proper procedure for testing the strength of sanitizer used for sanitizing food contact surfaces;
8. Unit Storage's had unlabeled food and refrigerators with high temperatures.
These failures had the potential to cause foodborne illness (illness resulting from contaminated food) for 223 of 232 residents who received food from the kitchen.
Findings:
1. During a kitchen observation on 7/11/22 at 8:53 a.m., the walk-in freezer's storage rack had four wire rack shelves with yellowish to golden brown color.
During a concurrent interview with the dietary manager (DM), she confirmed the above observation and stated the facility will replace it.
According to the Food & Drug Administration (FDA) 2017 Food Code, Section 4-202.16, Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.
2. During a kitchen observation on 7/11/22 at 8:56 a.m., two spatulas had crack/chipped.
During a concurrent interview with the DM, she acknowledged the above observation and stated items needs to be replaced.
3. During a kitchen observation on 7/11/22 at 8:58 a.m., the grater had yellowish substance.
During a concurrent interview with the DM, she confirmed the above observation and stated it needs to be cleaned.
2017 FDA Food Code Section 4-602.11, stated that utensils should be clean to sight and touch.
4. During an observation in the kitchen on 7/11/22 at 10:38 a.m., quaternary (sanitizer) bucket was stored near the juice boxes/juice machine.
During a concurrent interview with the DM, she acknowledged the above observation and stated it was ok.
During an interview with the registered dietitian (RD) on 7/12/22 at 3:55 p.m., the RD stated the quaternary bucket should be away from food items.
During a kitchen observation on 7/12/22 at 4:05 p.m., the quaternary bucket was stored near the juice boxes/juice machine. The RD confirmed the observation.
2017 FDA Food Code Section 3-304.14 (E) stated Containers of chemical sanitizing solutions specified in Subparagraph (B)(1) of this section in which wet wiping cloths are held between uses shall be stored off the floor and used in a manner that prevents contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, SINGLE-SERVICE, OR SINGLE-USE ARTICLES.
5. During an observation with the maintenance assistant (MA) on 7/11/22 at 5:21 p.m., a paper towel test was conducted in station UVW's ice machine. The paper towel revealed black particles.
During an interview with the administrator (ADM) on 7/11/22 at 5:27 p.m., the ADM confirmed the above observation.
During an observation with the MA on 7/11/22 at 5:49 p.m., the interior of station AAA's ice machine had black particles.
During a concurrent interview with the MA, he confirmed the above observation.
According to the Food Code 2017 as specified in paragraph 4-602.11, indicated water vending equipment, ice makers should be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganism.
6. During an observation on 7/11/22 at 5:25 p.m., there was a cooler containing ice near station UVW's ice machine. The cooler containing ice had a scoop inside.
During an interview with the ADM on 7/11/22 at 5:27 p.m., the ADM acknowledged the above observation.
During an interview with the RD on 7/12/22 at 3:53 p.m., the RD stated the scoop should not be stored inside the ice cooler.
7. During an observation on 7/12/22 at 4:07 p.m., dietary aide PP (DA PP) demonstrated how to check the sanitizer solution. DA PP prepared the solution and took the dishwasher temperature sensor label and dip it to the solution.
At 4:12 p.m., DA PP took the sanitizer strip paper and dip it for one second.
During an observation on 7/12/22 at 4:16 p.m., dietary aide QQ (DA QQ) demonstrated how to check the sanitizer solution. DA QQ prepared the solution and took the sanitizer strip paper and dip it for five seconds.
During a concurrent interview with DA QQ , she confirmed she dipped the strip for five seconds.
Review of the [brand name] QT-40 instructions indicated, dip the paper for 10 seconds.
During an interview with the DM on 7/12/22 at 5:41 p.m., the DM confirmed DA PP used the dishwasher temperature sensor label to check the strength of the sanitizer. The DM further stated, staff should use the quat strip. The DM acknowledged DA QQ did not dip the strip for 10 seconds.
Review of the facility's policy Sanitation and Infection Control dated 2018 indicated, Test the sanitizer solution by placing a sanitizing test strip in the solution. Allow the test strip to sit in the solution for 10 seconds.
8a. During an observation in station UVW storage room on 7/12/22 at 4:42 p.m., there was a food thickener in a container with no open date or label when it needs to be used.
During a concurrent interview with licensed vocational KK (LVN KK), she confirmed the above observation and stated she could not tell when it was taken from the kitchen.
8b. During an observation in station BBB storage room on 7/12/22 at 4:44 p.m., the following were observed:
- Bucket of graham crackers with no open date or expiration date
- Refrigerator temperature was 51F (F, [Fahrenheit-unit of measurement of temperature]).
- Ice cream with no label
During a concurrent interview with LVN KK, she confirmed the above observation.
8c. During an observation in station CCC storage room, there was a pitcher with orange liquid dated 7/10/22 inside the refrigerator.
During a concurrent interview with LVN KK, she confirmed the above observation.
8d. During an observation in station DDD with LVN KK on 7/12/22 at 5:03 p.m., the unit refrigerator's temperature was 55 F.
During an interview with the DM on 7/12/22 at 5:47 p.m., the DM stated the nursing department, housekeeping and maintenance department were responsible in maintaining the unit refrigerators not the kitchen staff.
During an interview with the director of nursing (DON) on 7/14/22 at 8:15 a.m., the DON stated licensed nurses (LNs) were responsible in maintaining the unit refrigerators. The LNs should throw the unlabeled food.
According to the United States Department of Agriculture (USDA) Food and Safety Inspection Service website (usda.gov) Food Product Dating indicated, food dating provides consumers when the product will be at its best quality.
Review of the facility's policy, Suggested Refrigerated Storage Guidelines dated 2018 indicated recommended refrigerated temperature was lesser or equal to 41F.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
9. During observation and concurrent interview with LVN W on 7/11/2022 at 9:25 a.m., LVN W was observed walking in the resident's hall with his mask on his chin and not covering his mouth or nose and ...
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9. During observation and concurrent interview with LVN W on 7/11/2022 at 9:25 a.m., LVN W was observed walking in the resident's hall with his mask on his chin and not covering his mouth or nose and his face shield was up and not covering his eyes or face. LVN W confirmed this observation and indicated his mask should be covering his nose and mouth. He added his face shield should be covering face.
During interview with RN R, on 7/11/2022 at 9:30 a.m., RN R confirmed the observation of improper personal protective equipment (PPE, equipment worn to minimize exposure to hazards) use by LVN W and stated the mask should be covering the nose and mouth and the face shield should be covering the face and not be propped up on the forehead.
Review of the Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/, indicated that masks are effective at reducing transmission of SARS-CoV-2, the virus that causes COVID-19, when worn consistently and correctly and should cover the nose and mouth along with goggles or a face shield to cover the eyes.
10. During observation and concurrent interview with the Activities Director (AD), on 7/12/2022 at 9:52 a.m., the AD was observed without a face shield or goggles on at nursing station four. Four residents were observed in the area. The AD confirmed this observation and stated she should have on a face shield or goggles and stated she left the PPE in her office.
Review of the Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/, indicated that masks are effective at reducing transmission of SARS-CoV-2, the virus that causes COVID-19, when worn consistently and correctly and should cover the nose and mouth along with goggles or a face shield to cover the eyes. The CDC further indicated that the PPE must remain in place and be worn correctly.
Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:
1. Kitchen staff did not wear N95;
2. Dietary aide HH (DA HH) was wearing gloves in the hallway;
3. Clear plastic garbage bag containing used gloves and used thermometer probe covers was attached to the vital signs machine tray;
4a. Licensed vocational nurse JJ (LVN JJ) personal coffee was on top of the medication cart;
4b. LVN JJ had a headache and did not follow facility's protocol for Covid-19 (a highly contagious respiratory disease);
5. Staff did not wear N95 properly;
6. A nursing staff did not use sanitary techniques during the administration of medications;
7. Laundry aide OO (LA OO) transferred soiled clothing and linen from the hampers to the big bin in the hallway;
8a. Licensed vocational nurse LL (LVN LL) did not wear faceshield properly when walking in the hallway;
8b. Restorative nursing Assistant (RNA CC) did not wear faceshield when walking in the hallways;
8c. The assistant director of nursing (ADON) did not wear faceshield when walking in the hallways;
9. Licensed vocational nurse W (LVN W) did not wear faceshield or mask properly while in resident hallway;
10. The activity director (AD) did not wear a faceshield while in the resident hallway.
These failures could result in the spread of infection and cross-contamination that could affect the 232 residents who resides in the facility.
Findings:
1. During an observation on 7/11/22 at 8:35 a.m., five dietary staff were observed not wearing N95 (a high filtering mask).
During a concurrent interview with the dietary manager (DM), the DM stated the facility had a Covid-19 (highly contagious respiratory disease) outbreak. The DM confirmed the kitchen staff could wear surgical mask in the kitchen.
During an interview with the infection preventionist (IP) on 7/12/22 at 5:21 p.m., the IP stated all staff including the kitchen staff should wear N95 because the facility had an outbreak. The IP added, staff were given N95 when they enter the facility.
2. During an observation on 7/11/22 at 12:01 p.m., dietary aid HH (DA HH) was in the hallway near the kitchen and was wearing gloves on both hands.
During a concurrent interview, DA HH confirmed the above observation and stated she was not supposed to wear gloves in the hallway. DA HH further stated she forgot to remove her gloves.
During an interview with the IP on 7/11/22 at 4:46 p.m., the IP stated gloves should not be worn in the hallway to prevent cross contamination.
According to the Centers for Disease Control and Prevention (CDC) website https://www.cdc.gov/niosh/npptl/pdfs/PPE-Sequence-508.pdf indicated USE SAFE WORK PRACTICES TO PROTECT YOURSELF AND LIMIT THE SPREAD OF CONTAMINATION.
3. During an observation on 7/11/22 at 12:31 p.m., the vital signs machine (blood pressure machine, pulse oximeter, thermometer in one machine attached to a pole with tray and wheels) had a clear plastic garbage bag that contained used gloves and used thermometer probe covers.
During an interview with certified nursing assistant II (CNA II) on 7/11/22 at 12:32 p.m., CNA II confirmed the above observation. CNA II acknowledged the garbage bag should not be attached to the vital signs machine and used gloves and probe covers should be disposed after they were used.
During an interview with the IP on 7/11/22 at 4:47 p.m., the IP stated garbage bag should not be attached in the vital signs machine and all trash should be discarded in the residents' room immediately to prevent cross contamination.
4a. During an observation on 7/11/22 12:45 p.m., licensed vocational nurse JJ (LVN JJ) was observed drinking his personal drink in front of the medication cart, preceded by putting his personal drink on top of the medication cart.
During an interview with LVN JJ on 7/11/22 at 12:47 p.m., LVN JJ confirmed the above observation. LVN JJ stated his personal drink should not be on top of the medication cart.
During an interview with the director of nursing (DON) on 7/11/22 at 5:04 p.m., the DON stated license nurses should not put personal items on top of the medication cart because of infection control.
4b. During an interview with LVN JJ on 7/11/22 at 12:47 p.m., LVN JJ stated I have a bad headache today. LVN JJ further stated he reported his headache to his supervisor.
At 1:09 p.m., the IP stated there was no report regarding a license nurse having a headache to the supervisor.
Review of LVN JJ's Covid 19 screening form dated 7/11/22 indicated, LVN JJ indicated he was not experiencing any symptoms of Covid-19 including headache.
During an interview with the IP on 7/12/22 at 5:26 p.m., the IP stated supervisors were asked about the LN who had a headache. The IP further added, LVN JJ did not disclose who was the supervisor he reported about his headache.
According to the CDC's website, Symptoms of Covid-19 updated 3/22/22 indicated, symptoms of Covid-19 includes headache.
5. During an observation with the IP on 7/18/22 at 8:08 a.m., housekeeping staff (HS) was observed with wearing N95. The respirator's straps were not resting at the back of his head and were not positioned around the neck. The straps were used as ear loops.
During concurrent interview with the IP, the IP confirmed the above observation.
According to the CDC website (https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/fs-respirator-on-off.pdf) indicated, the respirators top strap goes over and rest at the top back of the head and the bottom strap is positioned around the neck.
8a During an observation on 7/11/22 at 4:55 p.m., licensed vocational nurse LL (LVN LL) was observed walking
with another staff not wearing his faceshield properly and verified by LVN LL.
8b During an observation on 7/12/22 at 1:52 p.m., restorative nursing assistant CC (RNA CC) did not wear her faceshield while walking in the hallways in Station 2 and she confirmed the observation.
8c During an observation and concurrent interview on 7/13/22 at 10:06 a.m., the assistant director of nursing (ADON) did not wear faceshield while walking in the hallways. The ADON stated staff were only required to wear faceshield when providing direct resident care.
During an interview with the infection preventionist (IP) on 7/13/22 12:29 p.m., the IP stated the county guidelines indicated facility staff should wear face shield even in the hallways.
7. During an observation on 7/11/22 at 2:12 p.m., laundry aide OO (LA OO) was transferring dirty clothing and linen from the hampers to the big bin in the hallway in front of the soiled linen room.
During a concurrent interview, LA OO stated she should transfer dirty linen inside the soiled linen room.
During an interview with the infection preventionist (IP) on 7/11/22 at 2:17 p.m., she stated transferring dirty linen from the hampers to the big bin should be done inside the soiled linen room and not in the hallway.
Review of the facility's policy, Standard Precautions, dated 3/2004, indicated 8. Linen - Transport all linen in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.
6a. During a medication pass observation with LVN Q on 7/12/22 at 8:09 a.m., she was observed preparing 7 medications, including 5 solid tablets, for Resident 68. During this process, LVN Q put on a pair of gloves, took out the keys from her shirt pocket to open the medication cart, then removed 2 medication blister packs/cards (a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) from the medication cart. She removed the medication tablet from each blister card by punching the blister bubble with her right thumb, and placing her left gloved hand underneath the medication card to catch the pill. Then she placed it in a small medication cup.
During an interview with LVN Q on 7/12/22 at 8:50 a.m., she acknowledged she caught the medication tablets with her gloved hand instead of punching it from the medication card directly into the cup.
A review of the facility's Medication Pass Guidelines, dated 3/2002, indicated: Use sanitary technique to place medications into a souffle or medicine cup. Do not touch oral medication .
6b. During the same medication preparation as above, LVN Q placed each of the 5 solid tablets in a small plastic bag and crushed each medication individually by using a crushing device.
On 7/12/22 at 8:27 a.m., LVN Q was observed bringing the prepared medications to Resident 68's bedside and placing them on the over-bed table. She was still wearing the same gloves she had put on earlier during the preparation. Then, by touching the bathroom door handle, she opened the bathroom door, went inside, and moments later, brought back 3 cups of water. Then she closed the bathroom door by touching its door handle again, pulled the privacy curtain, and closed the room door by touching the door handle with the same gloved hand. LVN Q proceeded with the medication dilution by adding water to each crushed medication bag and pouring the contents into a medication cup. Then still with the same gloves on, she dipped her right forefinger into each medication cup, and stirred the contents inside each cup. She stated, My hands are clean while doing this. Then she changed her gloves after mixing the medications and proceeded with the medication administration.
During an interview on 7/12/22 at 08:50 a.m., LVN Q acknowledged she touched many surfaces including the sink's faucet knob to obtain the water, the bathroom door handle twice, and the room door handle; and diluted the medications with her forefinger after touching these surfaces with the same gloves on. She confirmed she should have used a spoon to mix/dilute the medications.
During an interview with the DON on 7/12/22 at 4:16 p.m., she stated the nurse should have changed gloves after touching many surfaces. When relayed the observation regarding LVN Q mixing medications with her forefinger, the DON did not respond but shook her head.
A review of the facility's Medication Pass Guidelines, dated 3/2000, indicated the nursing staff to follow sanitary practices during the medication administration.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms. This failure could affect the residents' safety an...
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Based on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms. This failure could affect the residents' safety and impede provision of care to the residents.
Findings:
Rm. No. # of beds/Rm. Sq. Ft./Res.
108, 109 3 73.6
114, 115, 2 76.5
210, 211
314, 315, 3 74.0
316, 317,
403, 201
thru 208
110, 111, 2 74.0
112, 217,
218, 219,
220
116, 117, 2 75.0
308, 311,
312, 619
309, 310 3 74.3
404, 405, 3 73.5
406, 409,
501 thru 509
407, 408 2 72.9
411, 412, 2 76.0
414, 415
thru 419
510, 511, 3 74.8
515, 516
512, 514, 2 71.4
601, 602,
614, 615
603, 604 3 75.6
609, 610, 3 77.0
611, 612
Interviews with staff and residents indicated the room sizes did not adversely impact the quality of care received by the residents.
Recommend continuance of the room size waiver.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $105,089 in fines. Review inspection reports carefully.
- • 100 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $105,089 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Skyline Healthcare Center - San Jose's CMS Rating?
CMS assigns SKYLINE HEALTHCARE CENTER - SAN JOSE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Skyline Healthcare Center - San Jose Staffed?
CMS rates SKYLINE HEALTHCARE CENTER - SAN JOSE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 58%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Skyline Healthcare Center - San Jose?
State health inspectors documented 100 deficiencies at SKYLINE HEALTHCARE CENTER - SAN JOSE during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 96 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Skyline Healthcare Center - San Jose?
SKYLINE HEALTHCARE CENTER - SAN JOSE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by MARINER HEALTH CARE, a chain that manages multiple nursing homes. With 253 certified beds and approximately 234 residents (about 92% occupancy), it is a large facility located in SAN JOSE, California.
How Does Skyline Healthcare Center - San Jose Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, SKYLINE HEALTHCARE CENTER - SAN JOSE's overall rating (1 stars) is below the state average of 3.1, staff turnover (40%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Skyline Healthcare Center - San Jose?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Skyline Healthcare Center - San Jose Safe?
Based on CMS inspection data, SKYLINE HEALTHCARE CENTER - SAN JOSE has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Skyline Healthcare Center - San Jose Stick Around?
SKYLINE HEALTHCARE CENTER - SAN JOSE has a staff turnover rate of 40%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Skyline Healthcare Center - San Jose Ever Fined?
SKYLINE HEALTHCARE CENTER - SAN JOSE has been fined $105,089 across 1 penalty action. This is 3.1x the California average of $34,130. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Skyline Healthcare Center - San Jose on Any Federal Watch List?
SKYLINE HEALTHCARE CENTER - SAN JOSE 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.
SKYLINE HEALTHCARE CENTER - SAN JOSE
2065 FOREST AVENUE, SAN JOSE, CA 95128 | (408) 280-2500
F
Trust Grade (0/100)
1.0
CMS Rating
100
Deficiencies
Strengths
- 4-star quality
Concerns
- 2 Immediate Jeopardy citations
- 1-star rating
- 100 deficiencies
Ask about: Inspection Response, Rn Coverage
nursinghomedata.org | Data: CMS November 2025