What is THE EARLWOOD's CMS rating?

THE EARLWOOD has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does THE EARLWOOD have any serious inspection findings?

Yes, THE EARLWOOD has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 90 total deficiencies from recent inspections.

What are the staffing levels at THE EARLWOOD?

THE EARLWOOD has a two-star staffing rating from CMS with 0.23 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is THE EARLWOOD located?

THE EARLWOOD is located in TORRANCE, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does THE EARLWOOD have?

THE EARLWOOD has 87 certified beds.

Who owns THE EARLWOOD?

THE EARLWOOD is a for profit - limited liability company facility and is part of the GENESIS HEALTHCARE chain.

Is THE EARLWOOD safe?

THE EARLWOOD has documented safety concerns including 1 immediate jeopardy citation. Families should ask about corrective actions taken.

Do nurses at THE EARLWOOD stick around?

THE EARLWOOD has average staff turnover at 40%, which is typical for the nursing home industry.

Was THE EARLWOOD ever fined?

Yes, THE EARLWOOD has been fined $12,649 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is THE EARLWOOD on any federal watch list?

No, THE EARLWOOD is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at THE EARLWOOD?

Medicare inspectors have found 90 deficiencies at THE EARLWOOD: 1 critical, 1 serious, 87 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting THE EARLWOOD?

Families visiting THE EARLWOOD should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does THE EARLWOOD compare to other nursing homes?

THE EARLWOOD has a 1-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

THE EARLWOOD | 21/100 (Grade F)

Sept 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0559 (Tag F0559)

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 obtain resident's written consent and document in his chart the bas...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain resident's written consent and document in his chart the basis of why the move was required prior to a room change for one of four randomly selected residents (Resident 3). This deficient practice resulted in the lack of opportunity for Resident 3 to see the new location, meet the new roommate and ask questions about the move prior to the room changes. Findings: During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing), gastro-esophageal reflux disease ([GERD] a chronic condition that occurs when stomach contents move up into the esophagus, causing irritation), and muscle weakness (a lack of muscle strength). During a review of Resident 3's Minimum Data Set (MDS] a resident assessment tool), dated 8/2/2025, the MDS indicated Resident 3's cognition (thought process) was intact. During a review of the facility's Room Change Form, dated 8/8/2025, the Room Change Form indicated Resident 3 was moved to another room. The Room Change Form indicated the reason for the room change was roommate compatibility. The Room Change Firm indicated Resident 3's and/or his responsible party (RP) were notified. During a review of Resident 3's Clinical Record, the Clinical Record indicated there was no documentation indicating Resident 3 received written notice or consented when he was transferred to another room prior to or on 8/8/2025 when Resident 3's room change occurred. During a review of the facility's Room Change Form, dated 8/28/2025, the Room Change Form indicated that Resident 3 was moved to another room. The Room Change Form indicated Resident 3 was self-responsible. The Room Change Form indicated there was no documentation indicating what was the reason for the room change. During a review of Resident 3's Clinical Record, the Clinical Record indicated there was no documentation indication Resident 3 received written notice or consent when he was transferred to another room prior to or on 8/28/2025 when Resident 3's room change occurred. During an interview on 9/3/2025 at 1:08 p.m., with Resident 3, Resident 3 stated that he was upset because he had two room changes in the month of 8/2025 without his consent. Resident 3 stated he was not asked if he wanted to change rooms nor was provided with a reason as to why the room changes occurred. Resident 3 stated he was not aware that he could have refused the room changes and thought he did not have a choice. During an interview on 9/3/2025 at 3:10 p.m., with the Social Worker (SW), the SW stated her job functions include helping the facility with resident room changes. The SW stated this process includes having a discussion with the Interdisciplinary Care Team ([IDT] an interdisciplinary team that brings together knowledge from different health care professionals from each discipline that work together to provide care for people, goal is for all residents to receive individualized care that maximizes a patient's quality of life) regarding upcoming room changes the facility has. SW then notifies the resident and or their responsible party of the upcoming room change, the reason for the room change and receives consent for the room change. The SW stated this process is then documented in the resident's medical record. The SW stated the Director of Nursing (DON) had recently implemented the Room Change Form to be filled out prior to any room changes. The SW stated this form is not considered a consent and it should not have replaced the documentation in the resident's medical record. The SW stated she did not find any documentation for Resident 3's room changes on 8/8/2025 and 8/28/2025 and stated she must have forgotten to document it in Resident 3's medical record. The SW stated it was her responsibility to receive consent and follow up with the proper documentation in Resident 3's chart but forgot. During an interview on 9/3/2025 at 4:18 p.m., with the DON, the DON stated her job functions include reviewing discharges and room changes. The DON stated prior to staff changing a resident's room, they should inform the resident and/or their responsible party (RP) the reason for the room change, obtain consent, and provide a room change notification prior to a resident's room change. The DON stated Resident 3 should have received notification, and consent from prior to his room being changed. During a review of the facility's Policy and Procedure (P/P) titled, Room or Roommate Change, dated 6/27/2022, the P/P indicated to ensure that a resident can exercise their right to change rooms or roommates. Prior to changing a room or roommate assignment, the resident, the resident's representative (if available), the resident's new roommate, and the resident's current roommate will be given timely advance of such change and will include the following: 1. The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. 2. Notification of Room Change notify the residents of the room change. The P/P indicated information regarding room transfers will be documented in the resident's medical record.

Aug 2025 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

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 physicians for four of four sampled residents (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 notify the physicians for four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) when their appointments for test and/or consultations were missed or not scheduled. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, and 4. a. During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 3/11/2025, the Physician's Order indicated a micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx (voice box) for vocal cord lesion removal was scheduled for Resident 1 on 3/21/2025. During a review of Resident 1's Physician's Order dated 4/10/2025, the Physician's Order indicated an appointment for a cardiac stress test on 4/21/2025 at 7:30 a.m. During a review of Resident 1's Nurses Progress Note dated 6/12/2025, the Nurses Progress Note indicated Resident 1's physician informed Registered Nurse (RN) 1, that Resident 1 needed a micro laryngoscopy for vocal cord lesion removal as soon as possible and Resident 1 had missed two cardiac stress test appointments. The Nurses Progress Note indicated RN 1 would inform the social worker to make another cardiac stress test appointment. During a review of Resident 1's Physician's Progress Note dated 8/1/2025, the Physician's Progress Note indicated Resident 1 should have had a cardiac clearance (a medical evaluation performed by a cardiologist [a doctor who specializes in diagnosing and treating diseases of the heart and blood vessels]) to assess Resident 1's heart health and determine if it was safe for Resident 1 undergo a planned medical procedure, but the cardiac stress test appointments were overlooked by facility. The Physician's Progress Note indicated facility staff were working on scheduling a cardiac stress test and cardiac clearance for Resident 1's surgery (3/21/2025). During a telephone interview on 8/19/2025 at 1:53 p.m., Resident 1's physician stated he called the facility in 6/2025 (exact date unknown), to inquire about and reschedule Resident 1's surgery because Resident 1's surgery had been delayed because he missed his cardiac stress test and cardiac clearance. b. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidneys due to a blockage in the urinary tract caused by a kidney stone) and degenerative disc disease (a condition where the spinal discs wear down over time due to aging and daily stress). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact, and Resident 2 required supervision or touch assistance (providing verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff to complete his activities of daily living ADLs. During a review of Resident 2's Physician's Order dated 2/13/2025, the Physician's Order indicated Resident 2 required a follow up appointment with urology (a branch of medicine concerned with the function and disorders of the urinary system) for kidney stones. During a review of Resident 2's Physician's Order dated 5/21/2025, the Physician's Order indicated Resident 2 required a follow up appointment with a neurosurgeon (a medical doctor who diagnoses and treats conditions that affect the nervous system including the brain, spinal cord, and nerves) due to degenerative disc disease During a review of Resident 2's Medical Records, there was no documentation to indicate that Resident 2's urology and neurosurgeon appointments had been scheduled or that Resident 2 had gone to the appointments. c. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis Parkinson's Disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was moderately impaired, and Resident 3 required partial/moderate assistance from facility staff to complete his ADLs. During a review of Resident 3's Physician's Order dated 6/02/2025, the Physician's Order indicated Resident 3 had a neurology appointment for 6/11/2025. During a review of Resident 3's Medical Record, there was no documentation to indicated that Resident 3's neurology appointment had been scheduled or that Resident 3 had gone to the appointment. d. During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with the diagnoses including acute kidney failure (a sudden and rapid decline in kidney function) and benign prostatic hyperplasia ([BPH] a condition in which the prostate gland grows larger than normal, but the growth is not caused by cancer). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was intact, and Resident 4 required partial/moderate assistance from facility staff to complete his activities of daily living ADLs. During a review of Resident 4's Physician's Order dated 5/29/2025, the Physician's Order indicated Resident 4 had a urology appointment scheduled for 7/7/2025. During a review of Resident 4's Medical Records, there was no documentation to indicated that Resident 4's urology appointment had been scheduled or that Resident 4 had gone to the appointment. During an interview on 8/14/2025 at 10:49 a.m., the Director of Staff Development (DSD) stated, after reviewing Residents 1, 2, 3 and 4's medical record, there was no documentation to indicate an appointment was scheduled to follow up with Resident 2's urologist or neurosurgeon. The DSD stated there was no documentation to indicate Resident 3 and 4 completed their scheduled appointments. The DSD stated there was no documentation to indicate Resident 1, 2, 3 and 4's physicians were notified regarding their missed and/or unscheduled appointments. The DSD stated the resident's physicians should be notified regarding the status of the resident's appointments because the resident's treatment plan could be affected based on the results of the appointments and/or evaluation. During a telephone interview on 8/15/2025 at 11:57 a.m., the resident's physicians stated he did not recall being notified that Residents 1, 2, 3 and 4's appointments were missed and/or had not been scheduled. During an interview on 8/15/2025 at 12:34 p.m., the Director of Nursing (DON) stated physicians should be notified when appointments were missed and/or consultations were not scheduled as ordered because could cause a delay in treatment. During a review of the facility's policy and procedure (P/P) titled Change in Condition: Notification of dated 8/25/2021, the P/P indicated the facility should consult with the resident's physician and/or Nurse Practitioner (NP) where there is a need to alter treatment significantly.

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

Medical Records (Tag F0842)

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 one of four sampled residents (Resident 1), who had a consul...

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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 one of four sampled residents (Resident 1), who had a consultation outside of the facility with a cardiologist (a doctor who specializes in the heart and blood vessels) on 3/24/2025, returned to the facility with progress notes and instructions for care that were available for review in Resident 1's medical record. This deficient practice resulted in a delay in scheduling Resident 1's micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx ([voice box]) for vocal cord lesion removal and had the potential for complications occurring based on that delay in surgery.During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 3/11/2025, the Physician's Order indicated a micro laryngoscopy for vocal cord lesion removal was scheduled for 3/21/2025. During a review of Resident 1's Physician's Order dated 3/19/2025, the Physician's Order indicated Resident 1 had an appointment to see a cardiologist for a cardiology clearance (an evaluation performed by a cardiologist to determine if a patient's heart is healthy enough to undergo a planned surgical procedure) on 3/24/2025. During a review of Resident 1's Medical Records, there was no documentation to indicate consultation note and/or care instructions following Resident 1's cardiologist appointment on 3/24/2025. During an interview on 8/14/2025 at 1:14 p.m., the Social Services Director (SSD) stated she could not recall if Resident 1 went to his cardiology appointment on 3/24/2025. Later the same day the SSD called the cardiologist office to obtain the cardiology progress notes from Resident 1's cardiology appointment on 3/24/2025. During a review of Resident 1's cardiology Progress Notes dated 3/24/2025, the cardiology Progress Notes indicated they were faxed to the facility on 8/14/2025 at 4:23 p.m. During an interview on 8/14/2025 at 1:54 p.m., the Director of Staff Development (DSD) stated when residents leave the facility for doctor appointments, the physician usually transfers the residents back to the facility with orders in a packet, the visit notes take a couple of days to complete. The DSD stated if the resident returns to the facility without orders or instructions for care, the licensed nurses should follow up with the physician who provided the care to obtain those instructions because the facility should know what was discussed during the appointment and what the instructions for care were. During an interview on 8/14/2025 at 2:12 p.m., the Director of Nursing (DON), after reviewing Resident 1's medical record, stated the progress note from Resident 1's cardiology visit on 3/24/2025 was not available in Resident 1's medical record. The DON stated she was made aware that Resident 1 had an appointment on 3/24/2025 but she did not see the note from the cardiologist, assumed Resident 1 had not been seen by the cardiologist and made another appointment to see the cardiologist on 8/13/2025. The DON stated if Resident 1's cardiologist progress notes from his 3/24/2025 appointment had been available for review in Resident 1's medical record, she would have called Resident 1's surgeon (MD 2) to schedule Resident 1's surgery and there would have been no delay. The DON stated if Resident 1 did not have care instructions/notes with him when he returned to the facility from his appointment, the nursing staff should have called the physician's office to obtain the instructions for care, and if after 24 hours the documents were not received, medical records should have been made aware so they could have followed up. During a review of the facility's Policy and Procedure (P/P) titled Location and Storage of Medical Records dated 12/2006, the P/P indicated all current medical records are filed in the Medical Records Department and maintained by the Medical Records Clerk. During a review of the facility's undated P/P titled Appointments the P/P indicated any orders and follow up appointment are to be documented in the electronic record and the MD progress notes to be included in the resident's

CONCERN (E) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of four sampled residents (Resident 1, Resident 2, Resi...

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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 four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4), who had orders in place for test and/or consultations, had those orders implemented. These deficient practices resulted in Resident 1's surgery being delayed for five months and had the potential to result in a delay in treatment and services for Residents 2, 3, 4.a. During a review of Resident 1's admission Record (Face Sheet), the Face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD] irreversible kidney failure). During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 7/21/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and Resident 1 required partial/moderate assistance (helper does less than half the effort) from facility staff to complete his activities of daily living ([ADLs] activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Physician's Order dated 3/11/2025, the Physician's Order indicated a micro laryngoscopy (a minimally invasive surgical procedure to diagnose and treat various conditions affecting the vocal cords and larynx (voice box) for vocal cord lesion removal was scheduled for 3/21/2025. During a review of Resident 1's Physician's Order dated 4/10/2025, the Physician's Order indicated an appointment for a cardiac stress test on 4/21/2025 at 7:30 a.m. During a review of Resident 1's Nurses Progress Note dated 6/12/2025, the Nurses Progress Note indicated Resident 1's physician informed Registered Nurse (RN) 1, that Resident 1 needed a micro laryngoscopy for vocal cord lesion removal as soon as possible and Resident 1 had missed two cardiac stress test appointments. The Nurses Progress Note indicated RN 1 would inform the social worker to make another cardiac stress test appointment. During a review of Resident 1's Physician's Progress Note dated 8/1/2025, the Physician's Progress Note indicated Resident 1 should have had a cardiac clearance (a medical evaluation performed by a cardiologist (a doctor who specializes in diagnosing and treating diseases of the heart and blood vessels) to assess his heart health and determine if it was safe to undergo a planned medical procedure) but appointments were overlooked by facility. The Physician's Progress Note indicated facility staff were working on scheduling a cardiac stress test and a cardiac clearance for surgery. During a telephone interview on 8/19/2025 at 1:53 p.m., Resident1's physician stated he called the facility in 6/2025 (exact date unknown) because Resident 1's surgery had been delayed because Resident 1 missed his cardiac stress test and cardiac clearance. b. During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of hydronephrosis with renal and ureteral calculous obstruction (swelling of the kidneys due to a blockage in the urinary tract caused by a kidney stone) and degenerative disc disease (a condition where the spinal discs wear down over time due to aging and daily stress). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was intact, and Resident 2 required supervision or touch assistance (providing verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff to complete his activities of daily living ADLs. During a review of Resident 2's Physician's Order dated 2/13/2025, the Physician's Order indicated Resident 2 required a follow up appointment with urology (a branch of medicine concerned with the function and disorders of the urinary system) for kidney stones. During a review of Resident 2's Physician's Order dated 5/21/2025, the physician order indicated Resident 2 required a follow up appointment with a neurosurgeon (a medical doctor who diagnoses and treats conditions that affect the nervous system including the brain, spinal cord, and nerves) due to degenerative disc disease During a review of Resident 2's Medical Records, there was no documentation to indicate that Resident 2's urology and neurosurgeon appointments had been scheduled or that Resident 2 had gone to the appointments. c. During a review of Resident 3's admission Record (Face Sheet), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with a diagnosis Parkinson's Disease (a progressive disease of the nervous system marked by tremors, muscular rigidity, and slow, imprecise movements). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition was moderately impaired, and Resident 3 required partial/moderate assistance from facility staff to complete activities his of daily living ADLs. During a review of Resident 3's Physician's Order dated 6/02/2025, the Physician's Order indicated Resident 3 had a neurology appointment for 6/11/2025. During a review of Resident 3's Medical Record, there was no documentation to indicated that Resident 3's neurology appointment had been scheduled or that Resident 3 had gone to the appointment. d. During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with the diagnoses including acute kidney failure (a sudden and rapid decline in kidney function) and benign prostatic hyperplasia ([BPH] a condition in which the prostate gland grows larger than normal, but the growth is not caused by cancer). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was intact, and Resident 4 required partial/moderate assistance from facility staff to complete his activities of daily living ADLs. During a review of Resident 4's Physician's Order dated 5/29/2025, the Physician's Order indicated Resident 4 had a urology appointment scheduled for 7/7/2025. During a review of Resident 4's Medical Records, there was no documentation to indicated that Resident 4's urology appointment had been scheduled or that Resident 4 had gone to the appointment. During an interview on 8/14/2025 at 10:49 a.m., the Director of Staff Development (DSD) stated, after reviewing Residents 1, 2, 3 and 4's medical record, there was no documentation to indicate an appointment was scheduled to follow up with Resident 2's urologist or neurosurgeon. The DSD stated there was no documentation to indicate Resident 3 and 4 completed their scheduled appointments. The DSD stated there was no documentation to indicate Resident 1, 2, 3 and 4's physicians were notified regarding their missed and/or unscheduled appointments. The DSD stated the resident's physicians should be notified regarding the status of the resident's appointments because the resident's treatment plan could be affected based on the results of the appointments and/or evaluation. During an interview on 8/14/2025 at 12:17 p.m. and 3:50 p.m. with the Social Services Director (SSD), the SSD stated previously she oversaw arranging and scheduling appointments and transportation for residents when there was an order for an consultation or test. The SSD stated the previous system was not working because she was not scheduling the appointments in a timely manner, it would take her about 2 weeks to schedule the appointments. The SSD stated she was not aware of Resident 1, Resident 3, and Resident 4 appointments, so she did not make the arrangements for transportation. The SSD stated she was not aware of Resident 2's physician orders for follow-up appointments, so she did not make any appointments for Resident 2. During an interview on 8/14/2025 at 2:21 p.m. with the Director of Nursing (DON), the DON stated there was miscommunication between nursing and social services regarding appointments and consultations. The DON stated previously there was no system to communicate the appointments and transportation arrangements between nursing and social services staff which resulted in missed appointments and consultations. During a review of the facility's Job Description titled Registered Nurse (RN) dated 5/2022, the Job Description indicated the RN's duties and responsibilities included initiating requests for consultations or referrals as requested. During a review of the facility's Job Description titled Licensed Practical (Vocational) Nurse (LPN)/(LVN) dated 5/2022, the Job Description indicated the LVN's duties and responsibilities included providing nursing services to residents in accordance with scope of practice, facility policies and professional standards of care. During a review of the facility's Policy and Procedure (P/P) titled Physician Orders dated 3/22/2022, the P/P indicated whenever possible, the licensed nurse receiving the order will be responsible for documenting and implementing the order. The P/P indicated an order pertaining to other health care disciplines will be transcribed onto the appropriate communication system for that discipline.

Jul 2025 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

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 interview and record review, the facility failed to ensure two of the four sampled residents (Resident 1 and Resident 2...

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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 two of the four sampled residents (Resident 1 and Resident 2) change of condition (COC: when there is an alteration in an individual's physical or psychosocial wellbeing) were implemented by: 1. Failing to monitor Resident 1 who was diagnosed with Scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) after treatment was administered. 2. Failing to initiate a COC on 2/19/2025 when there was a change in Resident 2's skin assessment These deficient practices had the potential to negatively affect the delivery of care and services necessary for Resident 1 who was being treated for scabies and resulted in Resident 2 developing a stage II pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). Findings: A.During a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain by underlying medical condition [diabetes: a disorder characterized by difficulty in blood sugar control and poor wound healing]), infection and inflammation reaction due to indwelling urethral catheter, and functional quadriplegia (complete inability to move due to severe disability or frailty). During a review of Resident 1's history and physical (H&P) dated 2/10/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions as Resident 1 has dementia (a progressive state of decline in mental abilities).During a review of Resident 1's Minimum Data Set (MDS: a resident assessment tool) dated 5/28/2025, the MDS indicated Resident 2 was cognitively impaired. The MDS indicated Resident 1 was dependent on chair/bed-to-chair transfer, toileting hygiene, bathing, lower body (below waist) dressing, required maximal assistance (provides more than half the effort) for lying to sitting on side of bed, required moderate assistance (provides less than half the effort) for personal hygiene, upper body (above waist) dressing, and required supervision for eating and oral hygiene. The MDS indicated Resident 1 utilized a wheelchair and had impairment on both upper (arms/shoulder) extremity and impairment on one side on the lower (hips, legs) extremity. During a concurrent interview and record review on 7/2/2025 at 12:16p.m. with the Infection Preventionist Nurst (IPN), the IPN stated after Resident 1's COC on 5/2/2025, there was no follow up documentation to see if there were any improvements or any adverse reactions from the treatment. IPN stated that when there is a COC, residents are monitored for 72 hours to indicate if the resident is improving or getting worse. B. During a review of Resident 2's Face Sheet, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of encephalopathy (any damage or disease that affects the brain), dementia, and difficulty walking. During a review of Resident 2's H&P dated 2/14/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 was moderately impaired for making daily decisions. The MDS indicated Resident 2 required maximal assistance for bathing, required moderate assistance for eating, oral hygiene, toileting hygiene, upper and lower body dressing, personal hygiene, and required supervision for chair/bed-to-chair transfer. The MDS indicated Resident 2 was occasionally incontinent (involuntary) for bladder (an organ that holds urine) and was frequently incontinent for bowel (part of the digestive system.During a review of Resident 2's CNA skin monitoring worksheet (a document in which a visual assessment of the resident's skin is performed when giving a shower) dated 2/15/2025, the CNA monitoring sheet indicated Resident 2 did not have any skin issues. During a review of Resident 2's CNA skin monitoring worksheet dated 2/19/2025, the CNA monitoring sheet indicated on 2/19/2025, there was a wound on the sacrococcyx (fused bone structure that consists of the sacrum [triangular bone at the base of the spine] and coccyx [tail bone]) area. Resident 2's CNA skin monitoring worksheet indicated the Treatment Nurse (TXN) was notified. During a review of Resident 2's Change of Condition (COC) dated 2/22/2025 at 3:09 p.m., the COC indicated Resident 2 had a stage 2 pressure injury, measuring 1.5cm x 1cm. During a concurrent interview and record review on 7/3/2025 at 11:36a.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated the CNA skin monitoring worksheet dated 2/19/2025 indicated the TXN was notified Resident 2's sacrococcyx wound. RNS 1 stated a COC for Resident 2's skin change was done on 2/22/2025 (3 days later) but should have been done on 2/19/2025. During an interview on 7/3/2025 at 2:34p.m. with the Director of Nursing (DON), the DON stated that the COC is when there is a change of condition in a resident from normal to abnormal and a COC documentation would include the time of change, notification to the doctor, calling the family, and follow up documentation on the COC. The DON stated the staff must document the effectiveness of treatment or until the issue is resolved in the progress notes. The DON stated if there is no monitoring, the condition may get worse, and the interventions might not be effective if they are not following up, so they need to assess the resident every day and document every shift.During a review of the facility's policy and procedure (P&P) titled, [NAME] in Condition: Notification of dated 8/25/2021, the P&P indicated to ensure residents, family, legal representatives, and physicians are informed of changes in the resident's conditions. A facility must immediately inform the resident, consult with the resident's physician and/or NP, and notify, consistent with his/her authority, resident representative when there is: a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications).a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one out of four sampled residents (Resident 2) received care...

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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 one out of four sampled residents (Resident 2) received care to prevent pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to the sacrococcyx area.This deficient practice resulted in Resident 2 developing a stage II pressure injury on the sacrococcyx (fused bone structure that consists of the sacrum [triangular bone at the base of the spine] and coccyx [tail bone]) area and had the potential for risk of infection and pain. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including encephalopathy (any damage or disease that affects the brain), dementia (group of thinking and social symptoms that interferes with daily functioning), and difficulty walking. During a review of Resident 2's history and physical (H&P) dated 2/14/2025, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2's minimum data set (MDS: a resident assessment tool) dated 5/28/2025, the MDS indicated Resident 2 was moderately impaired for making daily decisions. The MDS indicated Resident 2 required maximal assistance (provides more than half the effort) for bathing, required moderate assistance (provides less than half the effort) for eating, oral hygiene, toileting hygiene, upper (above waist) and lower (below waist) body dressing, personal hygiene, and required supervision for chair/bed-to-chair transfer. The MDS indicated Resident 2 was occasionally incontinent (involuntary) for bladder (an organ that holds urine) and was frequently incontinent for bowel (part of the digestive system). During a review of the Body Check dated 2/12/2025 at 12:39 p.m., the body check indicated Resident 2 did not have any skin issues. During a review of the Braden Scale (assessment tool used to predict a resident's risk of developing pressure injuries) dated 2/12/2025 at 12:41p.m., the Braden Scale indicated Resident 2 was at mild risk (score range 15-18) with a score of 17. During a review of Resident 2's CNA skin monitoring worksheet (a document in which a visual assessment of the resident's skin is performed when giving a shower) dated 2/15/2025, the CNA monitoring sheet indicated Resident 2 did not have any skin issues. During a review of Resident 2's CNA skin monitoring worksheet dated 2/19/2025, the CNA monitoring sheet on 2/19/2025 indicated there is a wound on the sacrococcyx area with documentation the Treatment Nurse (TXN) was notified. During a review of Resident 2's Change of Condition (COC) dated 2/22/2025 at 3:09 p.m., the COC indicated Resident 2 had a stage 2 pressure injury. The COC indicated Resident 2 was being changed by a Certified Nursing Assistant (CNA) 1 when CNA 1 noticed the wound on sacrococcyx. measuring 1.5cm x 1cm. During a review of Resident 2's care plan (CP) untitled initiated 2/23/2025, the CP indicated Resident 2 has a stage 2 pressure injury measuring 1.5centimeter (cm: unit of length) by (x) 1cm. During an interview on 7/1/2025 at 3:25p.m. with Resident 2's Family Member 2 (FM 2), FM 1 stated Resident 2 got a bed sore at the facility and indicated the day prior to getting transferred to the General Acute Care Hospital (GACH) on 2/26/2025, the staff had left Resident 2 in her feces for a long time, and it was all over the bed. FM 2 stated the staff would not get Resident 2 up out of bed on a regular basis and would only get out of bed for 30 to 45 minutes with Physical Therapy (PT: diagnose and treat individuals to improve movement). FM 2 stated Resident 2 did not walk, had a diaper that was not changed on a regular basis, and the staff would state they are short-staffed when asked for assistance. During a concurrent interview and record review on 7/2/2025 at 4:00p.m. with the TXN, the TXN stated Resident 2's stage 2 pressure injury would be considered acquired in the and indicated if a resident is lying on their back and not turning much, or due to immobility, the resident can develop a pressure injury. The TXN stated Resident 2 was being changed by a CNA and has a stage 2 measurement of 1.5cm x 1cm. The TXN stated, in two hours, a stage I can develop to a stage 2 if the resident is not cleaned or turned. During an interview on 7/3/2025 at 10:02 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated if a resident is not being repositioned or if they sit in urine/feces for too long, it can cause the skin to breakdown. LVN 1 stated this can create pressure injuries to the skin and can become painful. During a concurrent interview and record review on 7/3/2025 at 11:36 a.m. with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 2 was incontinent for both bowel and bladder. RNS 1 stated Resident 2's Braden Score dated 2/24/2025 indicated Resident 2 was at moderate risk (score of 13-14) with a score of 13. RNS 1 stated the CNA skin monitoring worksheet dated 2/19/2025 indicated the TXN was notified of Resident 2's skin changes on the sacrococcyx and the COC for Resident 2's skin change was done on 2/22/2025 (3 days later). RNS 1 stated the COC should have been done on the same day, 2/19/2025. RNS 1 stated Resident 2's stage II pressure injury could have been preventable. During a concurrent interview and record review on 7/3/2025 at 2:24p.m., with the Director of Nursing (DON), the DON stated pressure injuries are preventable by turning and repositioning, cleaning the residents, providing good nutrition, and providing a low air mattress. During a review of the facility's policy and procedure (P&P) titled, Skin Integrity Management dated 5/26/2021, the P&P indicated the purpose is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. The implementation of an individual patient's skin integrity management occurs within the care delivery process. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. During a review of the facility's P&P titled, Wound Prevention, undated, the P&P indicated the purpose of this program is to assist the facility in the care, services and documentation related to the occurrence, treatment, and prevention of pressure as well as non-pressure related wounds. All residents will have the following nursing care procedures implemented: as tolerated by the resident encourage ambulation and out of bed activity, as tolerated by the resident encourage mobility, as needed position and reposition the resident with pillows and other supportive devices, when the resident requires incontinence brief, check for moisture frequently and apply house stock barrier cream after each incontinent episode.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control measures for one of two s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control measures for one of two sample residents (Resident 1) by failing to: 1. Ensure proper Personal Protective Equipment (PPE: equipment worn (gown, gloves, goggles) to help create a barrier between a healthcare worker and germs) was worn for Resident 1 that was on Enhanced Barrier Precaution (EBP: infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs).2. Ensure proper hand hygiene was performed during glove changes.3. Ensure Resident 1's indwelling catheter (or known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag was not touching the floor.4. Ensure the rooms were deep cleaned after medication to treat Scabies (a contagious skin condition caused by tiny insects called mites that infest and irritate skin causing intense itching, inflammation, and red patches) were applied. These deficient practices had the potential to transmit infectious microorganisms and increase the spread of infection to all residents and staff in the facilityDuring a review of Resident 1's admission Record (Face Sheet), the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy (any damage or disease that affects the brain by underlying medical condition [diabetes: a disorder characterized by difficulty in blood sugar control and poor wound healing]), infection and inflammation reaction due to indwelling urethral catheter, and functional quadriplegia (complete inability to move due to severe disability or frailty). During a review of Resident 1's history and physical (H&P) dated 2/10/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions as Resident 1 had dementia (a progressive state of decline in mental abilities).During a review of Resident 1's minimum data set (MDS: a resident assessment tool) dated 5/28/2025, the MDS indicated Resident 1 was cognitively mildly impaired. The MDS indicated Resident 1 was dependent on chair/bed-to-chair transfer, toileting hygiene, bathing, lower body (below waist) dressing, required maximal assistance (provides more than half the effort) for lying to sitting on side of bed, required moderate assistance (provides less than half the effort) for personal hygiene, upper body (above waist) dressing, and required supervision for eating and oral hygiene. During a review of Resident 1's Change of Condition (COC) dated 5/2/2025 at 2:30p.m., the COC indicated Resident 1 had a rash all over body. The COC indicated Resident 1 had a rash with persistent mild to moderate itching unrelieved by topical treatment or mild antihistamines (medication to alleviate symptoms such as itching). The COC indicated the recommendation for Resident 1 was Permethrin (a medication applied to the entire body to treat scabies) 5% cream. During a review of Resident 1's lab result report 5/2/2025 at 3:32p.m., the lab report indicated Resident 1 tested positive for scabies. During a record review of Resident 1's Medication Administration Record (MAR: electronic medication administration document) dated 5/1/2025 - 5/31/2025, the MAR indicated Resident 1 had an order for Permethrin External Cream with a start date of 5/3/2025. During a record review of Resident 1's Treat Administration Record (TAR: electronic treatment administration document) dated 5/1/2025 - 5/31/2025, the TAR indicated Resident 1 was treated with Permethrin External Cream with a start date of 5/23/2025 and discontinued on 5/25/2025. During a record review of Resident 1's TAR dated 6/1/2025 - 6/3/2025, the TAR indicated Resident 1 was treated with Permethrin External Cream with a start date of 5/26/2025 and discontinued 6/2/2025.During a record review of Resident 1's TAR dated 6/1/2025 - 6/30/2025, the TAR indicated Resident 1 was treated with Permethrin External Cream with a start date of 6/18/2025 every Wed and Sat for itching until 6/25/2025 and must shower resident the next day. During a review of Quality Control Inspection (QCI)-Housekeeping, the QCI indicated Resident 1's room was deep cleaned on the following days:-5/1/2025-5/14/2025-5/28/2025-6/7/2025-6/12/2025-6/15/2025-6/25/2025During an interview on 7/1/2025 at 2:35p.m. with Family Member 1 (FM 1), FM 1 stated Resident 1 had scabies, the staff never wore PPE protection during care and indicated the facility has placed Resident 1 back onto dirty sheets after a shower.During a concurrent observation and interview on 7/1/2025 at 4:01p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 1 is on EBP precautions because she has an indwelling catheter. LVN 2 was observed wearing gloves without prior hand hygiene and taking the blood pressure cuff off Resident 1's right arm without an isolation gown. No hand hygiene was observed after LVN 2 removed her gloves and proceeded to pour water into a cup and opened a straw paper for Resident 1. LVN 2 was observed going back into Resident 1's room, without an isolation gown while administering medication, touched Resident 1's forehead and left cheek with her right hand, and gave Resident 1 water for the medications. LVN 2 stated isolation gowns are worn when they have close contact with residents, move or turn the residents and when they are administering medications. LVN 2 stated when she touched Resident 1's forehead and cheek, she did not have to wear a gown because she was wearing gloves. LVN 2 stated direct contact means when you are touching the resident skin and indicated she was supposed to wear a gown when she touched Resident 1's forehead and cheek to protect herself and the resident. LVN 2 stated hand hygiene is performed prior to entering and leaving the residents room and when gloves are removed. LVN 2 stated hand hygiene is done for cleanliness. During a concurrent observation and interview on 7/1/2025 at 4:22p.m. with the Infection Preventionist (IPN), Resident 1's indwelling catheter was observed touching the floor. The IPN stated the foley catheter should not be touching the floor due to infection control practices. The IPN stated Resident 1 is on EBP due to the foley catheter, and when you are having direct contact with the residents, such as touching their face, you must wear a gown to protect the resident and yourself from infection. The IPN stated hand hygiene is performed in between tasks, prior to entering residents' rooms and exiting residents' rooms to prevent any transmission of bacteria. During an interview on 7/2/2025 at 12:08p.m. with the IPN, the IPN stated prior to Resident 1 going back to the room, everything must be disinfected to prevent the resident from getting scabies again after each shower. During a concurrent interview and record review on 7/3/2025 at 1:59p.m. with the Maintenance Supervisor (MS), the MS stated every day that two rooms are chosen to deep clean and indicated deep cleaning includes cleaning the curtains, disinfecting the bed, and cleaning the whole bedroom. The MS stated based on the Quality Control Inspection ([QCI]-Housekeeping document), Resident 1's room was cleaned on 6/12/2025, 6/15/2025, 6/19/2025, 6/22/2025, and 6/25/2025. The MS stated Resident 1's room was also deep cleaned on 5/14/2025, but it was not until June 2025 that he started cleaning Resident 1's room constantly due to FM 1's concerns regarding linen. The MS stated as soon as he is told a resident has scabies, they would deep clean the room as they do not want it to spread but is not sure how often the rooms have to be deep cleaned if a resident tested positive for scabies. The MS stated he had not started a shower log and does not have any documents to indicate when the showers were deep cleaned. The MS stated showers are usually cleaned 3 times a week. During a concurrent observation and interview on 7/3/2025 at 2:24p.m. with the Director of Nursing (DON), the DON stated EBPs indicated the resident is on isolation, and PPE equipment is worn to protect the residents and staff. The DON stated if there is no direct contact with the resident, a gown is not needed, however per observation of LVN 2 giving medication to Resident 1 without a gown, who has an indwelling catheter; the DON indicated LVN 2 needed to wear a gown. The DON stated hand hygiene is performed before and after taking care of a resident, when encountering a resident, and in between glove changes. The DON stated hand hygiene is performed to prevent transmitting bacteria to others and yourself. The DON stated foley catheters should not touch the floor to prevent any infection. The DON stated Resident 1 was confirmed with scabies and indicated after the permethrin treatment, they would have to deep clean Resident 1's room as there may be more bugs in the room. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene dated 9/18/2023, the P&P indicated this facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections and other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol after contact with blood, body fluids, visibly contaminated surface or after contact with objects in the resident room.after removing personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. During a review of the facility's P&P titled, Polices and Procedures-Infection Prevention and Control revised date 12/2023, the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Infection prevention and control policies and procedures apply to all personnel, consultants, contractors, residents, visitors, and volunteers. The objectives of the infection prevention and control policies and procedures are to: a. monitor, prevent, detect, investigate, and control infections in the facility;b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; and c. provide evidence-based guidelines for infection prevention and control based on current best practices. During a review of the facility's P&P titled, Enhanced Standard/Barrier Precautions revised date 2/21/2025, the P&P indicated it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.

Jun 2025 4 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

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 ensure one of three sampled residents (Resident 1) who had a histor...

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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 one of three sampled residents (Resident 1) who had a history of elopement (act of leaving a facility unsupervised and without prior authorization) and wandering (moving from place to place) behaviors did not elope from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 6/5/2025 at approximately 5:32 p.m., unbeknownst to staff. Resident 1 was returned to the facility on the same day after being found by a Good Samaritan at approximately 5:55 p.m. This deficient practice place Resident 1 at risk for harm as a result of in climate weather, motor vehicle accidents, fall, violence at the hands of others and death. This deficient practice resulted in Resident 1 eloping from the facility and placed Resident 1 at risk for the potential excessive changes in temperature, motor vehicle accidents, falls, violence and death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscle rigidity and slow, imprecise movements), dementia (a progressive state of decline in mental abilities) and muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/27/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to register and recall information) was moderately impaired. During a review of Resident 1's Nursing Documentation Evaluation form, dated 5/25/2025, the Nursing Documentation Evaluation form indicated Resident 1 was alert and confused and had wandering (traveling aimlessly from place to place) behaviors. During a review of Resident 1's untitled Care Plan, revised on 5/27/2025, the Care Plan indicated Resident 1 was at risk for wandering/elopement (the act of leaving a facility unsupervised and without prior authorization). The Care Plan's goal indicated Resident 1 would not leave facility unattended and his safety would be maintained. The Care Plan's interventions included engaging Resident 1 in purposeful activity, identifying any triggers for wandering/eloping, identifying certain times of the day that wander/elopement attempts occur, identifying patterns and purpose of wandering, implementing wander/elopement de-escalation behaviors, and Resident 1 should be in a common area or attend activities of choice for close monitoring. During a review of Resident 1's Change of Condition (COC) Evaluation, dated 5/27/2025, the COC Evaluation indicated Resident 1 was noted to have at risk for elopement due to wandering behavior (unsure what the behavior was). The COC Evaluation indicated Resident 1's physician was notified on 5/27/2025 at 12:20 p.m. and a wander guard (a bracelet worn by residents at risk for wandering/elopement that alerts caregivers when residents approach a monitored door by triggering an alarm) bracelet was ordered to be applied. During a review of Resident 1's Order Summary Report (Physician's Order) dated 5/27/2025, the Physician's Order indicated a wander guard for Resident 1 and to check for placement for wander guard to left wrist every shift. During a review of Resident 1's COC Evaluation, dated 6/5/2025, the COC Evaluation indicated Resident 1 was served dinner at approximately 5.25 p.m., on 6/5/2025, and at approximately 5:32 p.m., Certified Nurse Assistant (CNA) 1, noticed Resident 1 was not in his room and she (CNA 1) alerted Licensed Vocational Nurse (LVN) 1. The COC Evaluation indicated staff searched throughout the building, the surrounding premises and streets by foot and car. The COC Evaluation indicated Resident 1 was found by a Good Samaraitan at approximately 5:50 p.m., (6/5/2025), the Good Samaritan called the Fire Department who contacted the facility. The COC Evaluation indicated the Administrator (ADM) picked Resident 1 up and returned Resident 1 to the facility at 6:20 p.m., on 6/5/2025. During a review of the facility's Unusual Occurrence letter, dated 6/6/2025, the Unusual Occurrence letter indicated on 6/5/2025 at approximately 5.25 pm., Resident 1 was served dinner in the hallway and at 5:32 p.m., Resident 1 was not in the hallway eating dinner. The Unusual Occurrence letter indicated facility staff immediately initiated a search of the facility premises and nearby areas. The Unusual Occurrence letter indicated at approximately 5:55 p.m., the facility received a call from the local police department reporting that Resident 1 had been located. The Unusual Occurrence letter indicated the ADM drove to Resident 1's location picked him up and returned him to the facility. During an interview on 6/6/2025 at 11:40 a.m., Resident 1 stated he walked out of the facility's door, but he did not remember which door. Resident 1 stated he left because he wanted to leave. During an interview on 6/6/2025 at 3:08 p.m., CNA 1 stated at approximately 5:20 p.m., on 6/5/2025, she (CNA 1) directed Resident 1 to sit in his wheelchair in the hallway, to eat dinner while she passed dinner trays to other residents. CNA 1 stated she did not have visual confirmation of Resident 1's location while she passed dinner trays, nor did she inform other staff members that she would be unable to maintain a direct line of sight of Resident 1's whereabouts. CNA 1 stated at approximately 5:35 pm., she did not see Resident 1 in his wheelchair and immediately notified LVN 1 along with other staff members to search for Resident 1. CNA 1 did not hear a wander guard alarm alerting her that Resident 1 had left the building. During an interview on 6/6/2025 at 3:26 p.m., the Director of Staff Development (DSD) stated on 6/5/2025 at approximately 5:50 p.m., she and the ADM received a phone call from the police that Resident 1 had been located on the street about a four minute drive from the facility. During an interview on 6/6/2025, at 4:30 p.m., the DON stated a wander guard bracelet is worn by residents, who are at risk for elopement, but it does not prevent a resident from eloping, it is only a monitoring system. The DON stated it is the responsibility of the facility staff to supervise, monitor and redirect residents to prevent them from eloping. The DON stated Resident 1 eloping from the facility placed him at risk for injury from falls, car accidents or violence. During an interview on 6/6/2025, at 4:40 p.m., the ADM stated the wander guard was a reactive monitoring system that enhanced interventions that staff should have been providing such as monitoring Resident 1. During a review of the facility's Product Document for the wander guard, titled System Installment Guide for Code Alert dated 12/2017, the Product Document indicated the most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. During a review of the facility's Policy and Procedure (P&P) titled, Elopements revised 2/21/2025, the P&P indicated residents who exhibit wandering behavior and/or were at risk for elopement, receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of elopement (act of leaving a facility unsupervised and without prior authorization) and wandering (moving from place to place) behaviors did not elope from the facility. This deficient practice resulted in Resident 1 eloping from the facility on 6/5/2025 at approximately 5:32 p.m., unbeknownst to staff. Resident 1 was returned to the facility on the same day after being found by a Good Samaritan at approximately 5:55 p.m. This deficient practice place Resident 1 at risk for harm as a result of in climate weather, motor vehicle accidents, fall, violence at the hands of others and death. This deficient practice resulted in Resident 1 eloping from the facility and placed Resident 1 at risk for the potential excessive changes in temperature, motor vehicle accidents, falls, violence and death. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremors, muscle rigidity and slow, imprecise movements), dementia (a progressive state of decline in mental abilities) and muscle weakness. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 5/27/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1's cognition (ability to register and recall information) was moderately impaired. During a review of Resident 1's Nursing Documentation Evaluation form, dated 5/25/2025, the Nursing Documentation Evaluation form indicated Resident 1 was alert and confused and had wandering (traveling aimlessly from place to place) behaviors. During a review of Resident 1's untitled Care Plan, revised on 5/27/2025, the Care Plan indicated Resident 1 was at risk for wandering/elopement (the act of leaving a facility unsupervised and without prior authorization). The Care Plan's goal indicated Resident 1 would not leave facility unattended and his safety would be maintained. The Care Plan's interventions included engaging Resident 1 in purposeful activity, identifying any triggers for wandering/eloping, identifying certain times of the day that wander/elopement attempts occur, identifying patterns and purpose of wandering, implementing wander/elopement de-escalation behaviors, and Resident 1 should be in a common area or attend activities of choice for close monitoring. During a review of Resident 1's Change of Condition (COC) Evaluation, dated 5/27/2025, the COC Evaluation indicated Resident 1 was noted to have at risk for elopement due to wandering behavior (unsure what the behavior was). The COC Evaluation indicated Resident 1's physician was notified on 5/27/2025 at 12:20 p.m. and a wander guard (a bracelet worn by residents at risk for wandering/elopement that alerts caregivers when residents approach a monitored door by triggering an alarm) bracelet was ordered to be applied. During a review of Resident 1's Order Summary Report (Physician's Order) dated 5/27/2025, the Physician's Order indicated a wander guard for Resident 1 and to check for placement for wander guard to left wrist every shift. During a review of Resident 1's COC Evaluation, dated 6/5/2025, the COC Evaluation indicated Resident 1 was served dinner at approximately 5.25 p.m., on 6/5/2025, and at approximately 5:32 p.m., Certified Nurse Assistant (CNA) 1, noticed Resident 1 was not in his room and she (CNA 1) alerted Licensed Vocational Nurse (LVN) 1. The COC Evaluation indicated staff searched throughout the building, the surrounding premises and streets by foot and car. The COC Evaluation indicated Resident 1 was found by a Good Samaraitan at approximately 5:50 p.m., (6/5/2025), the Good Samaritan called the Fire Department who contacted the facility. The COC Evaluation indicated the Administrator (ADM) picked Resident 1 up and returned Resident 1 to the facility at 6:20 p.m., on 6/5/2025. During a review of the facility's Unusual Occurrence letter, dated 6/6/2025, the Unusual Occurrence letter indicated on 6/5/2025 at approximately 5.25 pm., Resident 1 was served dinner in the hallway and at 5:32 p.m., Resident 1 was not in the hallway eating dinner. The Unusual Occurrence letter indicated facility staff immediately initiated a search of the facility premises and nearby areas. The Unusual Occurrence letter indicated at approximately 5:55 p.m., the facility received a call from the local police department reporting that Resident 1 had been located. The Unusual Occurrence letter indicated the ADM drove to Resident 1's location picked him up and returned him to the facility. During an interview on 6/6/2025 at 11:40 a.m., Resident 1 stated he walked out of the facility's door, but he did not remember which door. Resident 1 stated he left because he wanted to leave. During an interview on 6/6/2025 at 3:08 p.m., CNA 1 stated at approximately 5:20 p.m., on 6/5/2025, she (CNA 1) directed Resident 1 to sit in his wheelchair in the hallway, to eat dinner while she passed dinner trays to other residents. CNA 1 stated she did not have visual confirmation of Resident 1's location while she passed dinner trays, nor did she inform other staff members that she would be unable to maintain a direct line of sight of Resident 1's whereabouts. CNA 1 stated at approximately 5:35 pm., she did not see Resident 1 in his wheelchair and immediately notified LVN 1 along with other staff members to search for Resident 1. CNA 1 did not hear a wander guard alarm alerting her that Resident 1 had left the building. During an interview on 6/6/2025 at 3:26 p.m., the Director of Staff Development (DSD) stated on 6/5/2025 at approximately 5:50 p.m., she and the ADM received a phone call from the police that Resident 1 had been located on the street about a four minute drive from the facility. During an interview on 6/6/2025, at 4:30 p.m., the DON stated a wander guard bracelet is worn by residents, who are at risk for elopement, but it does not prevent a resident from eloping, it is only a monitoring system. The DON stated it is the responsibility of the facility staff to supervise, monitor and redirect residents to prevent them from eloping. The DON stated Resident 1 eloping from the facility placed him at risk for injury from falls, car accidents or violence. During an interview on 6/6/2025, at 4:40 p.m., the ADM stated the wander guard was a reactive monitoring system that enhanced interventions that staff should have been providing such as monitoring Resident 1. During a review of the facility's Product Document for the wander guard, titled System Installment Guide for Code Alert dated 12/2017, the Product Document indicated the most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. During a review of the facility's Policy and Procedure (P&P) titled, Elopements revised 2/21/2025, the P&P indicated residents who exhibit wandering behavior and/or were at risk for elopement, receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.

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

Notification of Changes (Tag F0580)

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 notify one of three sampled resident's (Resident 2) physician and th...

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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 one of three sampled resident's (Resident 2) physician and the facility's registered dietician (RD), when Resident 1, had a poor food intake, and refused to be weighed. These deficient practices resulted a delay in Resident 2's evaluation and care and had the potential for Resident 2 to become malnourished and lose weight. Findings: During a review of Resident 2 's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including surgical aftercare (care after surgery), malignant neoplasm (an abnormal tissue growth characterized by cells that can invade surrounding tissues and potentially spread to other parts of the body) of tongue and gastro-esophageal disease ([GERD] a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This action can irritate the esophagus, causing heartburn and other symptoms . During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 2/26/2025, the MDS indicated Resident 2 was a able to understand and be understood by others. The MDS indicated Resident 2's cognition (ability to register and recall information) was not impaired. The MDS indicated Resident 2 was diagnosed with malnutrition (body receiving inadequate nutrients) or was at risk for malnutrition. During a review of Resident 2's Nutritional Assessment, dated 2/24/2025, the Nutritional Assessment indicated Resident 2 reported she had poor appetite. The Nutritional Assessment indicated Resident 2's nutritional needs were not met; Resident 2 was consuming approximately 53% of nine meals and was not meeting greater than 75% of her nutritional needs. The Nutritional Assessment recommendation indicated Resident 2 may benefit from oral supplementation, will continue to monitor. During a review of Resident 2's untitled Care Plan, revised on 2/26/2025, the Care Plan indicated Resident 2 was at nutritional risk, related to a recent hospitalization and status post (after a certain event or procedure) laparoscopic cholecystectomy (surgical procedure to remove the gallbladder [organ in body] using small incisions and a small tubes to perform the surgery). The Care Plan's goals indicated Resident 2 would consume 75% of at least two-three meals every day for 30 days. The Care Plan's interventions included to weigh Resident 2 as ordered, monitor for changes in Resident 2's nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs), monitor intake at all meals, offer alternate choices as needed, and alert the dietician and physician to any decline in intake. During a review of the Resident 2's Physician's Order, the Physician's Order indicated the following: 1. On 2/20/2025 - Weigh Resident 1 every day shift each month beginning the third for one day (start on 3//3/2025) 2. On 2/20/2025 - Weigh Resident 1 every day shift each Wednesday for four weeks, (2/26/2025 through 3/26/2025). 3. On 3/3/2025 - Give Resident 2 Ensure (a food supplement) 237 milliliter ([ml] measurement of volume) with her medication pass, three times a day. During a review of Resident 2's Nursing Documentation Evaluation form, dated 2/20/2025, the Nursing Documentation form indicated Resident 2 had difficulty swallowing. During a review of Resident 2's Weights and Vitals Summary, dated 6/5/2025, the Weights and Vital Summary indicated Resident 2 reported she had a poor appetite. The Weights and Vitals Summary indicated the following: 1. On 2/21/2025 Resident 2 weighed 120 pounds (lbs.) 2. On 2/28/2025 - Resident 2 refused to be weighed, however her weight was documented as 120 lbs. 3. On 3/7/202045 - Resident 2 reused to be weighed, however her weight was documented as 120 lbs. During a review of Resident 2's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/1/2025 through 3/31/2025, the MAR indicated Resident 2 consumed the following percentage of Ensure from 3/3/2025 through 3/12/2025: 1. 100% of Ensure was consumed for eight doses 2. 75% of Ensure was consumed for 10 doses 3. 50% of Ensure was consumed for 12 doses. During a review of Resident 2's Document Survey Report, dated 3/2025. The Document Survey Report indicated Resident 2 was given 38 meals and ate 25% of the meals on two occasions, 50% of the meals on 17 occasions, 75% of the meals on six occasions, refused the meals on two occasions, there was no documentation entered on two occasions, and Resident 2 was not available/nonapplicable on three occasions. During an interview on 6/5/2025 at 3:11.p.m., the Registered Dietician (RD) stated when she conducted Resident 2's nutritional admission assessment on 2/24/2025, Resident 2 informed her that she her appetite was poor, and her plan was to reassess Resident 2 if there was a decline in her weight and meal consumption. The RD stated Resident 2's had a physician's order, dated 2/20/2025 for a ST evaluation and at the time of her assessment on 2/24/2025, she (RD) determined Resident 2's diet was regular and would wait on the ST's evaluation of Resident 2 for further determination of her nutritional status. The RD stated after reviewing Resident 2's clinical record the ST never evaluated Resident 2. She (RD) also noted that Resident 2's last documented weight was 120 lbs. on 2/21/2025 and although Resident 2 refused to be weighed on 2/28/2025 and 3/7/20205 a weight of 120 lbs. was entered for both of those days, which gives an incorrect status of Resident 2's weight/nutritional status. The RD says no one notified her that Resident 2 refused to be weighed on 2/28/2025 and 3/7/2025 or that Resident 2's meal consumption was poor several days. The RD stated had the information been communicated to her, she would have reassessed Resident 2 and revised her nutritional care plan. The RD stated the lack of communication regarding Resident 2's poor food intake, and refusal to be weighed caused a delay her evaluation and care. During an interview on 6/6/2024 at 4:30 p.m., the Director of Nursing (DON), after reviewing Resident 2's clinical record, stated Resident 2's was at risk for malnutrition and should have been monitored closely for weight loss and a decline food intake. The DON stated the nursing staff should have notified the RD and Resident 2's physician for any changes in Resident 2's nutritional status. The DON stated failure to notify the RD and Resident 's 2 physician led to Resident 2 experiencing a delay in evaluation and care. During a review of the facility's P/P, titled, Care Plan Comprehensive, dated 8/25/2021, the P/P indicated the facility's interdisciplinary team, in coordination with the resident and or her family, or representative, must develop and implement a comprehensive person centered plan of care for each resident. During a review of the facility's Policy and Procedure (P/P) titled, Change in Condition, Notification of dated 8/25/2021, the P/P indicated the purpose of the policy is ensure residents, family and legal representatives and physicians are informed of changes in the resident's condition. The facility must immediately notify the resident, consult with the resident's physician and or NP and notify consistent with his/her authority, the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment significantly, a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment. Based on interview and record review the facility failed to notify one of three sampled resident's (Resident 2) physician and the facility's registered dietician (RD), when Resident 1, had a poor food intake, and refused to be weighed. These deficient practices resulted a delay in Resident 2's evaluation and care and had the potential for Resident 2 to become malnourished and lose weight. Findings: During a review of Resident 2 's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including surgical aftercare (care after surgery), malignant neoplasm (an abnormal tissue growth characterized by cells that can invade surrounding tissues and potentially spread to other parts of the body) of tongue and gastro-esophageal disease ([GERD] a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This action can irritate the esophagus, causing heartburn and other symptoms . During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 2/26/2025, the MDS indicated Resident 2 was a able to understand and be understood by others. The MDS indicated Resident 2's cognition (ability to register and recall information) was not impaired. The MDS indicated Resident 2 was diagnosed with malnutrition (body receiving inadequate nutrients) or was at risk for malnutrition. During a review of Resident 2's Nutritional Assessment, dated 2/24/2025, the Nutritional Assessment indicated Resident 2 reported she had poor appetite. The Nutritional Assessment indicated Resident 2's nutritional needs were not met; Resident 2 was consuming approximately 53% of nine meals and was not meeting greater than 75% of her nutritional needs. The Nutritional Assessment recommendation indicated Resident 2 may benefit from oral supplementation, will continue to monitor. During a review of Resident 2's untitled Care Plan, revised on 2/26/2025, the Care Plan indicated Resident 2 was at nutritional risk, related to a recent hospitalization and status post (after a certain event or procedure) laparoscopic cholecystectomy (surgical procedure to remove the gallbladder [organ in body] using small incisions and a small tubes to perform the surgery). The Care Plan's goals indicated Resident 2 would consume 75% of at least two-three meals every day for 30 days. The Care Plan's interventions included to weigh Resident 2 as ordered, monitor for changes in Resident 2's nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs), monitor intake at all meals, offer alternate choices as needed, and alert the dietician and physician to any decline in intake. During a review of the Resident 2's Physician's Order, the Physician's Order indicated the following: 1. On 2/20/2025 - Weigh Resident 1 every day shift each month beginning the third for one day (start on 3//3/2025) 2. On 2/20/2025 - Weigh Resident 1 every day shift each Wednesday for four weeks, (2/26/2025 through 3/26/2025). 3. On 3/3/2025 - Give Resident 2 Ensure (a food supplement) 237 milliliter ([ml] measurement of volume) with her medication pass, three times a day. During a review of Resident 2's Nursing Documentation Evaluation form, dated 2/20/2025, the Nursing Documentation form indicated Resident 2 had difficulty swallowing. During a review of Resident 2's Weights and Vitals Summary, dated 6/5/2025, the Weights and Vital Summary indicated Resident 2 reported she had a poor appetite. The Weights and Vitals Summary indicated the following: 1. On 2/21/2025 Resident 2 weighed 120 pounds (lbs.) 2. On 2/28/2025 - Resident 2 refused to be weighed, however her weight was documented as 120 lbs. 3. On 3/7/202045 - Resident 2 reused to be weighed, however her weight was documented as 120 lbs. During a review of Resident 2's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/1/2025 through 3/31/2025, the MAR indicated Resident 2 consumed the following percentage of Ensure from 3/3/2025 through 3/12/2025: 1. 100% of Ensure was consumed for eight doses 2. 75% of Ensure was consumed for 10 doses 3. 50% of Ensure was consumed for 12 doses. During a review of Resident 2's Document Survey Report, dated 3/2025. The Document Survey Report indicated Resident 2 was given 38 meals and ate 25% of the meals on two occasions, 50% of the meals on 17 occasions, 75% of the meals on six occasions, refused the meals on two occasions, there was no documentation entered on two occasions, and Resident 2 was not available/nonapplicable on three occasions. During an interview on 6/5/2025 at 3:11.p.m., the Registered Dietician (RD) stated when she conducted Resident 2's nutritional admission assessment on 2/24/2025, Resident 2 informed her that she her appetite was poor, and her plan was to reassess Resident 2 if there was a decline in her weight and meal consumption. The RD stated Resident 2's had a physician's order, dated 2/20/2025 for a ST evaluation and at the time of her assessment on 2/24/2025, she (RD) determined Resident 2's diet was regular and would wait on the ST's evaluation of Resident 2 for further determination of her nutritional status. The RD stated after reviewing Resident 2's clinical record the ST never evaluated Resident 2. She (RD) also noted that Resident 2's last documented weight was 120 lbs. on 2/21/2025 and although Resident 2 refused to be weighed on 2/28/2025 and 3/7/20205 a weight of 120 lbs. was entered for both of those days, which gives an incorrect status of Resident 2's weight/nutritional status. The RD says no one notified her that Resident 2 refused to be weighed on 2/28/2025 and 3/7/2025 or that Resident 2's meal consumption was poor several days. The RD stated had the information been communicated to her, she would have reassessed Resident 2 and revised her nutritional care plan. The RD stated the lack of communication regarding Resident 2's poor food intake, and refusal to be weighed caused a delay her evaluation and care. During an interview on 6/6/2024 at 4:30 p.m., the Director of Nursing (DON), after reviewing Resident 2's clinical record, stated Resident 2's was at risk for malnutrition and should have been monitored closely for weight loss and a decline food intake. The DON stated the nursing staff should have notified the RD and Resident 2's physician for any changes in Resident 2's nutritional status. The DON stated failure to notify the RD and Resident 's 2 physician led to Resident 2 experiencing a delay in evaluation and care. During a review of the facility's P/P, titled, Care Plan Comprehensive, dated 8/25/2021, the P/P indicated the facility's interdisciplinary team, in coordination with the resident and or her family, or representative, must develop and implement a comprehensive person centered plan of care for each resident. During a review of the facility's Policy and Procedure (P/P) titled, Change in Condition, Notification of dated 8/25/2021, the P/P indicated the purpose of the policy is ensure residents, family and legal representatives and physicians are informed of changes in the resident's condition. The facility must immediately notify the resident, consult with the resident's physician and or NP and notify consistent with his/her authority, the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment significantly, a need to discontinue or change an existing form of treatment due to adverse consequences or to commence a new form of treatment.

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 F0692 (Tag F0692)

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 the weights and food consumption for one of three sampled res...

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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 weights and food consumption for one of three sampled residents (Resident 2) was obtained and/or assessed. These deficient practices resulted in Resident 2's weights and food consumption being unknown and a delay in evaluation and care. These deficient practices placed Resident 2 at risk for malnutrition and weight loss. Findings: During a review of Resident 2 's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including surgical aftercare (care after surgery), malignant neoplasm (an abnormal tissue growth characterized by cells that can invade surrounding tissues and potentially spread to other parts of the body) of tongue and gastro-esophageal disease ([GERD] a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This action can irritate the esophagus, causing heartburn and other symptoms . During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 2/26/2025, the MDS indicated Resident 2 was a able to understand and be understood by others. The MDS indicated Resident 2's cognition (ability to register and recall information) was not impaired. The MDS indicated Resident 2 was diagnosed with malnutrition (body receiving inadequate nutrients) or was at risk for malnutrition. During a review of the Resident 2's Order Summary Report (Physician's Order), dated 2/20/2025, the Physician's Order indicated the following: 1. On 2/20/2025 - Weigh Resident 1 every day shift each month beginning the third for one day (start on 3//3/2025) 2. On 2/20/2025 - Weigh Resident 1 every day shift each Wednesday for four weeks, (2/26/2025 through 3/26/2025). 3. On 3/3/2025 - Give Resident 2 Ensure (a food supplement) 237 milliliter ([ml] measurement of volume) with her medication pass, three times a day. During a review of Resident 2's Nursing Documentation Evaluation form, dated 2/20/2025, the Nursing Documentation form indicated Resident 2 had difficulty swallowing. During a review of Resident 2's Nutritional Assessment, dated 2/24/2025, the Nutritional Assessment indicated Resident 2 reported she had poor appetite. The assessment further indicated Resident 2's nutritional needs are not met; Resident 2 is consuming about 53% of nine meals and not meeting greater than 75% of nutritional needs. The assessment recommendation indicated the following, Resident 2 confirms poor appetite, may benefit from oral supplementation to better nutritional needs, will continue to monitor. During a review of Resident 2's Weights and Vitals Summary, dated 6/5/2025, the Weights and Vital Summary indicated Resident 2 reported she had a poor appetite. The Weights and Vitals Summary indicated the following: 1. On 2/21/2025 Resident 2 weighed 120 pounds (lbs.) 2. On 2/28/2025 - Resident 2 refused to be weighed, however her weight was documented as 120 lbs. 3. On 3/7/202045 - Resident 2 reused to be weighed, however her weight was documented as 120 lbs. During a review of Resident 2's Medication Administration Record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/1/2025 through 3/31/2025, the MAR indicated Resident 2 consumed the following percentage of Ensure from 3/3/2025 through 3/12/2025: 1. 100% of Ensure was consumed for eight doses 2. 75% of Ensure was consumed for 10 doses 3. 50% of Ensure was consumed for 12 doses. During a review of Resident 2's Document Survey Report, dated 3/2025. The Document Survey Report indicated Resident 2 was given 38 meals and ate 25% of the meals on two occasions, 50% of the meals on 17 occasions, 75% of the meals on six occasions, refused the meals on two occasions, there was no documentation entered on two occasions, and Resident 2 was not available/nonapplicable on three occasions. During a review of Resident 2's untitled Care Plan, revised on 2/26/2025, the Care Plan indicated Resident 2 was at nutritional risk, related to a recent hospitalization and status post (after a certain event or procedure) laparoscopic cholecystectomy (surgical procedure to remove the gallbladder [organ in body] using small incisions and a small tubes to perform the surgery). The Care Plan's goals indicated Resident 2 would consume 75% of at least two-three meals every day for 30 days. The Care Plan's interventions included to weigh Resident 2 as ordered, monitor for changes in Resident 2's nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs), monitor intake at all meals, offer alternate choices as needed, and alert the dietician and physician to any decline in intake. During an interview on 6/5/2025 at 10 a.m., Resident 2 stated she did not receive adequate nutrition during her stay at the facility and she lost so much weight her dentures became lose. Resident 2 stated she was given bread and which she could not chew. Resident 2 stated because of a surgery she'd had on her tongue due to cancer, she had difficulty chewing and swallowing. Resident 2 stated she was never evaluated for the appropriate diet and when she requested a different diet than the one she was given, she did not receive it. Resident 2 stated she felt weak and unhealthy because she was receiving an inappropriate diet During an interview on 6/5/2025 at 11 a.m., the Registered Dietician (RD) stated she conducted Resident 2's nutritional admission assessment on 2/24/2025 and was told by Resident 2 that she (Resident 2) had a poor appetite, and her plan was to reassess Resident 2 if there was a decline in her weight and meal consumption. The RD stated Resident 2's had a physician's order, dated 2/20/2025 for a ST evaluation and at the time of her assessment on 2/24/2025, she (RD) determined Resident 2's diet was regular and would wait on the ST's evaluation of Resident 2 for further determination of her nutritional status. The RD stated after reviewing Resident 2's clinical record the ST never evaluated Resident 2. She (RD) also noted that Resident 2's last documented weight was 120 lbs. on 2/21/2025 and although Resident 2 refused to be weighed on 2/28/2025 and 3/7/20205 a weight of 120 lbs. was entered for both of those days, which gives an incorrect status of Resident 2's weight/nutritional status. The RD says no one notified her that Resident 2 refused to be weighed on 2/28/2025 and 3/7/2025 or that Resident 2's meal consumption was poor several days. The RD stated had the information been communicated to her, she would have reassessed Resident 2 and revised her nutritional care plan. The RD stated the lack of communication regarding Resident 2's poor food intake, and refusal to be weighed caused a delay her evaluation and care. During an interview on 6/5/2025 at 4:45 p.m., Resident 2's Responsible Party (RP 2) stated she and Resident 2 frequently asked for a different diet because Resident 2 had a difficult time chewing and eating the food the facility provided. RP 2 stated their requests were never met and there was no communication from the facility staff regarding Resident 2's nutrition goal. During an interview on 6/6/2024 at 4:30 p.m., the Director of Nursing (DON), after reviewing Resident 2's clinical record, stated Resident 2's was at risk for malnutrition and should have been monitored closely for weight loss and a decline food intake. The DON stated the nursing staff should have notified the RD and Resident 2's physician for any changes in Resident 2's nutritional status. The DON stated failure to notify the RD and Resident 's 2 physician led to Resident 2 experiencing a delay in evaluation and care. During a review of the facility's undated Policy and Procedure (P/P), titled, Weight Management the P/P indicated it is the policy of the facility to obtain baseline weight and identify significant weight change; weighs will be obtained weekly for four weeks after admission. During a review of the facility's P/P, titled, Care Plan Comprehensive, dated 8/25/2021, the P/P indicated the facility's interdisciplinary team, in coordination with the resident and or her family, or representative, must develop and implement a comprehensive person centered plan of care for each resident. During a review of the facility's undated P/P, titled, Requesting, Refusing and or Discontinuing Care or Treatment, the P/P indicated if a resident/representative requests, discontinues or refuses care or treatment, an appropriate member of the IDT will meet with the resident/representative to determine why she is requesting, refusing or discontinuing care or treatment, try to address her concerns and discuss alternative options, and discuss the potential outcomes or consequences ( positive and negative) of that decision. Based on interview and record review the facility failed to accurately and consistently assess one of three sampled resident's (Resident 2) nutritional status (state of a person's health in terms of the nutrients in her diet) after admission. The facility failed to 1.notify the Registered Dietician(RD) and Resident 2's physician of Resident 2's decline in meal and Ensure (meal supplement for residents at nutritional risk, experiencing involuntary weight loss, recovering from illness or surgery) consumption . 2. Failed to accurately document Resident 2's weight, when Resident 2 refused to be weighed on 2/28/2025 and 3/7/2025. 3. Failed to implement a physician order for Speech Therapist (health professionals who evaluate, diagnose, and treat individuals with swallowing disorders) evaluation. 4. Conduct an interdisciplinary team (IDT-group of healthcare professional who work with the Resident and or Resident representative to care a plan of care with goals and interventions) to address Resident 2's risk for malnutrition. These deficient practices resulted in an 1.Lack of weights leading to inaccurate clinical assessment of Resident 2 ' s nutritional status status placing Resident 2 at further risk for malnutrition ( body receiving less nutrients). 2. Lack of appropriate Speech Therapy Evaluation to determine the proper diet for Resident 2. 3. Resident 2's feeling frustrated at not being involved in her plan of care. 4. Resident 2 stating she felt unwell and malnourished due to being unable to chew and swallow her food which was determined to be a Regular diet (consisting of foods of various textures, may be hard and crunchy or naturally soft) assessed once , upon Resident 2 ' s admission. Findings: During a review of Resident 2 's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including surgical aftercare (care after surgery), malignant neoplasm (abnormal tissue growth characterized by cells that can invade surrounding tissues and potentially spread to other parts of the body) of tongue and gastro-esophageal (affecting stomach and esophagus [muscular tube connecting throat to stomach) disease. During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool) dated 2/26/2025, the MDS indicated Resident 2 was always able to understand and be understood by others. The MDS indicated Resident 2's cognition (ability to register and recall information) was not impaired. The MDS indicated Resident 2 had an active diagnosis of malnutrition or at risk for malnutrition and underwent a major surgical procedure prior to her admission to the facility. During a review of the Resident 2's Order Summary Report, indicated on 2/20/2025, Speech Therapy (ST), Evaluation and Treatment as recommended. During a review of the Resident 2's Order Summary Report, indicated the following orders placed on 2/20/2025 : weigh for risk of malnutrition every day shift every month starting on the third for one day (start on 3/3/2025) ; weigh for risk of malnutrition every day shift every Wednesday for four weeks, (2/26/2025 through 3/26/2025). During a review of the Resident 2's Order Summary Report, to start on indicated on 3/3/2025, Administer Ensure 237 milliliter ( ml- measurement of volume) ls with med pass, three times a day. During a review of Resident 2's Nursing Documentation Evaluation form , dated 2/20/2025, the form indicated Resident 2 had difficulty swallowing. During a review of Resident 2's nutritional assessment, dated 2/24/2025, the assessment indicated Resident 2 reported she had poor appetite. The assessment further indicated Resident 2's nutritional needs are not met; Resident 2 is consuming about 53% of nine meals and not meeting greater than 75% of nutritional needs. The assessment recommendation indicated the following, Resident 2 confirms poor appetite, may benefit from oral supplementation to better nutritional needs, will continue to monitor. During a review of Resident 2's weights and vitals summary, dated 6/5/2025, the summary indicated Resident 2 reported she had poor appetite. The assessment further indicated the following weight values for Resident 2: on 2/21/2025 at 5:42 p.m., weight :120 pounds (lbs-unit of measurement), on 2/28/2025 at 9:20 p.m. weight : 120lbs , last weight obtained, Resident 2 refused; on 3/7/2025 at 5:03 p.m., weight : 120 lbs last weight obtained, Resident 2 refused. During a review of Resident 2's Medication Administration Record ( MAR) dated 3/1/2025 through 3/31/2025, the MAR indicated the following: Administer Ensure 237 mls with med pass starting on 3/3/2025 at 9am. The MAR indicated the following consumption percentages from 3/3/2025 through 3/12/2025. The MAR indicated the following consumption percentages, 100 % x 8 doses; 75% x 10 doses, and 50% x 12 doses. During a review of Resident 2's document survey report , dated 3/2025. The report indicated Resident 2 had 38 meal opportunities. The report indicated the following of 38 meals , Resident 2 consumed 25% of meals on 2 occasions, 50% of meals on 17 occasions, 75% of meals on six occasions, refused meals on two occasions, no documentations was entered on two occasions, resident was not available/ nonapplicable on three occasions. During a review of the Resident 2's Care Plan, revised on 2/26/2025, the Care Plan indicated Resident 2 was at nutritional risk, recent hospitalization, status post laparoscopic cholecystectomy. The Care Plan's goals indicated Resident 2 will consume 75% of at least 2-3 meals every day for 30 days, target date on 5/22/2025. The Care Plan's interventions included weigh as ordered, monitor for changes in nutritional status ( changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/ physician as indicated, monitor intake at all meals, offer alternate choices as needed, alert dietician and physician to any decline in intake. During an interview on 6/5/2025 at 10 a.m., Resident 2 stated she had lost weight during her stay at the facility and did not receive adequate nutrition. Resident 2 stated she lost so much weight that her dentures became lose due to her receiving an inappropriate diet. Resident 2 stated I was receiving bread which I couldn't chew. Resident 2 stated she previous had tongue cancer which make it difficult for her to chew and swallow. Resident 2 stated she asked for a different diet, but the request was unmet. Resident 2 stated she was never evaluated for the appropriate diet. Resident 2 stated the lack of nutrition caused her to feel weak and unhealthy. During an interview on 6/5/2025 at 11 a.m., the Registered Dietician (RD) stated when she conducted Resident 2's nutritional admission assessment on 2/24/2025, she (RD) noted Resident 2 informed her (RD) that she (Resident 2 ) had poor appetite. RD stated she planned to reassess Resident 2 if there was a decline in Resident 2's weight and meal consumption. RD stated based on her review of Resident 2's clinical records, Resident 2 had a physician order, dated 2/20/2025 for speech therapy evaluation. RD stated at the time of her assessment on 2/24/2025, RD determined Resident 2's diet to be regular until further determination by speech therapy. RD stated based on her review of Resident 2's clinical records, speech therapy did not assess Resident 2. RD stated based on further review, Resident 2's weight entered on 2/21/2025 was 120 pounds. RD stated although the clinical records indicate on 2/28/2025 and 3/7/2025 Resident 2 refused weight assessments, 120 pounds was entered which resulted in an inaccurate picture of Resident 2's nutritional status. RD stated she was not notified by the nursing staff of Resident 2's refusal to be weighed nor that Resident 2's meal and Ensure consumption was under 100%. RD stated had the information been communicated to her, she would have reassessed Resident 2 and revised Resident 2's nutritional care plans. RD stated she was not aware of an IDT meeting held to discuss Resident 2's nutritional status/goals. RD stated Resident 2's pre-albumin was 7mg/dL (range 18-38), collected on 2/24/2025, which considering Resident 2's clinical picture, could be an indication of malnutrition. RD stated there could have been better communication with the bedside staff and IDT regarding Resident ' s refusal of weights, decline in meal consumption and lack of speech therapy follow up. RD stated due to the lack of communication, there was a delay in ensuring Resident 2 received individualized, appropriate nutrition to support her (Resident 2's) overall health. During an interview on 6/5/2025 at 4:45 p.m., Resident 2's Responsible Party (RP 2) stated she and Resident 2 frequently asked for a different diet because Resident 2 had a difficult time chewing and consuming the food the facility had provided. RP 2 stated their requests were never met and they did not receive any communication from the facility staff regarding Resident 2's nutrition goal including being involved in Resident 2's plan of care. During an interview on 6/6/2025 at 12 p.m., the Minimum Data Set (MDS), stated Resident 2 should have had an IDT shortly after her admission to discuss nutritional goals including the importance of weekly weights, meal and supplement consumption tracking and speech therapy evaluation. MDS stated based on her review of Resident 2's clinical records, Resident 2 did not have an IDT focused on her nutritional goals, nor were there documentation indicating why Resident 2 weights were refused, no documentation indicating the licensed nurse was aware that Resident 2 had a pattern of consuming 75% of meals and supplements. The MDS nurse stated there was no documenting the above issues were addressed with Resident 2 or Resident 2's responsible party. During an interview on 6/6/2025 at 2 p.m., the Director of Rehabilitation (DOR), stated Resident 2 had a physician's order for speech therapy evaluation which was not carried out. The DOR stated she was not sure why it was overlooked by the rehabilitation department. The DOR stated speech therapy would be important in determining Resident 2's appropriate diets especially due to Resident 1's decreased consumption. The DOR stated Resident 2 should have had an IDT to discuss nutritional status. During an interview on 6/6/2024 at 4:30 p.m., the DON stated based on his review of Resident 2's clinical records, Resident 2 was at risk for malnutrition and should have been monitored closely for weight loss and a decline intake. The DON stated there should have been an IDT meeting to discuss Resident 2's nutritional goals which included a Speech Therapy evaluation. The DON stated, Resident 2 experienced a delay in assessments and services leading possible malnutrition. During a review of the facility's undated Policy and Procedure (P/P), titled, Weight Management the P/P indicated it is the policy of the facility to obtain baseline weight and identify significant weight change; weighs will be obtained weekly for four weeks after admission. During a review of the facility's P/P, titled, Care plan comprehensive, dated 8/25/2021, the P/P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical , mental and psychological needs shall be developed for each resident. The P/P further indicated , the facility's interdisciplinary team, in coordination with the resident and or her family, or representative, must develop and implement a comprehensive person centered plan of care for each resident that includes measurable objectives and timeframes to meet a resident's medical, physical and mental and psychosocial needs that are identified in the comprehensive care plan. During a review of the facility's undated P/P, titled, Requesting, Refusing and or Discontinuing Care or Treatment , the P/P indicated if a resident/ representative requests, discontinues or refuses care or treatment, an appropriate member of the IDT will meet with the resident/representative to determine why she is requesting, refusing or discontinuing care or treatment, try to address her concerns and discuss alternative options, and discuss the potential outcomes or consequences ( positive and negative) of that decision.

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 F0865 (Tag F0865)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to ensure their QA/QAPI (Quality Assurance/Quality Assurance and Performance Improvement, a data driven proactive approach to improvement used ...

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Based on interview and record review the facility failed to ensure their QA/QAPI (Quality Assurance/Quality Assurance and Performance Improvement, a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee monitored interventions put in place related to delays in receiving resident care. This deficient practices resulted in the inability of the facility to determine if interventions put in place to improve resident care in a timely manner were affective and placed residents at risk for continued delay in care and services. Findings: During a review of the facility's Grievance Report dated 5/16/2024, the Grievance Report indicated Resident 4 had concerns related to answering of call lights (device used by resident to ask for assistance) in a timely manner. The Grievance Report indicated the facility will continue to address the concern during their QAPI meeting. During a review of the facility's Grievance Report dated 4/15/2025, the Grievance Report indicated Resident 4 had concerns related to resident care, call lights and customer service. The Grievance Report indicated actions taken to resolve the concern was to provide in-service staff on answering call lights in a timely manner. During a review of the facility's Grievance Report dated 5/19/2025, the Grievance Report indicated Resident 5 did not receive resident care in a timely manner. The Grievance Report indicated actions taken to resolve the concern was for the Director of Nursing (DON) to provide in-services to staff on answering call lights in a timely manner. During an interview on 6/6/2025 at 4:40 p.m., the Administrator stated based on their review of their most recent QAPI programs, call light response and customer service was not listed as an area of focus. The DON stated it was important to address the grievances related to resident care. The DON stated, although in services were essential to educating staff on the importance of providing timely assistance to residents, there must be a system in place to evaluate if the corrective actions were affective. The ADM stated at this time, the facility did not have a system in place to determine if there was improvement in care of resident's in a timely manner. During a review of the facility's undated Policy and Procedure (P/P), titled, Quality Assurance and Performance Improvement (QAPI)Program - Governance and Leadership the P/P indicated the Quality Assurance and Performance Improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and governing body. The responsibilities of the QAPI committee are to :collect and analyze performance indicator data and other information, identify , evaluate, monitor and improve facility systems and process that support the delivery of care and services, coordinate the development, implementation ,monitoring and evaluation of performance improvement projects to achieve specific goals. Based on interview and record review the facility failed to ensure their QA/QAPI (Quality Assurance/Quality Assurance and Performance Improvement, a data driven proactive approach to improvement used to ensure services are meeting quality standards) committee monitored interventions put in place related to delays in receiving resident care. This deficient practices resulted in the inability of the facility to determine if interventions put in place to improve resident care in a timely manner were affective and placed residents at risk for continued delay in care and services. Findings: During a review of the facility's Grievance Report dated 5/16/2024, the Grievance Report indicated Resident 4 had concerns related to answering of call lights (device used by resident to ask for assistance) in a timely manner. The Grievance Report indicated the facility will continue to address the concern during their QAPI meeting. During a review of the facility's Grievance Report dated 4/15/2025, the Grievance Report indicated Resident 4 had concerns related to resident care, call lights and customer service. The Grievance Report indicated actions taken to resolve the concern was to provide in-service staff on answering call lights in a timely manner. During a review of the facility's Grievance Report dated 5/19/2025, the Grievance Report indicated Resident 5 did not receive resident care in a timely manner. The Grievance Report indicated actions taken to resolve the concern was for the Director of Nursing (DON) to provide in-services to staff on answering call lights in a timely manner. During an interview on 6/6/2025 at 4:40 p.m., the Administrator stated based on their review of their most recent QAPI programs, call light response and customer service was not listed as an area of focus. The DON stated it was important to address the grievances related to resident care. The DON stated, although in services were essential to educating staff on the importance of providing timely assistance to residents, there must be a system in place to evaluate if the corrective actions were affective. The ADM stated at this time, the facility did not have a system in place to determine if there was improvement in care of resident's in a timely manner. During a review of the facility's undated Policy and Procedure (P/P), titled, Quality Assurance and Performance Improvement (QAPI)Program - Governance and Leadership the P/P indicated the Quality Assurance and Performance Improvement program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and governing body. The responsibilities of the QAPI committee are to :collect and analyze performance indicator data and other information, identify , evaluate, monitor and improve facility systems and process that support the delivery of care and services, coordinate the development, implementation ,monitoring and evaluation of performance improvement projects to achieve specific goals.

May 2025 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

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 interview and record review, the facility failed to monitor two of two sampled resident (Resident 11 and Resident 12) a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor two of two sampled resident (Resident 11 and Resident 12) after a change of condition occurred. This failure had the potential to result in a potential delay of care to Resident 11 and Resident 12. Findings: During a review of Resident 11's admission record, the admission record indicated Resident 11 was admitted to the facility on [DATE] with diagnoses including fracture of left femur (break or injury of the thigh bone or hip) and hypertension (high blood pressure). During a review of Resident 11 ' s Minimum Data Set (MDS - a resident assessment tool), dated 4/23/2025, the MDS indicated Resident 11 had no cognitive (ability to learn, reason, remember, understand, and make decisions) impairment, required set-up assistance when eating, and required maximal assistance (helper does more than half the effort) with toileting and bathing. During a concurrent interview and record review on 5/29/2025 at 1:54 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 11 ' s medical record was reviewed. LVN 1 stated Resident 11 had an episode of emesis (vomiting), was perspiring (sweating), and was hypotensive (low blood pressure). LVN 1 stated Resident 11's blood pressure was 91/59 millimeters of mercury (mmHg- unit of measurement; normal blood pressure is 120/80) and her heart rate was 120 beats per minute (bpm - unit of measurement for heartbeat; normal heart rate is 80-100 bpm). LVN 1 stated on 4/25/2025 at 9:14 p.m., the facility informed the physician of Resident 11 ' s change of condition, and the physician recommended to continue to monitor Resident 11. LVN 1 stated the facility called 911 for the resident on 4/25/2025 at 9:16 p.m., but Resident 11 refused to transfer to the hospital at the time. LVN 1 stated Resident 11 had another episode of emesis on 4/26/2025 at 3:00 a.m., 911 was called by the facility, and Resident 11 was transferred to a general acute care hospital (GACH) on 4/26/2025 at 3:30 a.m LVN 1 stated there is no reassessment of vital signs between 4/25/2025 9:14 p.m. and 4/26/2025 3:30 a.m. LVN 1 stated in the 6 hours, resident ' s vital signs were not reassessed. During a review of Resident 12 ' s admission record, the admission record indicated Resident 11 was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and end stage renal disease (ESRD - irreversible kidney failure) with dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) . During a review of Resident 12 ' s MDS dated [DATE], the MDS indicated Resident 12 had no cognitive impairment, required set-up assistance when eating, and required moderate assistance (helper does less than half the effort) with toileting and bathing. During a concurrent interview and record review on 5/29/2025 at 1:54 p.m., with LVN 1, Resident 12 ' s medical record was reviewed. LVN 1 stated Resident 12 had a blood pressure of 79/46 mmHg on 5/28//2025 at 7:16 p.m. LVN 1 stated the facility informed the physician of Resident 112s change of condition, and the Nurse Practitioner 1 recommended to continue to recheck Resident 12 ' s blood pressure every thirty minutes three times. LVN 1 stated the facility called 911 for Resident12 on 5/29/2025 at 1:00 a.m. LVN 1 stated there was no reassessment of vital signs between 5/28//2025 at 7:16 p.m. 5/29/2025 at 1:00 a.m. LVN 1 stated in the 6 hours, resident ' s vital signs were not reassessed. During an interview on 5/29/2025 at 5:15 p.m., with the Director of Nursing (DON), the DON stated both Resident 11 and Resident 12 ' s vital signs should have been reassessed every 15-30 minutes even without a physician order. The DON stated it is important to reassess residents after a change of condition to know if resident ' s are improving or getting worse to get the residents proper care. During a review of the facility ' s policy and procedure (P&P), titled In-service Change in Condition, dated 8/25/2021, the P&P indicated the facility must consult with the resident ' s physician and/rr nurse practitioner and notify them when there I a significant change in the resident ' s physical, mental, or psychosocial status (that is a deterioration health, mental or psychosocial status in either life threatening ,conditions or clinical complications and or a decision to transfer or discharge the resident form the center/facility.

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

Respiratory Care (Tag F0695)

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 there was a physician's order before administering oxygen to...

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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 there was a physician's order before administering oxygen to one of three sampled residents (Resident 13). This failure had the potential to result in a potential for hyperoxygenation (too much oxygen) Resident 13. Findings: During a review of Resident 13's admission record, the admission record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 13 ' s Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 13 had no cognition (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, and required maximal assistance with toileting and bathing. During a concurrent interview and record review on 5/29/2025 at 1:54 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 13 ' s orders and oxygen monitoring were reviewed. LVN 1 stated Resident 13 uses suplemental oxygen. LVN 1 stated Resident 13 does not have an active order for oxygen administration. LVN 1 stated the order was discontinued on 4/21/2025. LVN 1 stated an order is required to administer oxygen to know how much oxygen to administer and to know what the oxygen saturation goals are. LVN 1 stated after 4/21/2025, Resident13 has 2 documented oxygen saturations (4/23/2025 and 5/23/2025). During an interview on 5/29/2025 at 3:15 p.m., with Resident 13 in the rehabilitation room, Resident 13 stated she wears 2 liters (L-unit of measurement) per minute (min) of oxygen every day when she needs it. Resident stated the nursing staff turn on her oxygen when she requests it. During an interview on 5/29/2025 at 5:15 p.m., with the Director of Nursing (DON), the DON stated all residents require a physician order for oxygen administration, including the amount of oxygen to be delivered and oxygen saturation goals, and required monitoring of oxygen saturation at least once a shift. The DON stated when a resident who has COPD is given oxygen without an order, there is a risk for hyperoxygenation. During a review of the facility ' s policy and procedure (P&P), titled Oxygen Administration, undated, the P&P indicated the facility is to verify that there is a physician ' s order for this procedure and review the physician ' s orders or facility protocol for oxygen administration.

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 F0726 (Tag F0726)

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 licensed nursing staff were competent in administering oxyge...

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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 licensed nursing staff were competent in administering oxygen. This failure had the potential to result in a potential for hyperoxygenation (too much oxygen) Resident 13. Findings: During a review of Resident 13's admission record, the admission record indicated Resident 13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 13 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 13 had no cognition (ability to learn, reason, remember, understand, and make decisions) impairment, required supervision when eating, and required maximal assistance with toileting and bathing. During a concurrent interview and record review on 5/29/2025 at 1:54 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 13 ' s orders and oxygen monitoring were reviewed. LVN 1 stated Resident 13 uses supllemental oxygen. LVN 1 stated Resident 13 does not have an active physican's order for oxygen administration. LVN 1 stated the order was discontinued on 4/21/2025. LVN 1 stated an order is required to administer oxygen to know how much oxygen to administer and to know what the oxygen saturation goals are. LVN 1 stated after 4/21/2025, Resident has 2 documented oxygen saturations (4/23/2025 and 5/23/2025). LVN 1 stated she not remember receiving training on oxygen administration, oxygen orders, or oxygen monitoring. During an interview on 5/29/2025 at 3:15 p.m. with Resident 13 in the rehabilitation room, Resident 13 stated she wears 2 liters (L-unit of measurement) per minute (min) of oxygen every day when she needs it. Resident stated the nursing staff turn on her oxygen when she requests it. During an interview on 5/29/2025 at 3:52 p.m. with the Director of Staff Development (DSD), the DSD stated the in-service for oxygen provided to the nursing staff does not include validating an order for oxygen, oxygen monitoring requirements, or how titrating oxygen. During an interview on 5/29/2025 at 5:15 p.m. with the Director of Nursing (DON), the DON stated nursing staff should be trained and in-serviced on how to administer oxygen and monitoring requirement to ensure proper use of oxygen. The DON stated when a resident who has COPD is given oxygen without an order, there is a risk for hyperoxygenation. During a review of the facility ' s policy and procedure (P&P), titled In-service Training, all staff, revised August 2022, the P&P indicated the primary objective of in-service training is to ensure that staff are able to interact in a manner that enhances the resident ' s quality of life and quality of care and can demonstrate competency in the topic areas of the training.

May 2025 6 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 F0604 (Tag F0604)

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 two of three sampled residents (Resident 1 and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 2) were free from unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) as evidenced by: 1. Resident 1 and 2 ' s bed was against the wall. This deficient practice had the potential to place Residents 1 and 2 at risk for injury and the potential for entrapment (when an individual is trapped or unable to get out of a small, enclosed area). Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (loss of blood flow to part of the brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set ({MDS}- a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1 ' s cognition (ability to think, understand, learn, and remember) was moderately intact and required maximal assistance (helper does more than half the effort) with transferring and sitting to standing. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and epilepsy (seizures- a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 2 ' s MDS dated , 4/21/2025, the MDS indicated Resident 2 ' s cognition was intact and was dependent (helper does all the effort) with dressing, toileting, and bathing. During an observation on 5/3/2025 at 10:11 a.m., Resident 1 ' s left side of the bed and Resident 2 ' s right side of the beds were observed to be against the wall. Residents 1 and 2 ' s siderails were up on the opposite side of the bed. During a concurrent observation and interview on 5/3/2025 at 11:14 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 verified Resident 1 and Resident 2 ' s beds were against the wall. LVN 1 stated a bed against the wall was considered a restraint, requires a doctors order, and restricts the residents movement and potentially cause an injury. During an interview on 5/4/2025 at 1:49 p.m., with Licensed Vocational Nure (LVN) 2, LVN 2 stated a bed against the wall was considered a restraint. LVN 2 stated that a bed against the wall was unsafe for the residents and could lead to an injury because it restricts their movement. During an interview on 5/4/2025 at 4:24 p.m., with the Director of Nursing (DON) the DON stated a bed against the wall was considered a restraint and was not a common practice. The DON stated there should be an order to have residents ' bed against the wall. During a review of the facility ' s policy and procedure (P&P) titled, Use of restraints undated, the P&P indicated, Residents shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident ' s medical symptoms and never for discipline or staff convenience, or for the prevention of falls. Physical restraints are defined any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to ones body.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan wit...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives, timeframes, and interventions for two of 10 sampled residents Resident 1and 2) by failing to: 1. Review and revise Resident 2 ' s care plan after each incident of fall. 2. Develop a care plan for Residents 1 and 2 ' s bed against the wall. These deficient practices had the potential to negatively affect the delivery of necessary care and services for Residents 1 and 2. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (loss of blood flow to part of the brain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1 ' s Minimum Data Set ({MDS}- a resident assessment tool), dated 3/27/2025, the MDS indicated Resident 1 ' s cognition (ability to think, understand, learn, and remember) was moderately intact and required maximal assistance (helper does more than half the effort) with transferring and sitting to standing. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) and epilepsy (seizures- a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 2 ' s MDS dated , 4/21/2025, the MDS indicated Resident 2 ' s cognition was intact and was dependent (helper does all the effort) with dressing, toileting, and bathing. During a concurrent interview and record review on 5/2/2025 at 11:14 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 and 2 ' s beds against the wall should be care planned because it was form of communication of the residents ' care between the licensed nurses. LVN 1 stated the care plan should be reviewed and revised when Resident 2 had repeated falls to ensure interventions were effective, and to prevent further falls. During a concurrent interview and record review on 5/4/2025 at 1:49 p.m., with LVN 2, LVN 2 stated the care plan was a guideline for the residents ' care and because Resident 2 had two falls the interventions should have been reviewed and revised after each of the falls. During an interview with the Director of Nursing (DON), the DON stated care plans should be revised and updated with new interventions after a resident fall. The DON stated revising care plans was important to ensure the staff were aware of what to do to minimize the risk of the residents having another fall. The DON stated that a bed against the wall was considered a restraint and should be care-planned. During a review of the facility ' s policy and procedure (P&P) titled, Care Plan Comprehensive, dated 8/25/2021, the P&P indicated, Each resident ' s comprehensive care plan is designed to incorporate identified problem areas and aid in preventing or reducing declines in the resident ' s functional status and/or functional levels. Assessments of residents are ongoing, and care plans are reviewed and revised when information about the residents and the resident ' s condition changes. During a review of the facility ' s P&P titled, Use of Restraints, undated, the P&P indicated, Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms.

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility ' s Quality Assessment and Assurance ({QAA} to develop and implement appropriate plans of action to correct identified quality deficiencies) and Qual...

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Based on interview and record review, the facility ' s Quality Assessment and Assurance ({QAA} to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Approvement ({QAPI} designed to bring about constant measurable improvement in the services to provide at the facility for continual improvement of quality care) committee failed to monitor, review, and analyze data performance improvement of facility issues such as falls. This deficient practice had the potential to not identify systemic approach to improve services to the residents. Findings: During an interview on 5/4/2025 at 4:24 p.m., with the Director of Nursing (DON), the DON stated they are currently working on falls but have had an increase in falls and should implement new intervention for fall prevention in the facility. The DON stated they were unable to locate the QAPI binder to address the increase in falls from the previous administrator. During a review of the facility ' s policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program, the P&P indicated The objectives of the QAPI program are to provide a means to measure current and potential indicators for outcomes of care and quality of life. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. Reinforce and build upon effective systems and processes related to the delivery of quality care and services.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a consistent and effective pest control program as evidenced...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a consistent and effective pest control program as evidenced by: 1. Multiple live cockroaches were found on the wall of Resident 4 and Resident 5 ' s room (room [ROOM NUMBER]). This deficient practice had the potential to affect the quality of life of Residents 4 & 5 and the potential of roaches spreading to other rooms in the facility. Findings: During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain, potentially leading to a stroke {loss of blood flow to part of the brain}). During a review of Resident 4 ' s Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated Resident 4 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and dressing. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including DM, and hypertension (HTN- high blood pressure). During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 ' s cognition was intact and required supervision with toileting, bathing, and dressing. During a concurrent observation and interview on 5/4/2025 at 3:03 p.m., in Resident 4 and 5 ' s room, Resident 5 moved his nightstand table, and multiple cockroaches were seen running. Resident 5 removed his air freshener from the wall and multiple cockroaches were seen inside the air freshener. Resident 5 stated the cockroaches in his room make him feel dirty. Resident 4 stated they have complained about the cockroaches in the past and it makes him feel creepy. CNA 3 stated she had seen cockroaches in resident drawers and coming out of the walls. CNA 3 validated the cockroaches in Resident 4 and 5 ' s room. During an interview on 5/4/2025 at 4:04 p.m., with the Maintenance Director (MD), the MD stated that 23 rooms have had treatment for cockroaches in the past (4/9/2025) but he did not follow up if the treatment was effective. The MD stated the cockroaches can possibly make the residents feel disgusted and if it was his room he would want something done about the cockroaches. During an interview on 5/4/2025 at 4:04 p.m., with the Director of Nursing (DON), the DON stated the residents may feel gross because the cockroaches in their room are unsanitary and disgusting. The DON stated she will have Resident 4 & 5 ' s room deep cleaned. During a review of the facility ' s policy and procedure (P&P) titled, Pest Control, dated 5/2008, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of the facility ' s P&P titled, Homelike Environment, dated 2/2021, the P&P indicated, The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. During a review of the facility ' s Director of Maintenance Job Description dated 10/2010, the Director of Maintenance Job Description indicated, Ensure facility is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. Cross reference F584

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 F0558 (Tag F0558)

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 four of 10 sampled residents, Resident 4, Resi...

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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 four of 10 sampled residents, Resident 4, Resident 5, Resident 6, and Resident 7) were provided with a safe, clean, comfortable, and homelike environment. The facility failed to: 1.Provide a room for Resident 4, Resident 6, and Resident 7) with functional sliding glass doors that able to be locked from the inside. 2. Provide a safe environment for the staff and residents by locking the entrance doors (front door) to the facility during the night. 3.Maintain Resident 4 and Resident 5 rooms free from cockroaches. These deficient practices had the potential to affect the residents ' dignity, the residents ' mood, and the residents ' rights to have a homelike and safe environment. Findings: 1. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabeted mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain, potentially leading to a stroke {loss of blood flow to part of the brain}). During a review of Resident 4 ' s Minimum Data Set ({MDS}- a resident assessment tool) dated 3/29/2025, the MDS indicated Resident 4 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and dressing. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including DM, and hypertension (HTN- high blood pressure). During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 ' s cognition was intact and required supervision with toileting, bathing, and dressing. During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated Resident 6 ' s cognition was intact. During a review of Resident 7 ' s admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including anxiety (a feeling of worry, unease, or nervousness) and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated Resident 7 ' s cognition was intact and required moderate assistance with toileting, showering, and bathing. During a facility tour on 5/3/2025 at 4:00 a.m., resident rooms sliding glass doors facing the outside of the facility were observed to be open and unable to close or lock. It was observed that the gates around the facility were broken and without locks. The fence surrounding the facility also observed to have broken wood panels with unstable parts of the fence tipping over. Several residents sliding glass doors were observed open and not able to close. When walking into the front door of the facility, the front door was unlocked, no staff present upon entrance, and no alarm. The back door to the facility was observed to be cracked open. During a concurrent observation and interview on 5/3/2025 at 5:37 a.m., with the Certified Nursing Assistant (CNA) 3, it was observed the back entrance to the facility ' s door was open ajar. CNA 3 came to close the door and stated the door should remain closed and locked because someone can just walk into the facility. During a concurrent observation and interview on 5/3/2025 at 6:25 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 validated the front door to the facility was unlocked without an alarm. LVN 5 stated the front entrance door was not usually locked and anyone can walk in from outside and enter the facility. LVN 6 stated she does get concerned about her safety and the safety of the residents and worried someone will walk in. During a concurrent observation and interview on 5/3/2025 at 8:39 a.m., in Resident 7 ' s room, the sliding glass door was observed to be off track and did not lock. Resident 7 stated it was concerning and unsafe because anyone can walk into her bedroom from the outside. 2. During a concurrent observation and interview on 5/3/2025 at 9:21 a.m., with the Maintenance Director (MD), the MD walked around the facility and validated there was no lock on the gate around the facility but should be because a stranger can walk into the facility. The MD stated he was aware that some of the resident sliding glass doors were broken, and some did not lock. The MD stated, the sliding glass doors were very worn down. The MD stated the sliding glass doors in the resident rooms should be able to lock, for the safety of the residents. Observed the other side of the facility, the MD validated there was no gate and stated this allows open access to the facility for anyone to walk in. The MD stated not having a gate places the facility at risk for trespassers or a possible active shooter. Entered the front entrance of the facility, the MD stated the front entrance door should be locked at night for the safety of the residents and facility staff. During an interview on 5/3/2025 at 10:09 a.m., with Resident 6 ' s caregiver at bedside, Resident 6 ' s caregiver stated the sliding glass door not locking was a huge safety concern because anyone can walk in. Resident 6 ' s wallet observed sitting on his bedside table near the sliding glass door. During an interview on 5/3/2025 at 10:12 a.m., with CNA 4, CNA 4 stated the residents sliding glass doors should be able to lock, for safety concerns because anyone from off the streets can enter the facility. During an interview on 5/3/2025 at 10:23 a.m., Resident 4 stated the sliding glass door to his room should be able to lock, for obvious safety concerns because anyone could wander in. During a concurrent observation and interview on 5/3/2025 at 11:01 a.m., with the Administrator (ADM) and the Director of Nursing (DON), walking around the outside of the facility, both the ADM and DON validated there was no side gate, the back gate did not have a lock on it, resident sliding glass doors that led to the outside of the facility were broken and did not lock, and the front door to the facility did not have a lock or alarm system in place. The DON stated these issues were a safety concern for the residents and the staff, anyone can walk into the facility exposing the residents and staff to danger. 3.During a concurrent observation and interview on 5/4/2025 at 3:03 p.m., in Resident 4 and 5 ' s room, Resident 5 moved his nightstand table, and multiple cockroaches were seen running. Resident 5 removed his air freshener from the wall and multiple cockroaches were seen inside the air freshener. Resident 5 stated the cockroaches in his room make him feel dirty. Resident 4 stated they have complained about the cockroaches in the past and it makes him feel creepy. CNA 3 stated she had seen cockroaches in resident drawers and coming out of the walls. CNA 3 validated the cockroaches in Resident 4 and 5 ' s room. During an interview on 5/4/2025 at 4:04 p.m., with the Maintenance Director (MD), the MD stated 23 rooms has had treatment for cockroaches in the past (4/9/2025) but he did not follow up if the treatment was effective. The MD stated the cockroaches can possibly make the residents feel disgusted and if it was his room he would want something done about the cockroaches. During an interview on 5/4/2025 at 4:04 p.m., with the DON, the DON stated the residents may feel gross because the cockroaches in their room were unsanitary and disgusting. The DON stated she will have Resident 4 and 5 ' s room deep cleaned. During a review of the facility ' s policy and procedure (P&P) titled, Pest Control, dated 5/2008, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of the facility ' s P&P titled, Homelike Environment, dated 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. During a review of the facility ' s Director of Maintenance Job Description dated 10/2010, the Director of Maintenance Job Description indicated, Ensure facility is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. During a review of the facility ' s P&P titled, Maintenance Services, dated 12/2009, the P&P indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Maintaining the building in good repair and free from hazards.

CONCERN (E) 📢 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of 10 sampled residents, Resident 4, Resi...

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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 four of 10 sampled residents, Resident 4, Resident 5, Resident 6, and Resident 7) were provided with a safe, clean, comfortable, and homelike environment. The facility failed to: 1.Provide a room for Resident 4, Resident 6, and Resident 7) with functional sliding glass doors that able to be locked from the inside. 2. Provide a safe environment for the staff and residents by locking the entrance doors (front door) to the facility during the night. 3.Maintain Resident 4 and Resident 5 rooms free from cockroaches. These deficient practices had the potential to affect the residents ' dignity, the residents ' mood, and the residents ' rights to have a homelike and safe environment. Findings: 1. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabeted mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain, potentially leading to a stroke {loss of blood flow to part of the brain}). During a review of Resident 4 ' s Minimum Data Set ({MDS}- a resident assessment tool) dated 3/29/2025, the MDS indicated Resident 4 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and dressing. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including DM, and hypertension (HTN- high blood pressure). During a review of Resident 5 ' s MDS dated [DATE], the MDS indicated Resident 5 ' s cognition was intact and required supervision with toileting, bathing, and dressing. During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 6 ' s MDS dated [DATE], the MDS indicated Resident 6 ' s cognition was intact. During a review of Resident 7 ' s admission Record, the admission Record indicated Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including anxiety (a feeling of worry, unease, or nervousness) and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 7 ' s MDS dated [DATE], the MDS indicated Resident 7 ' s cognition was intact and required moderate assistance with toileting, showering, and bathing. During a facility tour on 5/3/2025 at 4:00 a.m., resident rooms sliding glass doors facing the outside of the facility were observed to be open and unable to close or lock. It was observed that the gates around the facility were broken and without locks. The fence surrounding the facility also observed to have broken wood panels with unstable parts of the fence tipping over. Several residents sliding glass doors were observed open and not able to close. When walking into the front door of the facility, the front door was unlocked, no staff present upon entrance, and no alarm. The back door to the facility was observed to be cracked open. During a concurrent observation and interview on 5/3/2025 at 5:37 a.m., with the Certified Nursing Assistant (CNA) 3, it was observed the back entrance to the facility ' s door was open ajar. CNA 3 came to close the door and stated the door should remain closed and locked because someone can just walk into the facility. During a concurrent observation and interview on 5/3/2025 at 6:25 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 validated the front door to the facility was unlocked without an alarm. LVN 5 stated the front entrance door was not usually locked and anyone can walk in from outside and enter the facility. LVN 6 stated she does get concerned about her safety and the safety of the residents and worried someone will walk in. During a concurrent observation and interview on 5/3/2025 at 8:39 a.m., in Resident 7 ' s room, the sliding glass door was observed to be off track and did not lock. Resident 7 stated it was concerning and unsafe because anyone can walk into her bedroom from the outside. 2. During a concurrent observation and interview on 5/3/2025 at 9:21 a.m., with the Maintenance Director (MD), the MD walked around the facility and validated there was no lock on the gate around the facility but should be because a stranger can walk into the facility. The MD stated he was aware that some of the resident sliding glass doors were broken, and some did not lock. The MD stated, the sliding glass doors were very worn down. The MD stated the sliding glass doors in the resident rooms should be able to lock, for the safety of the residents. Observed the other side of the facility, the MD validated there was no gate and stated this allows open access to the facility for anyone to walk in. The MD stated not having a gate places the facility at risk for trespassers or a possible active shooter. Entered the front entrance of the facility, the MD stated the front entrance door should be locked at night for the safety of the residents and facility staff. During an interview on 5/3/2025 at 10:09 a.m., with Resident 6 ' s caregiver at bedside, Resident 6 ' s caregiver stated the sliding glass door not locking was a huge safety concern because anyone can walk in. Resident 6 ' s wallet observed sitting on his bedside table near the sliding glass door. During an interview on 5/3/2025 at 10:12 a.m., with CNA 4, CNA 4 stated the residents sliding glass doors should be able to lock, for safety concerns because anyone from off the streets can enter the facility. During an interview on 5/3/2025 at 10:23 a.m., Resident 4 stated the sliding glass door to his room should be able to lock, for obvious safety concerns because anyone could wander in. During a concurrent observation and interview on 5/3/2025 at 11:01 a.m., with the Administrator (ADM) and the Director of Nursing (DON), walking around the outside of the facility, both the ADM and DON validated there was no side gate, the back gate did not have a lock on it, resident sliding glass doors that led to the outside of the facility were broken and did not lock, and the front door to the facility did not have a lock or alarm system in place. The DON stated these issues were a safety concern for the residents and the staff, anyone can walk into the facility exposing the residents and staff to danger. 3.During a concurrent observation and interview on 5/4/2025 at 3:03 p.m., in Resident 4 and 5 ' s room, Resident 5 moved his nightstand table, and multiple cockroaches were seen running. Resident 5 removed his air freshener from the wall and multiple cockroaches were seen inside the air freshener. Resident 5 stated the cockroaches in his room make him feel dirty. Resident 4 stated they have complained about the cockroaches in the past and it makes him feel creepy. CNA 3 stated she had seen cockroaches in resident drawers and coming out of the walls. CNA 3 validated the cockroaches in Resident 4 and 5 ' s room. During an interview on 5/4/2025 at 4:04 p.m., with the Maintenance Director (MD), the MD stated 23 rooms has had treatment for cockroaches in the past (4/9/2025) but he did not follow up if the treatment was effective. The MD stated the cockroaches can possibly make the residents feel disgusted and if it was his room he would want something done about the cockroaches. During an interview on 5/4/2025 at 4:04 p.m., with the DON, the DON stated the residents may feel gross because the cockroaches in their room were unsanitary and disgusting. The DON stated she will have Resident 4 and 5 ' s room deep cleaned. During a review of the facility ' s policy and procedure (P&P) titled, Pest Control, dated 5/2008, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. During a review of the facility ' s P&P titled, Homelike Environment, dated 2/2021, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment. During a review of the facility ' s Director of Maintenance Job Description dated 10/2010, the Director of Maintenance Job Description indicated, Ensure facility is designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. During a review of the facility ' s P&P titled, Maintenance Services, dated 12/2009, the P&P indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Maintaining the building in good repair and free from hazards.

Apr 2025 6 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

Laboratory Services (Tag F0770)

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 obtain laboratory tests per medical doctor (MD) order prior to resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain laboratory tests per medical doctor (MD) order prior to resident scheduled appointment for one of three sampled residents (Resident 2). This deficient practice resulted in Resident 2 ' s medical doctor appointment to be canceled and had the potential delay in necessary care and services. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (a cancerous tumor) of the right breast and bone and thrombocytopenia (low blood platelet count). During a review of Resident 2 ' s Minimum Data Set (MDS- resident assessment tool) dated 3/24/2025 indicated Resident 2 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and dressing. During an interview on 4/24/2025 at 9:49 a.m., with Resident 2, Resident 2 stated she had an appointment on Friday 4/25/2025 with her oncologist (a doctor who specializes in cancer), but her laboratory tests were not drawn. Resident 2 stated because her laboratory tests were not drawn, she had to cancel her appointment with her oncologist. Resident 2 stated this had caused her to feel frustrated. During an interview on 4/24/2025 at 10:50 a.m., with the Social Services designee (SSD), the SSD stated she was responsible for informing the Registered Nurse (RN) to set up laboratory draw appointments for the residents. The SSD stated she told the RN (unknown), that Resident 2 required laboratory tests for her upcoming appointment on 4/25/2025, but the RN had left early that day, and she did not follow up to ensure it was done. The SSD stated she will develop a system to ensure laboratory tests ordered were follow through with licensed staff as to prevent a delay in Resident 2 ' s care as SSD had to reschedule her MD appointment. During a review of the facility ' s Social Worker Job Description revised 10/2020, the Social Worker Job Description indicated the duties included, Assist in obtaining resources from community social, health, and welfare agencies to meet the needs of the resident.

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 F0882 (Tag F0882)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to have an Infection Preventionist (IP) on staff with completed specialized training in Infection Control and Prevention. This deficient pract...

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Based on interview and record review, the facility failed to have an Infection Preventionist (IP) on staff with completed specialized training in Infection Control and Prevention. This deficient practice had the potential for failure to monitor and implement Infection Control and Prevention in the facility. Findings: During a record review of the Infection Prevention Nurse (IPN) certification, dated 12/30/2024, the IPN certification indicated it was from CDC Train certificate which did not indicate the hours completed. During an interview on 4/23/2025 at 3:23 p.m., with the IPN, the IPN indicated she began working at the facility on 11/2024 as a new graduate licensed nurse and has been the IPN since 2/2025. The IPN stated the CDC Train certificate was the one she was told she needed and was unable to locate the correct Infection Preventionist certificate. During an interview on 4/24/2025 at 4:36 p.m., with the Director of Nursing (DON), the DON indicated she was unaware that the IPN had the incorrect IP certificate. The DON stated it was important to have a full-time IP nurse with the correct IP certificate for the safety of the residents and staff. The DON stated the role of IP Nurse was crucial in maintaining infection control and prevention in the facility. During a review of the facility ' s Infection Preventionist Job Description, revised 10/2020, the Infection Preventionist Job Description indicated, Plan, develop, implement, evaluate, and oversee the infection prevention and control program in accordance with current regulations and guidelines governing skilled nursing facilities. Must have, as a minimum, two years clinical experience in a hospital, nursing care facility, or other related healthcare facility.

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

Notification of Changes (Tag F0580)

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 notify the physician when a resident experienced a change of condit...

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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 physician when a resident experienced a change of condition([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) for four of five sampled residents (Resident 1, 2, 3 and 4). The facility failed to: 1. Ensure licensed nurses notified Resident 1, 2, 3 and 4 ' s physician when Resident 1, 2, 3 and 4 did not receive their 9:00 a.m. scheduled medications on 4/19/2025. 2. Ensure licensed nurses documented a COC when schedule medications were not administered to Resident ' s 1, 2, & 4 on 4/19/2025 at 9 a.m. These deficient practices of not notifying the physician of the residents COC resulted in a delay of evaluation, care, treatment, and monitoring. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to part of the brain), atrial fibrillation (irregular and often very rapid heart rhythm), hypertension (HTN- high blood pressure), and pancytopenia (a lower-than-normal number of red and white blood cells and platelets in the blood). During a review of Resident 1 ' s Minimum Data Set (MDS- resident assessment tool) dated 3/21/2025 indicated Resident 1 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and bathing. During a review of Resident 1 ' s Medication Administration Record (MAR), the MAR indicated the scheduled 9:00 a.m. medications on 4/19/2025 were not administered. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (a cancerous tumor) of the right breast and bone and thrombocytopenia (low blood platelet count). During a review of Resident 2 ' s MDS dated [DATE], Resident 2 ' s cognition was intact and required moderate assistance with toileting and dressing. During a review of Resident 2 ' s MAR, the MAR indicated the scheduled 9:00 a.m. medications on 4/19/2025 were not administered. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain, potentially leading to a stroke {loss of blood flow to part of the brain}). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition was intact and required moderate assistance with toileting and dressing. During a review of Resident 3 ' s Medication Administration Record (MAR), the MAR indicated the scheduled 9:00 a.m. medications on 4/19/2025 were not administered. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including myocardial infarction (MI-heart attack), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing a difficulty in breathing). During a review of Resident 4 ' s MDS dated [DATE], indicated Resident 4 ' s cognition was intact and required moderate assistance with toileting, bathing, and dressing. During a review of Resident 4 ' s MAR, the MAR indicated the scheduled 9:00 a.m. medications on 4/19/2025 were not administered. During a concurrent interview and record review on 4/23/2025 at 1:53 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 indicated Resident 1 and Resident 4 ' s MAR was marked as red on 4/19/2025 at 9:00 a.m., indicating their medications were not administered. LVN 1 stated she was unable to locate documentation that Resident 1 or Resident 4 ' s physician was notified, or a COC was initiated. LVN 1 stated that when medications were not administered at the scheduled time, the physician should be notified, and a COC should be documented to ensure the residents receive accurate monitoring and prevent hospitalization. During an interview on 4/23/2025 at 3:56 p.m., with LVN 4, LVN 4 stated when medications were not administered at their scheduled time, the resident ' s physician should be notified, and a COC should be documented because the resident could experience an adverse reaction to missing a dose of their medication. During an interview on 4/24/2025 at 3:18 p.m., with the facility pharmacist (FP), the FP stated that anytime a medication was missed, the physician should be notified in case there needs to be close monitoring, laboratory blood draws, or frequent vital signs ordered. During an interview on 4/24/2025 at 4:36 p.m., with the Director of Nursing (DON), the DON stated if she was made aware of the missed medications on 4/19/2025 at 9:00 a.m. residents affected physicians and representatives will be informed. The DON stated at the time this occurred, the physicians should have been notified immediately, and a COC should have been documented but was not done. The DON stated missing the medications could potentially cause adverse outcomes such as hypertension, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and/or development of blood clots, depending on the medication missed. During a review of the facility ' s LVN Job Description, revised 5/2022, the LVN Job Description indicated, Administer medications within the scope of practice and according to practitioner orders. Report adverse consequences, side effects, or any medication errors. During a review of the facility ' s policy and procedure (P&P) titled, Change in Condition: Notification of, dated 8/25/2021, the P&P indicated, Purpose is to ensure residents, family, legal representatives, and physicians are informed of changes in the resident ' s condition.

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 F0725 (Tag F0725)

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 have sufficient staffing on 4/19/2025 when one licens...

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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 have sufficient staffing on 4/19/2025 when one licensed nurse called off and one no call no show (an employee fails to report to work as scheduled and fails to notify their employer of their absence) to accommodate resident needs in administering medications timely. This deficient practice resulted in Resident 1, 2, 3 and 4 not receiving all scheduled medications on 4/19/2025 at 9 a.m. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to part of the brain), atrial fibrillation (irregular and often very rapid heart rhythm), hypertension (HTN- high blood pressure), and pancytopenia (a lower-than-normal number of red and white blood cells and platelets in the blood). During a review of Resident 1 ' s Minimum Data Set (MDS- resident assessment tool) dated 3/21/2025 indicated Resident 1 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and bathing. During a review of Resident 1 ' s Medication Administration Record (MAR), the MAR indicated the scheduled 9:00 a.m. medications on 4/19/2025 were not administered. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (a cancerous tumor) of the right breast and bone and thrombocytopenia (low blood platelet count). During a review of Resident 2 ' s Minimum Data Set (MDS- resident assessment tool) dated 3/24/2025 indicated Resident 2 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and dressing. During a review of Resident 2 ' s Physician Order Details dated 2/24/2025, the Physician Order Details indicated Resident 2 ' s order for Anastrozole (a medication to treat breast cancer) to be administered at 8:00 a.m. daily. During a review of Resident 2 ' s Administration Details Report for the month of April 2025, the Administration Details Report indicated 10 out of 24 days for the month of April, the medication Anastrozole was administered late (after 10:00 a.m.). During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain, potentially leading to a stroke {loss of blood flow to part of the brain}). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition was intact and required moderate assistance with toileting and dressing. During a review of Resident 3 ' s Medication Administration Record (MAR), the MAR indicated the scheduled 9:00 a.m. medications on 4/19/2025 were not administered. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including myocardial infarction (MI-heart attack), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing a difficulty in breathing). During a review of Resident 4 ' s MDS dated [DATE], indicated Resident 4 ' s cognition was intact and required moderate assistance with toileting, bathing, and dressing. During a review of Resident 4 ' s MAR, the MAR indicated the scheduled 9:00 a.m. medications on 4/19/2025 were not administered. During an interview on 4/23/2025 at 9:00 a.m., with Resident 2 stated there were times she does not receive her 8:00 a.m. medication until 10:00 a.m. or 12:00 p.m. Resident 2 stated not receiving her 8:00 a.m. medication on time causes her to feel upset and stressed because the medication was important to take on time as prescribed. During an interview on 4/24/2025 at 11:59 a.m. with Resident 4, Resident 4 stated there was a day recently (unknown date) she did not receive her morning medications and there were some days her morning medications were given late. Resident 4 stated not receiving her medications concerns her because she needs her medications, especially her blood thinning medication. During an interview on 4/24/2025 at 2:06 p.m., with Resident 3, Resident 3 stated this past weekend he did not receive his 9:00 a.m. medications until 1:47 p.m. Resident 3 stated the facility was short staffed because there were days, he receives his medications several hours late and some days he will not see his nurse until noon. During an interview on 4/24/2025 at 4:36 p.m., with the Director of Nursing (DON), the DON stated she was responsible for the licensed nurses schedules and this weekend there was a sick call and no call no show. The DON stated it was her responsibility to cover when licensed staff call off. The DON stated she should have come this past weekend (4/19/2025). During a review of the facility ' s policy and procedure (P&P) titled, Staffing, undated, the P&P indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. During a review of the facility ' s Director of Nursing Job Description revised 10/2020, the Director of Nursing Job Description indicated the duties included, Determine the staffing needs of the nursing services department necessary to meet the total nursing needs of the resident population.

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

Pharmacy Services (Tag F0755)

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 four of five sampled resident (Resident 1,2,3, and 4) medica...

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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 four of five sampled resident (Resident 1,2,3, and 4) medications were administered within one hour of their scheduled administration time in accordance with the facility ' s policy and procedures titled Administering Medications, (undated). These deficient practices placed Residents 1, 2, 3, and 4, at risk to experience medication adverse reactions, and complications including a high blood pressure leading to stroke (damage to the brain from interruption of its blood supply), venous thromboembolism (blood clots in the veins), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and hospitalization. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to part of the brain), atrial fibrillation (irregular and often very rapid heart rhythm), hypertension (HTN- high blood pressure), and pancytopenia (a lower-than-normal number of red and white blood cells and platelets in the blood). During a review of Resident 1 ' s Minimum Data Set (MDS- resident assessment tool) dated 3/21/2025 indicated Resident 1 ' s cognition (ability to think, understand, learn, and remember) was intact and required moderate assistance (helper does less than half the effort) with toileting and bathing. During a review of Resident 1 ' s Medication Administration Record (MAR), the MAR indicated Resident 1 ' s scheduled 9:00 a.m. medications on 4/19/2025 were not administered. The medications were as follows: 1. one tablet of apixaban (a medication used to treat atrial fibrillation) 2.5 milligrams (mg- a unit of measurement for mass). 2. one tablet of losartan potassium (a medication used to treat HTN) 50 mg. 3. one tablet of metoprolol succinate (a medication used to treat HTN) 0.5 mg. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm (a cancerous tumor) of the right breast and bone and thrombocytopenia (low blood platelet count). During a review of Resident 2 ' s MDS dated [DATE], Resident 2 ' s cognition was intact and required moderate assistance with toileting and dressing. During a review of Resident 2 ' s Physician Order Details dated 2/24/2025, the Physician Order Details indicated Resident 2 ' s order for Anastrozole (a medication to treat breast cancer) to be administered at 8:00 a.m. daily. During a review of Resident 2 ' s Administration Details Report for the month of April 2025, the Administration Details Report indicated 19 out of 24 days for the month of April, the medication Anastrozole was administered late (after 9:00 a.m.). During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD- a slow progressive narrowing of the blood flow to the arms and legs), and cerebrovascular disease (condition that affects the blood vessels and blood flow to the brain, potentially leading to a stroke {loss of blood flow to part of the brain}). During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition was intact and required moderate assistance with toileting and dressing. During a review of Resident 3 ' s MAR, the MAR indicated Resident 3 ' s scheduled 9:00 a.m. medications on 4/19/2025 were not administered. The medications were as follows: 1. one tablet of benazepril (a medication used to treat HTN) 20 mg. 2. one tablet of gabapentin (a medication used to treat neuropathy [when nerve damage leads to pain, weakness, numbness or tingling in one or more parts body parts]) 300mg. 3. one tablet of Jardiance (a medication used to treat DM) 25 mg. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including myocardial infarction (MI-heart attack), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing a difficulty in breathing). During a review of Resident 4 ' s MDS dated [DATE], indicated Resident 4 ' s cognition was intact and required moderate assistance with toileting, bathing, and dressing. During a review of Resident 4 ' s MAR, the MAR indicated Resident 4 ' s scheduled 9:00 a.m. medications on 4/19/2025 were not administered. The medications were as follows: 1. two tablets of acetaminophen (a medication used to treat pain) 325 mg. 2. one inhalation of advair diskus (a medication used to treat COPD) 250-50 mg. 3. one tablet of aspirin (a medication used for stroke prevention) 81 mg. 4. one inhalation of budesonide (a medication used to treat COPD) 0.5 mg. 5. one tablet of bupropion (a medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest] ) 75 mg. 6. one tablet of carvedilol (a medication used to treat HTN) 3.125 mg. 7. one tablet of clopidogrel bisulfate (a medication used for blood clot prevention) 75 mg. 8. one tablet of folic acid (a medication used to treat low folate levels) 1 mg. 9. one scoop of glycolax powder (a medication used for bowel management) 17 grams (gm- a unit of measure for mass). 10. one tablet of Lasix (a medication used to treat congestive heart failure [CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling]) 20 mg. 11. one tablet of levetiracetam (a medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 750 mg. 12. one tablet of sacubitril-valsartan (a medication used to treat CHF) 24-26 mg. 13. one tablet of sertraline (a medication used to treat major depressive disorder) 50 mg. 14. Half a tablet of spironolactone (a medication used to treat HTN and CHF) 25 mg. During an interview on 4/23/2025 at 9:00 a.m., with Resident 2 stated there were times she does not receive her 8:00 a.m. medication until 10:00 a.m. or 12:00 p.m. Resident 2 stated not receiving her 8:00 a.m. medication on time causes her to feel upset and stressed because the medication was important to take on time as prescribed. During a concurrent interview and record review on 4/23/2025 at 1:53 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Residents 1 and 4 did not receive their 9:00 a.m. schedule medications on 4/19/2025 as indicated in residents MAR marked red which indicated it was not given. LVN 1 stated if a resident missed a blood thinning medication, the resident could develop a blood clot, become hospitalized and potentially die. During an interview on 4/23/2025 at 3:56 p.m., with LVN 4, LVN 4 stated if a resident missed a blood pressure medication, the resident could become hypertensive and if they miss a blood thinning medication, the resident could develop a clot, potentially have a stroke and die. During an interview on 4/24/2025 at 11:59 a.m. with Resident 4, Resident 4 stated there was a day recently (unknown date) she did not receive her morning medications and there were some days her morning medications were given late. Resident 4 stated not receiving her medications concerns her because she needs her medications, especially her blood thinning medication. During an interview on 4/24/2025 at 2:06 p.m., with Resident 3, Resident 3 stated this past weekend (4/19/2025) he did not receive his 9:00 a.m. medications until 1:47 p.m. Resident 3 stated the facility was short staffed because there were days, he receives his medications several hours late and some days he will not see his nurse until noon. Resident 3 stated this makes him upset and angry. During an interview on 4/24/2025 at 3:18 p.m., with the facility pharmacist (FP), the FP stated when a resident missed a seizure medication it puts them at risk for seizures. The FP stated if a resident missed a blood pressure medication, it places them at risk for hypertension. During an interview on 4/24/2025 at 4:36 p.m., with the Director of Nursing (DON), the DON stated she was responsible for the licensed nurses ' schedules and this weekend (4/19/2025) there was a sick call and no call no show. The DON stated it was her responsibility to cover when licensed staff call off. The DON stated she should have come this past weekend (4/19/2025). The DON stated if a resident missed a blood pressure medication it could result in a stroke, if a blood thinning medication was missed it could result in a development of a blood clot, and if a seizure medication was missed it could result in the resident experiencing a seizure. During a review of the facility ' s undated P&P titled, Administering Medications, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time. During a review of the facility ' s Director of Nursing Job Description revised 10/2020, the Director of Nursing Job Description indicated the duties included, Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and treatments are provided as scheduled. Cross referenced F725

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 and interview, the facility failed to implement and maintain infection control practices when Certified Nurse Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 2 failed to per...

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Based on observation and interview, the facility failed to implement and maintain infection control practices when Certified Nurse Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 2 failed to perform hand hygiene between resident care and prior to entering and exiting resident rooms. These failures had potential of cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and placed residents and staff at risk for the spread of infection. Findings: During the initial tour of the facility on 4/25/2025, observed two of four resident rooms did not have hand sanitizing gel in the dispensers. Observed there were no hand sanitizing gel dispensers on the walls in the hallways. During a concurrent observation and interview on 4/23/2025 at 10:53 a.m., outside of resident room, LVN 2 was observed not performing hand hygiene prior to entering a resident ' s room to change an oxygen machine or prior to exiting the resident ' s room. LVN 2 stated she was supposed to perform hand hygiene before entering a resident room and prior to exiting a resident room and should have done so but forgot. LVN 2 stated hand sanitizing gel dispenser inside the resident room was empty. LVN 2 stated that not performing hand hygiene could potentially cause a spread of infection. During a concurrent observation and interview on 4/23/2025 at 11:11 a.m., with CNA 1 outside a resident room, CNA 1 was observed not performing hand hygiene prior to entering and exiting the resident room. CNA 1 stated the hand sanitizer gel dispenser was empty, but she should have gone to the nurses ' station to wash her hands. CNA 1 stated hand hygiene was important to prevent the spread of infection. During an interview on 4/23/2025 at 12:21 p.m., with the Infection Prevention Nurse (IPN), the IPN nurse stated she educates the staff on performing hand hygiene before entering a resident room, prior to leaving a resident room, and before and after resident care to prevent the transmission of infection and germs from resident to resident. IPN stated she was aware that some rooms did not have hand sanitizing gel because there was a back order on hand sanitizing gel, but the staff were educated to wash their hands at the station. IPN stated there were no hand sanitizing gel dispensers in the hallways because of the facility undergoing renovation. During an interview on 4/25/2025 at 4:36 p.m., with the Director of Nursing (DON), the DON stated hand hygiene between residents ' care was the most important way to prevent cross contamination and the spread of infection in the facility. The DON stated staff should be washing their hands before and after resident care, prior to entering and exiting a resident ' s room because not doing so can affect the safety of the residents and the staff. During a review of the facility ' s policy and procedure (P&P), titled, Handwashing/Hand Hygiene, dated 9/18/2023, the P&P indicated, This facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained in the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub before and after contact with the resident.

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

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 sampled residents (Resident 1) rec...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care by failing to: 1. Document on the Medication Administration Record (MAR) meclizine (medication used to help with dizziness) medication was given as ordered by the physician. 2. Initiate a plan of care and change of condition when a Resident 1 has new onset of cough . These deficient practices had the potential to cause Resident 1 side effects of the medication not being monitored and had to potential to miss treatment and care for new onset of cough. Findings: During a record review of Resident 1 ' s admission Record (AR), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including atherosclerosis of aorta ( a build up of fat and other substances on the inner walls of the heart which can lead to hardening of the arteries in the heart), Klebsiella pneumoniae ( a bacteria found in the intestines ) and history of falling. During a record review of Resident 1 ' s Minimum Data Set (MDS a resident assessment tool), dated 1/22/2025, The MDS indicated, Resident 1 had decision making capacity, was independent ( resident completed all the activities by themselves, with or without an assistive device , with no assistance from a helper ) in self-care , indoor mobility ( ambulation) and upper and lower body dressing. During a record review of Resident 1's MAR dated 1/16/2025, indicated an order for: 1.Meclizine HCL ( medication for dizziness) Oral tablet 25 milligram ( a unit of measurement of mass in the metric system ) give one tablet by mouth three times a day for vertigo ( dizziness) . 2. Monitor for signs and symptoms of new onset sore throat, chest congestion, cough, increased shortness of breath, worsening of confusion, malaise (weakness)and or muscle pain, nausea, vomiting, diarrhea, chills and / or shaking pain, headache new lost of taste or smell, fever, tachycardia o2 sat ( oxygen ) , runny nose, every eight hours or when necessary for 30 days document 0 = not present or 1= present if any symptoms present complete E interact (change of condition) and 3. Delsym oral suspension extended release 30 milligram per five milliliters (a metric unit of length). During an observation and interview on 1/ 30/ 2025 at 10:42 am, with Resident 1, Resident 1 stated sometimes she don ' t get her medications, and need to inform nurse what type of medication she needs and the dosage of the medication. Resident 1 stated she have been coughing since 1/21/2024 the week when she came to the facility and have not stopped coughing. Resident 1 stated the facility supposedly will do a chest X ray, but it was never done. During an interview on 1/30/2025 at 12:45 p.m. with Licensed Vocational Nurse 1(LVN 1), LVN 1 stated Resident 1 had a cough 1/30/2025 and cough medicine was given . LVN 1 stated when a cough is noticed for the first time the orders are to record it on the MAR and care plan it . LVN 1 stated Resident 1 started receiving cough medicine ( Delsym) on 1/22/2025 but there was no documentation of a cough also the nurses were not monitoring Resident 1 for cough and was not care plan. LVN 1 stated it is important to start a care plan so interventions that we can follow to care for the resident. LVN 1 stated if medication is given we need to document it LVN 1 stated Meclizine HCL oral tablet was not signed for 1/19/2025 at 17:00 and 1/23/2025 at 13:00 she stated it is important to sign the medication report so everyone will know it was given ,she stated if it is not signed it was not given. During an interview on 1/31/2025 at 10:00 a.m. with LVN 2 , LVN 2 stated when giving medication we must explain the type of medication you are giving and when the resident has taken the medication you must chart that it was given on the MAR to prevent errors. LVN 2 stated Resident 1 ' s Meclizine HCL was not signed on the MAR and stated the resident could become dizzy and fall . During an interview on 1/31/2025 at 11:59 with the Director of Nursing (DON) , DON stated the process of passing medication is to verify the medication against the medication record, educate the resident on medication that will be given, give resident the medication and chart the medication on the MAR . DON stated if the medication is not signed on MAR, it is considered a medication error. DON verified there was no signatures for giving meclizine on 1/19/2025 and 1/23/2025. [NAME] stated It is important to put the right documentation in your charting because you are monitoring the resident for specific health changes and making sure the care plan is initiated. During a review of the facility ' s policy and procedure (P&P) titled, Administering Medications { undated}, indicates the individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next one. During a review of the facility ' s policy and procedure (P&P) titled, Nursing Documentation, dated 6/27/2022, indicates the purpose is to communicate patients ' status and to provide complete, comprehensible and assessable accounting of care and monitoring provided.

Nov 2024 17 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain respect and dignity to one of three sampled r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain respect and dignity to one of three sampled residents (Resident 57) by standing over the resident while assisting them during a meal. This failure had the potential to result in decreased self-esteem and self-worth for Resident 57. Findings: During a review of Resident 57's admission Record, the admission Record indicated Resident 57 was admitted to the facility on [DATE] with diagnoses including unspecified dementia(a progressive state of decline in mental abilities) without behavioral disturbance, cerebral infarction without residual effects ( stroke without lasting impairments or resident had recovered after the event), and oropharyngeal dysphagia (difficulty of swallowing that occurs when the food or liquid is moved from the mouth to the esophagus). During a review of Resident 57's Minimum Data Set (MDS- a resident assessment tool) dated 8/6/2024, the MDS indicated Resident 57 had moderately impaired cognitive skills (ability to think, understand, learn, and remember) and required substantial assistance (helper does more than half the effort) with eating. During an observation on 11/12/2024, at 12:44 p.m., in Resident 57's room, Resident 57 was lying in bed in an upright position and Certified Nursing Assistant (CNA1) standing over the resident while feeding her lunch. During an interview on 11/13/2024, at 2:59 p.m., with CNA1, CNA1 stated she was standing while feeding Resident 57 during lunch yesterday (11/12/2024). CNA1 stated she should have gotten a chair and sit down while feeding Resident 57 because for her comfort and resident's safety. CNA1 stated feeding the resident in a sitting position should have been done so she would be in level to resident's mouth and ensure resident's needs would be anticipated. During an interview on 11/13/2024, at 3:09 p.m., with Director of Staff Development (DSD), DSD stated the facility provided training on activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care, how to transfer, feeding residents, incontinence care ( process of helping someone maintain or regain of their bladder and bowel functions), and repositioning during CNA's orientation. DSD stated CNA 1 needed to sit down and should be within eye level so she could see signs and symptoms of aspiration (happens when food, liquid, or other material breathed into the lungs). DSD stated sitting down to be within eyelevel of the resident was important for resident's safety and maintaining their dignity. During an interview on 11/15/2024, at 2:55 p.m. with the Director of Nursing (DON), the DON stated whoever was feeding the resident, should be sitting in a chair to maintain resident's dignity and to ensure the resident was not aspirating the food. During a review of facility's policy and procedure (P&P) titled Dignity revised 12/2021, the P&P indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being and feelings of self-worth and self-esteem. The P&P indicated the residents will be provided with a dignified dining experience while assisting with their care.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a change of condition (COC), was completed when Resident 30 developed a urinary tract infection ([UTI]- an infection in any part of ...

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Based on interview and record review, the facility failed to ensure a change of condition (COC), was completed when Resident 30 developed a urinary tract infection ([UTI]- an infection in any part of the urinary system). This failure had the potential to result in the inability to determine the improvement or worsening of the infection leading to Resident 30 not receiving the appropriate care. Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility 6/4/2021 with diagnoses including obstructive uropathy (urine cannot drain through the urinary tract) and benign prostatic hyperplasia ([BPH]- enlarged prostate). During a review of Resident 30's Minimum Data Set ([MDS]- a resident assessment tool) dated 9/29/2024, the MDS indicated Resident 30's has intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 30 required partial/moderate assistance (helper does less than half the effort) with toileting, bathing, and dressing. During a review of Resident 30's Medication Administration Record (MAR), the MAR indicated Bactrim (medication used to treat infections) was administered to Resident 30 for a UTI times seven days beginning on 11/7/2024. During a concurrent interview and record review on 11/15/2024 at 9:03 a.m., with the Infection Prevention Nurse (IPN), the IPN stated a COC represents a change from a resident's baseline, such as a UTI, and was a form of communication between the staff. IPN stated there was no COC for Resident 30's UTI on 11/7/2024 but there should be, so the staff were aware of what was going on with the resident. During a concurrent interview and record review on 11/15/2024 at 10:38 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated a COC should be done when there was a change in condition, such as a UTI. LVN 1 stated there was no COC form done for Resident 30's UTI on 11/7/2024. LVN 1 stated there should be a COC so the staff can monitor his UTI for improvement. During a concurrent interview and record review on 11/15/2024 at 3:30 p.m., with the Director of Nursing (DON), the DON stated there was no COC for Resident 30's UTI but should have been so the staff can better monitor the resident. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, undated, the P&P indicated, Licensed nurses are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. During a review of the facility's P&P titled, Nursing Documentation, dated 6/27/2022, the P&P indicated the purpose, To communicate patient's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's condition, situation, and complexity.

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 accurately complete a Preadmission Screening and Resident Review (P...

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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 a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) I for one of three sampled residents (Resident's 18). This failure had the potential to result in an inappropriate placement and delay of needed services for Resident's 18. Findings: During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). During a review of Resident 18's Minimum Data Set ([MDS]- a resident assessment tool) dated 8/15/2024, the MDS indicated Resident 18 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 18 was dependent with toileting, bathing, eating, and dressing. During a review of Resident 18's History and Physical (H&P) dated 1/17/2024, the H&P indicated a diagnosis of paranoid schizophrenia. During a review of Resident 18's care plan titled Schizoaffective disorder manifested by auditory hallucinations (hearing sounds or voices that aren't actually there) and talking to someone non-existent initiated on 2/17/2022, the Care Plan interventions for Resident 18 included monitoring medications for side effects and resident's/patient's response contributing to verbal behaviors. During a review of Resident 18's Medication Administration Record (MAR), dated 1/1/2024-2/31/2024, the MAR indicated Resident 18 was receiving Seroquel (an anti-psychotic medication that treats several kinds of mental health conditions including schizophrenia). During a review of Resident 18's PASARR I, dated 1/17/2024, the PASARR I indicated a negative Level I am screening. The PASARR I indicated Resident 18 did not have a serious diagnosis of mental disorder (conditions that affect your thinking, feeling, mood, and behavior) and was not prescribed psychotropic medications (medications that affect the mind, emotions, and behaviors) for mental illness. During a concurrent interview and record review on 11/15/2024 at 11:46 a.m., with the Director of Nursing (DON), the DON stated he was responsible for ensuring the PASARR was completed and accurate. The DON stated Resident 18 has a diagnosis of paranoid schizophrenia and is currently taking Seroquel. The DON stated Resident 18's PASARR was inaccurate, and this could cause a delay in services. During a review of the facility's policy and procedure (P&P) titled, PASARR Completion Policy, undated, the P&P indicated, The Center will male sure all admissions have the appropriate PASARR completed, and the facility will follow state-specific guidelines for completion.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 45's admission Record, the admission record indicated Resident 45 was admitted to the facility on...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 45's admission Record, the admission record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (progressive state of decline in mental abilities), difficulty of walking, major depressive disorder (mental health condition with persistent low mood and loss of interest in activities that were once enjoyable), and benign prostatic hyperplasia (BPH- enlargement of the prostate gland). During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 had severe cognitive impairment The MDS indicated Resident 45 required substantial/maximal assistance (helper does more than half the effort) with toileting hygiene, dressing and bathing. During a review of Resident 45's Activity of Daily Living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Task for toileting for the month of October 2024, the ADL Task for toileting indicated Resident 45 had no bowel movement from 10/26/2024, 10/27/2024, 10/28/2024, 10/29/2024 and 10/30/2024. During a review of Resident 45's Medication Administration Record (MAR) dated 10/26/2024 to 10/31/2024, the MAR indicated Milk of Magnesia (MOM- medicine to treat constipation, upset stomach or heartburn), Dulcolax suppository (medication to treat constipation) or fleets enema (a saline laxative used to relieve constipation and clean the intestines) were administered to the resident. During a review of Resident 45's Physician Order Summary Report, the Physician Order Summary report dated 10/4/2024 indicated an order of milk of magnesia 400 milligrams (mgs. - unit of measurement) give 30 milliliters (ml- unit of measurement) every 24 hours as needed for constipation if no bowel movement in 3 days. During a review of Resident 45's Physician Order Summary Report dated 10/4/2024, the Physician Order Summary Report indicated an order for Dulcolax suppository 10 mgs. insert one suppository rectally every 24 hours as needed for constipation if no result from milk of magnesia. During a review of Resident 45's Physician Order Summary Report dated 10/4/2024, the Physician Order Summary Report indicated to monitor side effects of anti-psychotic medicines (medicines that work by altering brain chemistry to help reduce symptoms like hallucinations [perception that seem real but are not], delusions { a fixed false belief that a person holds onto, even when presented with evidence that it is not true} and disorganized thinking) related to Seroquel (medicine used to treat depression) like dry mouth, constipation, blurry vision confusion involuntary and loss of appetite. During a review of Resident 45's Care Plan titled Resident is at risk for gastrointestinal symptoms or complications related to history of constipation initiated 10/4/2024, the Care Plan goals indicated Resident 45 will not develop gastrointestinal complications for 90 days. The Care Plan interventions included monitoring, recording of bowel movements and providing bowel regimen (set of medications to help residents avoid or relieve constipation), utilize pharmacologic agents (medicines) as appropriate like stool softeners, laxative and document effectiveness. During a concurrent interview and record review on 11/15/2024, at 1:30 p.m. with Certified Nursing Assistant (CNA 2), reviewed Resident 45 's ADL Task. CNA 2 stated she document not applicable on the ADL Task which indicate no bowel movement. CNA 2 stated residents (in general) who had no bowel movement for three days should be communicated to the charge nurse. During a concurrent interview and record review on 11/15/2024, at 1:23 p.m. with Licensed Vocational Nurse (LVN 2), reviewed Resident 45's ADL task. LVN 2 confirmed Resident 45 had no bowel movement for five days and no medications were administered. LVN 2 stated the Resident 45 was on Seroquel and constipation was one of the side effects. LVN 2 stated the charge nurse would ask the residents (in general) if they had bowel movement and check the ADL task for any bowel movement. LVN 2 stated constipation could get worse if the appropriate medications for constipation was not administered and bowel movement was not properly monitored. During an interview on 11/15/2024, at 2:55 p.m. with the Director of Nursing (DON), the DON stated Resident 45's constipation and not having a bowel movement for five days could lead to gastrointestinal complications like fecal impaction and bowel obstruction. During a review of the facility's LVN job description, revised 5/2022, the job description indicated, Monitor residents for and immediately report developments of acute changes of condition including constipation. Based on interview and record review, the facility failed to provide the necessary services and care to two of four sampled residents (Resident 18 and Resident 45) by failing to: a.Ensure Resident 18 was provided the necessary medications for constipation (a condition in which stool becomes hard, dry, difficult to pass and bowel movements become infrequent) when the resident had no bowel movement (movement of feces through the bowel and out the anus) for five days. b. Monitor occurrence of bowel movement for Resident 45 and provide necessary medications for constipation as ordered by the physician. These failures had the potential to put Resident 18 and Resident 45 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to bowel obstruction (partial or complete blockage of small or large intestines which is life threatening). Findings: a.During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including dementia (the loss of cognitive functioning- thinking, remembering, and reasoning- to such an extent that it interferes with a person's daily life and activities) and major depressive disorder ( a mood disorder that causes a persistent feeling of sadness and loss of interest) . During a review of Resident 18's Minimum Data Set ([MDS] resident assessment tool) dated 8/15/2024, the MDS indicated Resident 18 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 18 was dependent with eating, toileting, dressing, and bathing. During a review of Resident 18's Care Plan titled Resident 18 was at risk for gastrointestinal (the organs and system that digest and move food and liquids through the body) complications related to constipation initiated 11/29/2020, the care plan with goals included Resident 18 to not develop any gastrointestinal complications. The Care Plan interventions for Resident 18 included to monitor and record bowel movements, provide bowel regimen, and to assess for signs and symptoms of constipation. During a review of Resident 18's Physician Order Summary Report, the Physician Order Summary Report indicated an order was placed on 1/16/2024 for MiraLAX Powder (medication to prevent and treat occasional constipation) to be given as needed if resident has not had a bowel movement in the past 72 hours. During a review of Resident 18's Activities of Daily Living (ADL) Task screen, the ADL toileting task indicated Resident 18 had not had a bowel movement from 11/9/2024 to 11/14/2024. During a concurrent interview and record review on 11/14/2024 at 12:31 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 18's last bowel movement was 11/8/2024 and no medications were administered to Resident 18 for his constipation. LVN 2 stated if a resident does not have a bowel movement in three days, the resident needs to be given a laxative (a medication that helps you have a bowel movement when you're constipated). LVN 2 stated Resident 18 should have received MiraLAX because she had not had a bowel movement in over three days, and this could result in Resident 18 experiencing nausea, vomiting, and bowel obstruction. During a concurrent interview and record review on 11/14/2024 at 2:12 p.m., with the Director of Nursing (DON), the DON stated Resident 18 could develop a bowel obstruction because she has not had a bowel movement for several days. The DON stated their policy was to give a laxative if a resident does not have a bowel movement in three days. During an interview on 11/14/2024 at 2:40 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated if a resident does not have a bowel movement for three days, he informs the charge nurse immediately. CNA 4 stated the resident not having a bowel movement for three days could cause the resident to not feel well or not eat. During an interview on 11/15/2024, at 1:30 p.m. with Director of Staff Development (DSD), DSD stated licensed nurses were responsible to know if the resident was having constipation. DSD stated CNAs should notify the charge nurse for any missed bowel movement because the residents are on medications that can be given for constipation. DSD stated residents should be monitored for constipation or occurrences of bowel movement because the resident could have a change of condition like vomiting, and abdominal pain which could lead to bowel obstruction.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

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 maintain a medication error rate of less than 5% (per...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% (percent) during medication pass for two of five sampled residents (Resident 1 and 228) by failing to provide medications within one (1) hour of the prescribed time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019. This deficient practice of medication administration error rate of 25.93% exceeded the five (5) percent threshold. Findings: 1. During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 11/13/2024, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, acute embolism (a blockage in blood vessel) and thrombosis (blood clotting) of unspecified deep veins of left lower extremity, personal history of transient ischemic attack (a brief episode where blood flow to the brain is temporarily blocked), and cerebral infarction (a condition where blood flow to the brain is blocked) without residual effects, hypertensive (high blood pressure) and heart disease without heart failure. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/27/2024, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 1 required setup or clean up assistance for eating and required partial assistance to supervision for some activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as showering, toileting, dressing and oral hygiene. During a review of Resident 1's Order Summary Report (a document containing a summary of all active physician orders), dated 11/13/2024, the order summary report included, but not limited to the following medications: a. Amlodipine besylate (a medication used to treat high blood pressure) tablet 10 milligrams (mg - a unit of measure for mass), give 1 tablet by mouth one time a day for HTN, hold for systolic blood pressure (SBP - the pressure in arteries when heart is pumping blood into arteries) <110, order date 12/26/2022. b. Eliquis (Generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain) oral tablet 2.5 mg, give 1 tablet by mouth two times a day for deep vein thrombosis (DVT - a medical condition when a blood clot forms in a vein deep inside the body) prophylaxis (prevention), order date 5/17/2024. c. Hydralazine hydrochloride (HCl) (a medication used to treat high blood pressure) tablet 50 mg, give 1 tablet by mouth two times a day for HTN, hold for SBP <110, order date 12/26/2022. During an observation of medication administration on 11/13/2024 from 10:30 a.m. to 10:46 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered Resident 1's medications that included (but not limited to) 1 tablet of Amlodipine 10 mg, 1 tablet of Eliquis 2.5 mg and 1 tablet of Hydralazine 50 mg. During a medication reconciliation review on 11/13/2024 at 12:08 p.m., Resident 1's order entry details and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/13/2024 were reviewed. The order details and MAR indicated the scheduled administration time was 9 a.m. for Amlodipine 10 mg, Eliquis 2.5 mg and Hydralazine 50 mg. However, LVN 1 was observed administering Resident 1's Amlodipine, Eliquis and Hydralazine at 10:46 a.m. on 11/13/2024, which was one hour and 46 minutes after the scheduled administration time of 9 a.m. During an interview on 11/13/2024 at 3:00 p.m. with LVN 1, LVN 1 stated the scheduled administration time for Resident 1's medications was 9 a.m. and should have been administered at the prescribed time or before 10 a.m. LVN 1 stated that there was an increased risk of hypertension, deep venous thrombosis, blood clotting, and hospitalization for Resident 1 when the medications were not administered on time. 2. During a review of Resident 228's admission Record, dated 11/13/2024, the admission record indicated Resident 228 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to, end stage renal disease (ESRD - irreversible kidney failure), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and recurrent major depressive disorder. During a review of Resident 228's MDS, dated [DATE], the MDS indicated Resident 228's cognition was intact. The MDS indicated Resident 228 required partial or moderate assistance for eating and oral hygiene. The MDS indicated Resident 228 was fully dependent or required maximal assistance for toileting, showering and dressing. During a review of Resident 228's Order Summary Report, dated 11/13/2024, the order summary included, but not limited to the following medications: a. Amlodipine oral tablet 5 mg, give 1 tablet by mouth in the morning for hypertension, order date 11/11/2024. b. Escitalopram (a medication used to treat depression and mood disorders) oral tablet 10 mg, give 1 tablet by mouth in the morning for depression and anxiety, order date 11/11/2024. c. Heparin (a medication used to prevent blood clots) sodium injection 5000 units / milliliter (mL - a unit of measure for volume), inject 1 mL subcutaneously (under the skin) every 12 hours for venous thromboembolism (VTE -a condition with blood clot in veins) prophylaxis, order date 11/11/2024. d. Hydralazine HCl oral tablet 25 mg, give 1 tablet by mouth two times a day for hypertension, order date 11/11/2024. During an observation of medication administration on 11/13/2024 at 10:57 a.m. with LVN 1, LVN 1 prepared and administered Resident 228's medications that included (but not limited to) 1 tablet of Escitalopram 10 mg, 1 tablet of Amlodipine 5 mg, 1 tablet of Hydralazine 25 mg and 1 mL or 5000 units of Heparin. During a medication reconciliation review on 11/13/2024 at 12:08 p.m., Resident 228's order entry details and MAR dated 11/13/2024 were reviewed. The order details and MAR indicated the scheduled administration time was 7 a.m. for Escitalopram 10 mg, 8 a.m. for Amlodipine 5 mg, Heparin 5000 units and Hydralazine 25 mg. However, LVN 1 was observed administering Resident 228's Escitalopram 10 mg, Amlodipine 5 mg, Heparin 5000 units (1 mL) and Hydralazine 25 mg at 10:57 a.m. on 11/13/2024, which was almost four hours after the scheduled administration time of 7 a.m. for Escitalopram, and three hours after the scheduled administration time of 8 a.m. for Amlodipine, Heparin and Hydralazine. During an interview on 11/13/2024 at 3:00 p.m. with LVN 1, LVN 1 stated the Resident 228's medications should have been administered at the prescribed time or within one hour before or one hour after scheduled administration time. LVN 1 stated that there was an increased risk of hypertension, deep venous thrombosis, blood clotting, mood change or agitation and hospitalization for Resident 228 when the medications were not administered on time. During an interview on 11/13/2024 at 1:29 p.m. and on 11/14/2024 at 4:41 p.m. with the Director of Nursing (DON), DON stated the medications should have been administered at prescribed time or within one hour before or one hour after prescribed administration time. DON stated if medications for Residents 1 and 228 were administered outside of the one-hour timeframe, then they were considered as late administration. DON stated the facility staff would need to be retrained for order entry because the medication orders that were entered with 7 a.m. and 8 a.m. times were supposed to be entered with 9 a.m. scheduled administration. DON stated late administration of antihypertensive medications, Eliquis and psychotropic medications placed the residents at an increased risk for uncontrolled blood pressure, stroke, thrombosis, clotting, heart complications, mood and behavioral problems, and hospitalization. During a review of the facility's P&P titled, Administering Medications, dated 04/2019, the P&P indicated, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During a review of the facility's P&P titled, Medication Errors, dated 6/28/2022, the P&P indicated, a. The facility will work to keep medication error rates five percent or lower. b. Medication error means the administration of medication at the wrong time.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

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 significant medicatio...

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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 significant medication errors for two (Resident 1 and 228) of five sampled residents, by failing to administer: 1. Resident 1's Amlodipine (a medication used to treat high blood pressure), Eliquis (Generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain) and Hydralazine (a medication used to treat high blood pressure) within one (1) hour of the prescribed time of administration as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019. 2. Resident 228's Amlodipine, Escitalopram (a medication used to treat depression and mood disorders), Heparin (a medication used to prevent blood clots) and Hydralazine within one (1) hour of the prescribed time of administration as per facility's P&P titled, Administering Medications, dated 04/2019. These failures had the potential to result in hypertension (HTN - high blood pressure), stroke (loss of blood flow to a part of the brain), venous thromboembolism (blood clots in veins), behavioral disturbances and hospitalization for Residents 1 and 228. Findings: 1. During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 11/13/2024, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, acute embolism (a blockage in blood vessel) and thrombosis (blood clotting) of unspecified deep veins of left lower extremity, personal history of transient ischemic attack (a brief episode where blood flow to the brain is temporarily blocked), and cerebral infarction (a condition where blood flow to the brain is blocked) without residual effects, hypertensive (high blood pressure) and heart disease without heart failure. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/27/2024, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 1 required setup or clean up assistance for eating and required partial assistance to supervision for some activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as showering, toileting, dressing and oral hygiene. During a review of Resident 1's Order Summary Report (a document containing a summary of all active physician orders), dated 11/13/2024, the order summary report included, but not limited to the following medications: a. Amlodipine besylate (a medication used to treat high blood pressure) tablet 10 milligrams (mg - a unit of measure for mass), give 1 tablet by mouth one time a day for HTN, hold for systolic blood pressure (SBP - the pressure in arteries when heart is pumping blood into arteries) <110, order date 12/26/2022. b. Eliquis (Generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain) oral tablet 2.5 mg, give 1 tablet by mouth two times a day for deep vein thrombosis (DVT - a medical condition when a blood clot forms in a vein deep inside the body) prophylaxis (prevention), order date 5/17/2024. c. Hydralazine hydrochloride (HCl) (a medication used to treat high blood pressure) tablet 50 mg, give 1 tablet by mouth two times a day for HTN, hold for SBP <110, order date 12/26/2022. During an observation of medication administration on 11/13/2024 from 10:30 a.m. to 10:46 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered Resident 1's medications that included (but not limited to) 1 tablet of Amlodipine 10 mg, 1 tablet of Eliquis 2.5 mg and 1 tablet of Hydralazine 50 mg. During a medication reconciliation review on 11/13/2024 at 12:08 p.m., Resident 1's order entry details and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/13/2024 were reviewed. The order details and MAR indicated the scheduled administration time was 9 a.m. for Amlodipine 10 mg, Eliquis 2.5 mg and Hydralazine 50 mg. However, LVN 1 was observed administering Resident 1's Amlodipine, Eliquis and Hydralazine at 10:46 a.m. on 11/13/2024, which was one hour and 46 minutes after the scheduled administration time of 9 a.m. During an interview on 11/13/2024 at 3:00 p.m. with LVN 1, LVN 1 stated the scheduled administration time for Resident 1's medications was 9 a.m. and should have been administered at the prescribed time or before 10 a.m. LVN 1 stated that there was an increased risk of hypertension, deep venous thrombosis, blood clotting, and hospitalization for Resident 1 when the medications were not administered on time. 2. During a review of Resident 228's admission Record, dated 11/13/2024, the admission record indicated Resident 228 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to, end stage renal disease (ESRD - irreversible kidney failure), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and recurrent major depressive disorder. During a review of Resident 228's MDS, dated [DATE], the MDS indicated Resident 228's cognition was intact. The MDS indicated Resident 228 required partial or moderate assistance for eating and oral hygiene. The MDS indicated Resident 228 was fully dependent or required maximal assistance for toileting, showering and dressing. During a review of Resident 228's Order Summary Report, dated 11/13/2024, the order summary included, but not limited to the following medications: a. Amlodipine oral tablet 5 mg, give 1 tablet by mouth in the morning for hypertension, order date 11/11/2024. b. Escitalopram (a medication used to treat depression and mood disorders) oral tablet 10 mg, give 1 tablet by mouth in the morning for depression and anxiety, order date 11/11/2024. c. Heparin (a medication used to prevent blood clots) sodium injection 5000 units / milliliter (mL - a unit of measure for volume), inject 1 mL subcutaneously (under the skin) every 12 hours for venous thromboembolism (VTE -a condition with blood clot in veins) prophylaxis, order date 11/11/2024. d. Hydralazine HCl oral tablet 25 mg, give 1 tablet by mouth two times a day for hypertension, order date 11/11/2024 During an observation of medication administration on 11/13/2024 at 10:57 a.m. with LVN 1, LVN 1 prepared and administered Resident 228's medications that included (but not limited to) 1 tablet of Escitalopram 10 mg, 1 tablet of Amlodipine 5 mg, 1 tablet of Hydralazine 25 mg and 1 mL or 5000 units of Heparin. During a medication reconciliation review on 11/13/2024 at 12:08 p.m., Resident 228's order entry details and MAR dated 11/13/2024 were reviewed. The order details and MAR indicated the scheduled administration time was 7 a.m. for Escitalopram 10 mg, 8 a.m. for Amlodipine 5 mg, Heparin 5000 units and Hydralazine 25 mg. However, LVN 1 was observed administering Resident 228's Escitalopram 10 mg, Amlodipine 5 mg, Heparin 5000 units (1 mL) and Hydralazine 25 mg at 10:57 a.m. on 11/13/2024, which was almost four hours after the scheduled administration time of 7 a.m. for Escitalopram, and three hours after the scheduled administration time of 8 a.m. for Amlodipine, Heparin and Hydralazine. During an interview on 11/13/2024 at 3:00 p.m. with LVN 1, LVN 1 stated the Resident 228's medications should have been administered at the prescribed time or within one hour before or one hour after scheduled administration time. LVN 1 stated that there was an increased risk of hypertension, deep venous thrombosis, blood clotting, mood change or agitation and hospitalization for Resident 228 when the medications were not administered on time. During an interview on 11/13/2024 at 1:29 p.m. and on 11/14/2024 at 4:41 p.m. with the Director of Nursing (DON), DON stated the medications should have been administered at prescribed time or within one hour before or one hour after prescribed administration time. DON stated if medications for Resident 1, 228 and other residents were administered outside of the one-hour timeframe, then they were considered as late administration. DON stated the facility staff would need to be retrained for order entry because the medication orders that were entered with 7 a.m. and 8 a.m. times were supposed to be entered with 9 a.m. scheduled administration. DON stated late administration of antihypertensive medications, Eliquis and psychotropic medications placed the residents at an increased risk for uncontrolled blood pressure, stroke, thrombosis, clotting, heart complications, mood and behavioral problems, and hospitalization. During a review of the facility's P&P titled, Administering Medications, dated 04/2019, the P&P indicated, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During a review of the facility's P&P titled, Medication Errors, dated 6/28/2022, the P&P indicated, medication error means the administration of medication at the wrong time.

CONCERN (D)

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

Medical Records (Tag F0842)

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 Restorative Nursing Aide ([RNA] certified ...

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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 Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) Records for one of four sample residents (Resident 17) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) indicated Resident 17's refusal to wear the right elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) on 11/12/2024. This failure resulted in the inaccurate provision of care recorded in Resident 17's clinical records. Findings: During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (brain damage due to a loss of oxygen to the area), aphasia (loss of ability to understand or express speech as a result of brain damage), hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) affecting right dominant side, and acquired absence of the left leg above the knee. During a review of Resident 17's Minimum Data Set ([MDS] a resident assessment tool), dated 10/4/2024, the MDS indicated Resident 17 did not have any speech, rarely/never understood others, rarely/never expressed ideas, and wants, and was severely impaired for daily decision making. The MDS indicated Resident 17 had ROM limitations in one arm and one leg. The MDS also indicated Resident 17 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) with toileting, dressing, lying to sitting on the side of the bed, and chair/bed-to-chair transfer. During a review of Resident 17's Physician Orders, dated 5/16/2022, the Physician Orders indicated for the RNA to perform passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) on Resident 17's right arm, five times per week as tolerated. During a review of Resident 17's Physician Orders, dated 10/26/2023, indicated for the RNA to apply a right elbow splint and a right-hand splint, five times per week for three hours as tolerated. During an observation on 11/12/2024 at 11:06 a.m. in Resident 17's room, Resident 17 was lying awake in bed and moved the left arm normally. Resident 17's right shoulder was positioned in internal rotation (arm rotated toward the body), the right elbow was bent more than 90 degrees, the right wrist was positioned in extension (bent upward) while wearing a right-hand splint, and the right fingers were bent. Resident 17 was observed not wearing a right elbow splint. During an observation on 11/13/2024 at 9:53 a.m. in Resident 17's room, Resident 17's RNA session with Restorative Nursing Aide 1 (RNA 1) and RNA 2 was observed. RNA 1 stood on the right side of Resident 17's bed while RNA 2 stood on the left side of the bed. RNA 1 performed PROM exercises to Resident 17's right shoulder, elbow, wrist, and hand. RNA 1 applied Resident 17's right-hand splint, but Resident 17 refused the application of the right elbow extension splint. During an interview on 11/13/2024 at 10:06 a.m. with RNA 1 and RNA 2, RNA 1 stated Resident 17 refused the right elbow splint but will attempt to place the splint again later in the day. RNA 2 stated Resident 17 also refused to apply the right elbow splint yesterday (11/12/2024). During a review of Resident 17's RNA Record (record of RNA sessions) for 11/2024, the RNA Record indicated Resident 17's right elbow splint was applied on 11/12/2024 and refused on 11/13/2024. During a concurrent interview and record review on 11/14/2024 with RNA 2, Resident 17's RNA Record for 11/2024 was reviewed. RNA 2 stated Resident 17 allowed RNA 2 to perform the PROM exercises on the right arm and application of the right-hand splint but refused the right elbow splint application on 11/12/2024. RNA 2 reviewed Resident 17's RNA record for 11/12/2024 and stated she should have indicated Resident 17 refused the right elbow splint. During a concurrent interview and record review on 11/15/2024 with the Director of Staff Development (DSD), Resident 17's RNA Record for 11/12/2024 was reviewed. The DSD stated the RNAs should circle their initial and write on the back of the RNA Record if a resident (in general) refused to participate in RNA exercises or application of splints. The DSD reviewed Resident 17's RNA Record for 11/12/2024, which included the RNA's initial but not circled. The DSD stated it was important to indicate in the documentation when a resident refuses treatment to notify the family for assistance or the resident's physician for recommendations. During a review of the facility's Policy and Procedure (P&P) titled, Nursing Documentation, dated 6/27/2022, the P&P indicated nursing documentation will be accurate based on the resident's condition.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] for one of three re...

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Based on interview and record review, the facility failed to implement antibiotic stewardship program (measures used by the facility to ensure antibiotics [drug to treat infection] for one of three residents (Resident 25). This failure had the potential to put Resident 25 at risk for antibiotic resistance (not effective to treat infection) and inappropriate use of antibiotic. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility 4/19/2022 with diagnoses including diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cerebral infarction (a part of the brain has been damaged because it wasn't getting enough blood supply). During a review of Resident 25's Minimum Data Set ([MDS]- a resident assessment tool), the MDS indicated Resident 25 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent with bathing, toileting, and transferring. During a review of Resident 25's Antibiotic Surveillance Data Collection dated 10/17/2024, the Antibiotic Surveillance Data Collection indicated Resident 25 did not have the LOEB's criteria (set of guidelines used by healthcare providers in for long term care facilities to determine when a resident likely has a significant infection and needs antibiotics based on symptoms) indicating antibiotic use. During a concurrent interview and record review on 11/15/2024 at 9:32 a.m., with the Infection Prevention Nurse (IPN), the IPN stated Resident 25 was prescribed Ciprofloxacin (medication to treat a bacterial infection) but did not meet the LOEBS criteria. IPN stated Resident 25 was prescribed Keflex (medication to treat infection) from 10/17/24 to 10/24/2024 and then Ciprofloxacin from 10/29/2024 to 11/5/2024. IPN stated she spoke with Resident 25's primary physician that ordered the antibiotic and he still wanted the resident to receive the Ciprofloxacin despite not meeting the criteria. IPN stated she did not reach out to the facility's Medical Director (MD), and should have done so, to inform him Resident 25 did not meet the criteria for antibiotic use. During an interview on 11/15/2024 at 12:17 a.m., with the Director of Nursing (DON), the DON stated Resident 25 should not have been prescribed Ciprofloxacin because he did not meet the LOEBS criteria. The DON stated the MD should have been involved. The DON stated unnecessary medications like use of antibiotics can cause antibiotic resistance. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 9/18/2023, the P&P indicated, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. During a review of the facility's P&P titled, Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, dated 9/18/2023, the P&P indicated, As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP). The IP will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are consistent with the appropriate use of antibiotics. Cross Reference F757

CONCERN (D)

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

Deficiency F0912 (Tag F0912)

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 four out of 40 resident rooms measured at leas...

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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 four out of 40 resident rooms measured at least 80 square feet ([sq. ft.]- unit of area equal to a square foot long on each side) per resident in multiple resident rooms. Rooms one and 23 house two residents per room and Rooms two and four housed four residents per room. This deficient practice had the potential to result in inadequate nursing care to the residents. Findings: During an observation on 11/12/2024 at 9:30 a.m., the following rooms were observed, Rooms one, two, four, and 23 did not meet the requirement of 80 square feet per resident. During a concurrent observation and interview on 11/12/2024, at 3:32 p.m., in Resident 37's room, Resident 37's bed was near the closet area with a small space in between the closet and resident's bed. Resident 37 stated he hated the small living space of the room because it affected his mobility especially when the staff member would provide care to his roommate because they would occupy the space where his wheelchair was located causing him to be moved to the side of the bed. Resident 37 stated he could not get into his closet easily because of the small space in between the bed and closet and he was not offered a room change for his concern. Resident 37 stated he would not be able to get out of his room easily if there was an emergency in the facility. During a review of the Client Accommodations Analysis Form provided by the Maintenance Supervisor (MS) on 11/14/2024, the Client Accommodations Analysis Form indicated. Rooms 1 measures 142 sq ft occupied by two residents. room [ROOM NUMBER] measures 154 sq. ft. occupied by two residents. room [ROOM NUMBER] and room [ROOM NUMBER] measures 295 sq. ft. occupied by four residents. During a review of the facility's request for waiver of room size letter dated 11/27/2024 submitted by ADM, for four resident rooms was reviewed. The waiver request letter indicated, These room are in accordance with the special needs of the residents and will not adversely affect resident's health and /or safety.

CONCERN (E)

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

Deficiency F0558 (Tag F0558)

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 accommodate the individual needs and preferences of t...

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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 accommodate the individual needs and preferences of two of 21 sampled residents (Resident 37 and Resident 179) by failing to: a. Address Resident 37's concern regarding insufficient space of his room which prevented him to move around comfortably and access his closet and wheelchair easily due to limited space. b. Address Resident 179's concern about the noise coming from resident's roommate which affected his sleep. These failures had the potential to affect Resident 37's and Resident 179's health, psychosocial wellbeing and safety. Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia ( a condition in which there are high levels of fat in the blood), and hydronephrosis with renal and ureteral calculous obstruction( a condition where one or both kidneys swell due to a blockage in the urinary tract that prevents urine from draining properly). During a review of Resident 37's Minimum Data Set (MDS resident assessment tool) dated 10/24/2024, the MDS indicated Resident 37 had an intact cognition (ability to think, understand, learn, and remember) and required supervision or touching assistance (helper provides verbal cues or touching / steadying as resident complete the activity) with chair/bed-to-chair transfer, toilet transfer and walking. The MDS indicated Resident 37 used wheelchair and walker as mobility devices. During a review of Resident 37's History and Physical (H&P) dated 9/6/2024, the H&P indicated Resident 37 had the capacity to understand and make decisions. During a concurrent observation and interview on 11/12/2024, at 3:32 p.m., in Resident 37's room, Resident 37's bed was near the closet area with a small space in between the closet and resident's bed. Resident 37 stated he hated the small living space of the room because it affected his mobility especially when the staff member would provide care to his roommate because they would occupy the space where his wheelchair was located causing him to be moved to the side of the bed. Resident 37 stated he could not get into his closet easily because of the small space in between the bed and closet and he was not offered a room change for his concern. Resident 37 stated he would not be able to get out of his room easily if there was an emergency in the facility. During a concurrent observation and interview on 11/14/2024 with Maintenance Supervisor (MS), observed MS measured the room of Resident 37 and his roommate. MS stated it was 154 square feet of the room with two residents inside. MS stated Resident 37 had lots of things in his room and he was aware the room did not have enough space. During an interview on 11/15/2024, at 2:55 p.m. with the Director of Nursing (DON), the DON stated having an insufficient living space could lead to accident and will cause inconvenience to the resident. b. During a review of Resident 179's admission Record, the admission Record indicated Resident 179 was admitted to the facility on [DATE] with diagnoses including heart failure (serious condition that occurs when the heart cannot pump enough blood and oxygen to the body's organs), weakness, angina pectoris(chest pain or discomfort that occurs when the heart muscle does not receive enough blood and oxygen), and acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood). During an interview on 11/12/2024, at 9:44 a.m., and subsequent interview on 11/14/2024, at 3:45 p.m. with Resident 179, Resident 179 stated he was feeling tired and could not sleep at night because his roommate would scream and talked loudly at night. Resident 179 stated he told an unnamed staff member this morning (11/14/2024) and another staff yesterday (11/13/2024) for a room change. During an observation on 11/14/2024, at 3:49 p.m., Resident 179's roommate was lying in bed and screaming and calling someone's name. During an interview on 11/14/2024, at 4:08 p.m., with Certified Nursing Assistant (CNA 2), CNA 2 stated Resident 179 was complaining about the noise coming from his roommate and requested to get a room change. CNA 2 stated he told his charge nurse yesterday (11/13/2024). During an interview on 11/15/2024, at 12:08 p.m., with Case Manager (CM), CM stated she was aware Resident 179 was complaining of the noise level coming from his roommate and this was communicated to Social Service Director (SSD) on 11/13/2024 Interdisciplinary Team Meeting (IDT- a gathering of various healthcare professionals to coordinate care for a resident). CM stated the noise coming from his roommate will affect Resident 179's sleep at night and could affect his health and should be addressed right away. During a review of Resident 179's IDT Care Conference dated 11/13/2024, the IDT Care Conference indicated resident's concern for inability to sleep at night due to noise was not addressed in the meeting. During an interview on 11/15/2024, at 12:22 p.m., with SSD, SSD stated she knew Resident 179's concern about the noise at night which preventing Resident 179 to get some sleep. SSD stated Resident 179 was not transferred right away because of the room availability. SSD stated Resident 179 lack of sleep could have an effect on his psychosocial being which could prevent him not doing any activities due to fatigue. During a review of facility's census for 11/14/2024, the facility's census indicated 11 empty beds. During a review of facility's census for 11/13/2024, the facility's census indicated 13 empty beds. During an interview on 11/15/2024, at 2:55 p.m. with the DON, the DON stated inability to get sleep due to noise level could affect Resident 179's health and psychosocial being. During a review of facility's policy and procedure (P&P) titled' Accommodation of Needs undated, the P&P indicated in order to accommodate individual needs and preferences, adaptations may be made in their physical environment to maintain and achieve safe, independent functioning, dignity, and well-being. During a review of facility's P&P titled Homelike Environment undated, the P&P indicated the facility staff will provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences, The P&P indicated the facility staff and management will maximize to the extent possible the characteristics of the facility that reflect a personalized , homelike setting that include comfortable sound levels, clean, orderly environment and personalized furniture and room arrangements.

CONCERN (E)

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

Deficiency F0583 (Tag F0583)

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 three of 45 sampled residents (Resident 6, 17,...

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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 three of 45 sampled residents (Resident 6, 17, and 34), were provided privacy curtains to completely cover the residents during care. This failure prevented Resident 6, 17, and 34 from having complete privacy during care and had the potential to affect their dignity and self-worth. Findings: a. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area), dysphagia (difficulty swallowing) affecting the left non-dominant side, and contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of the left leg. During a review of Resident 34's Care Plan titled Incontinence (involuntary loss of bladder or bowel control), initiated 11/15/2023, the interventions indicated to provide Resident 34 with privacy and comfort. During a review of review of Resident 34's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 34 had clear speech, understood verbal content, expressed ideas, and wants, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 34 had range of motion ([ROM] full movement potential of a joint [where two bones meet]) limitations in one arm and both legs. The MDS further indicated Resident 34 required partial/moderate assistance (helper does less than half the effort) for upper body dressing and rolling to both sides while lying in bed and required substantial/maximal assistance (helper does more than half the effort) with lower body dressing and toileting. During an observation on 11/13/2024 at 8:46 a.m. with Restorative Nursing Aide 1 (RNA 1) and RNA 2, the door of Resident 34's room was closed. RNA 1 and RNA 2 entered Resident 34's room. Resident 34's privacy curtain was pulled on the left side of the bed in-between Resident 34 and Resident 34's roommate (Bed B). There was no privacy curtain observed on the right side of Resident 34's bed. Resident 34 was visibly turned to the right side while Certified Nursing Assistant 3 (CNA 3) stood on the right side of the bed holding an incontinence brief. Resident 34 was observed waving the right arm in a shooing away motion. CNA 3 stated Resident 34 wanted privacy since the curtain did not cover the right side of Resident 34's bed. During an interview on 11/13/2024 at 9:41 a.m., CNA 3 stated Resident 34's curtain was not wide enough to provide Resident 34 with full privacy. CNA 3 pulled the curtain between Resident 34 and Bed B and then closed the door for privacy. During an interview on 11/13/2024 at 11:44 a.m., CNA 3 stated she had to choose which side of Resident 34's bed to cover. CNA 3 stated ideally the privacy curtain should be fully closed to prevent Resident 34 from being visible from the door and Resident 34's roommates. CNA 3 stated she would feel embarrassed if someone walked into the room while CNA 3 was getting dressed. b. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), dementia (a progressive state of decline in mental abilities), dysphagia, contracture of muscles in both lower legs, and stiffness in the left shoulder, right elbow, wrist (unspecified), and right hand. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 5 did not have any speech, was never/rarely understood, never/rarely understood others, and was severely impaired for daily decision making. The MDS indicated Resident 6 had ROM limitations in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for toileting, showering, dressing, personal hygiene, rolling to either side in bed, and chair/bed-to-chair transfers. During an observation on 11/13/2024 at 9:13 a.m., RNA 1 went into Resident 6's room to assist Certified Nursing Assistant 4 (CNA 4) with Resident 6's care. During a concurrent observation and interview on 11/13/2024 at 9:15 a.m., in Resident 6's room with CNA 4, RNA 1, and RNA 2, Resident 6's privacy curtain covered the left of Resident 6's bed upon entering the room. There was no privacy curtain observed on the right side of Resident 6's bed in-between Resident 6 and Resident 6's roommate. CNA 4 pulled Resident 6's curtain between the beds, which caused the curtain to pull away from the left side of Resident 6's bed near the entrance door. RNA 2 stated Resident 6's curtain did not provide Resident 6 with full privacy around the entire bed. During an interview on 11/13/2024 at 9:21 a.m., CNA 4 stated he was giving Resident 6 a bed bath. CNA 4 stated the privacy curtain was not pulled between Resident 6 and Resident 6's roommate. During an interview on 11/13/2024 at 11:44 a.m., CNA 4 stated Resident 6 was dependent on staff for assistance. CNA 4 stated he would feel embarrassed if the privacy curtain was not closed completely while being undressed. c. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses included cerebral infarction, aphasia (loss of ability to understand or express speech as a result of brain damage) following a cerebral infarction, hemiparesis affecting right dominant side, and acquired absence of the left leg above the knee. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 did not have any speech, rarely/never understood others, rarely/never expressed ideas, and wants, and was severely impaired for daily decision making. The MDS indicated Resident 17 had ROM limitations in one arm and one leg. The MDS also indicated Resident 17 was dependent with toileting, dressing, lying to sitting on the side of the bed, and chair/bed-to-chair transfer. During a concurrent observation and interview on 11/13/2024 at 9:48 a.m. in Resident 17's room with RNA 1 and RNA 2, RNA 2 pulled the curtain on the right side of Resident 17's bed in-between Resident 17 and Resident 17's roommate prior to performing exercises with Resident 17. There was no curtain observed on the left side of Resident 17's bed. RNA 2 stated the curtain did not fully cover around Resident 17's bed which was a privacy issue. RNA 2 stated Resident 17's door needed to be closed for privacy and proceeded to close the door. During an interview on 11/15/2024 at 12:04 p.m. with the Administrator (ADM), the Environmental Services Supervisor (ESS), and the Environmental Services Regional Consultant (ESRC), the ADM stated the facility was in the process of renovating the facility's public spaces. The ADM stated the residents' rooms will be the next renovation project, which included the privacy curtains. The ADM stated she would feel not great if someone walked in while the ADM was getting dressed. During an interview on 11/15/2024 at 12:21 p.m. with the Director of Nursing (DON), the DON stated the residents (in general) should be covered completely while providing care for the resident's privacy and dignity. During a review of the facility's Policy and Procedure (P&P) titled, Dignity, revised 2/2021, the P&P indicated the facility staff promoted, maintained, and protected resident privacy, including bodily privacy during assistance with personal care and during treatment. During a review of the facility's P&P titled, Confidentiality of Information and Personal Privacy, revised 10/2017, indicated the facility will strive to protect the resident's privacy during personal care.

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

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 revise the care plans for two of four sampled residen...

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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 revise the care plans for two of four sampled residents (Resident 6 and 20) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns by failing to: a. Revise Resident 6's care plans and conduct an Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) conference with the resident's representative after discharge from hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) on 1/13/2024. b. Revise Resident 20's care plan for Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) after passive range of motion ([PROM] movement of joint through the ROM from an external force with no effort from the person) exercises for the left leg and application of the left knee splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) was discontinued on 9/13/2024. These failures resulted in Resident 6 not receiving any intervention to address ROM limitations from 1/13/2024 to 3/5/2024 and had the potential to affect Resident 20's provision of care. Findings: a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), contracture (a stiffening/shortening at any joint that reduces the joint's range of motion) of muscles in both lower legs, and stiffness in the left shoulder, right elbow, wrist (unspecified), and right hand. During a review of Resident 6's Physician Orders, dated 1/13/2024, the Physician Orders indicated to transfer Resident 6 to custodial care (care with activities of daily living [ADLs] related to personal care including bathing, dressing, hygiene, eating, and mobility) from hospice care. During a review of Resident 6's Minimum Data Set ([MDS] a resident assessment tool), dated 1/16/2024, the MDS indicated Resident 6 had a significant change in status. The MDS indicated Resident 6 did not have any speech, was never/rarely understood, never/rarely understood others, and was severely impaired for daily decision making. The MDS indicated Resident 6 had ROM limitations in both arms and legs and was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for toileting, showering, dressing, personal hygiene, rolling to either side in bed, and chair/bed-to-chair transfers. Resident 6's MDS was signed as complete on 1/30/2024. During a review of Resident 6's care plan review for the significant change in status, the care plan review began on 2/13/2024 and was completed on 3/12/2024. During a review of Resident 6's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 3/5/2024, the OT Evaluation indicated Resident 6 had rigid muscle tone and ROM impairments in both arms, including ROM limitation in both shoulders, both elbows, the left wrist, and the right hand. During a review of Resident 6's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 3/9/2024, the PT Evaluation indicated Resident 6 had ROM impairments in both legs, including ROM limitations in both knees and longstanding plantarflexion (ankle bent with toes pointing away from the body) contractures in both ankles. During a review of Resident 6's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated the RNA (unknown) was trained and provided a good return demonstration of PROM exercises to both arms and application of both arm splints to maintain Resident 6's current ROM and to prevent further contractures. During a review of Resident 6's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated the RNA (unknown) was instructed on proper handling during PROM to maintain Resident 6's ROM. The PT Recommendations included an RNA program (unspecified). During a review of Resident 6's Physician Orders, dated 4/25/2024, the Physician Order indicated for the RNA to perform PROM on both legs, five times per week as tolerated. Resident 6's Physician Orders, dated 5/2/2024, also indicated for the RNA to provide Resident 6 with PROM on both arms, application of the right resting hand splint for four hours, and application of both elbow splints for four hours, five times per week as tolerated. During a review of Resident 6's care plan titled, Restorative Range of Motion (ROM), initiated 4/25/2024, the care plan indicated the RNA would provide PROM to both arms and legs, five times per week as tolerated. During a review of Resident 6's care plan titled, Restorative splinting and/or brace, initiated 7/11/2024, indicated the RNA would apply Resident 6's right resting hand splint and both elbow splints for four hours, five times per week as tolerated with skin checks. During an observation on 11/13/2024 at 9:22 a.m., in Resident 6's room, Resident 6's RNA session was observed. Resident 6 was lying in bed with both shoulders internally rotated (rotated toward the body) and both elbows bent more than 90 degrees, which caused both arms to cross over Resident 6's chest. Restorative Nursing Aide 1 (RNA 1) stood on the left side of Resident 6's bed while RNA 2 stood on the right side of the bed. RNA 2 performed PROM to Resident 6's right arm and applied the right elbow splint. RNA 1 performed PROM to Resident 6's left arm and applied the left elbow splint. RNA 1 stated the right-hand splint had to be cleaned prior to applying to Resident 6's right hand. During a concurrent interview and record review on 11/14/2024 at 12:34 p.m. with the Director of Rehabilitation (DOR), Resident 6's MDS, dated [DATE], was reviewed. The DOR stated Resident 6's MDS was a significant change of condition since Resident 6 was discharged from hospice care on 1/13/2024. The DOR stated the MDS indicated Resident 6 had ROM impairments to both arms and legs. The DOR stated PT and OT were not notified of Resident 6's significant change of condition on 1/13/2024. The DOR stated Resident 6 did not receive any intervention from PT and OT for ROM impairments until the OT Evaluation, dated 3/5/2024. During an interview on 11/14/2024 at 4:22 p.m. with the MDS Coordinator (MDSC), the MDSC stated comprehensive MDS assessments included the admission, annual, and significant change of status. The MDSC stated the care plans (in general) identified and included interventions for a resident's problems or preferences. The MDSC stated a resident's care plan conference (in general) was completed within the week of completing the MDS to keep the resident and family updated regarding the resident's care plan. During a concurrent interview and record review on 11/14/2024 at 4:41 p.m. with the MDSC, Resident 6's MDS, dated [DATE], and IDT notes were reviewed. The MDSC stated Resident 6's significant change of status assessment was completed on 1/16/2024 due to the resident's discharge from hospice care on 1/13/2024. The MDSC stated the MDS indicated Resident 6 had impairments to both arms and both legs. The MDSC reviewed the IDT notes and assessments. The MDSC was unable to locate any IDT notes for Resident 6's significant change of condition. The MDSC stated the IDT should have met with the resident or representative either the week of or the week after Resident 6's significant change assessment (1/13/2024). During a concurrent interview and record review on 11/15/2024 at 12:50 p.m. with the MDSC, Resident 6's care plans were reviewed. The MDSC reviewed all of Resident 6's care plans and was unable to locate any care plans and interventions for Resident 6's ROM limitations from 1/13/2024 (discharge from hospice) to 3/5/2024 (OT Evaluation). The MDSC stated Resident 6's MDS, dated [DATE], was completed on 1/30/2024. The MDSC stated Resident 6's care plans should have been reviewed seven days after the completion of the MDS on 1/30/2024. The MDSC stated Resident 6's care plan review was started late on 2/13/2024 and was completed late on 3/22/2024. During an interview on 11/15/2024 at 1:42 p.m. with the Director of Nursing (DON), the DON stated care plans identified a resident's problems and the interventions for the problem. The DON stated the resident's needs (in general) may not be met if the care plans were not revised. b. During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following a cerebrovascular disease (loss of blood flow to the brain) affecting the left non-dominant side, contracture of the left lower leg, and acquired absence of the right leg above the knee. During a review of Resident 20's MDS, dated [DATE], the MDS indicated Resident 20 had clear speech, understood verbal content, expressed ideas, and wants, and had intact cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 20 had ROM limitations in one arm and both legs. During a review of Resident 20's Physician Orders, dated 2/16/2024, the Physician Orders indicated for the RNA to provide PROM to the left arm, five times per week, and application of the left resting hand splint for four hours, five times per week. Resident 20's Physician Orders, dated 2/19/2024, for RNA to provide PROM to the left leg and application of the left knee splint, five times per week, was discontinued on 9/13/2024. During a review of Resident 20's care plan titled, Restorative Range of Motion (ROM), initiated 2/19/2024, the care plan interventions included for the RNA to provide PROM to the left arm and left leg, five times per week as tolerated. The care plan also included for the RNA to apply a left resting hand splint and the left knee splint for four hours, five times per week. During an interview on 11/13/2024 at 10:10 a.m., with Restorative Nursing Aide 1 (RNA 1), RNA 1 stated Resident 20 received RNA for PROM to the left arm and application of the left-hand splint. RNA 1 stated Resident 20 received PT services for the left leg and application of the left knee splint. During an observation on 11/13/2024 at 10:13 a.m., in Resident 20's room with RNA 1, Resident 20's RNA session was observed. RNA 1 provided PROM to the left arm and applied the left-hand splint. During an observation on 11/13/2024 at 2:19 p.m., in Resident 20's room with Physical Therapist Assistant 1 (PTA 1), Resident 20's PT session was observed. PTA 1 provided manual therapy (skilled hand movements to treatment pain and disability) to Resident 20's left leg and applied the left knee splint. During a concurrent interview and record review on 11/14/2024 at 4:29 p.m., with the MDSC, Resident 20's Restorative (RNA) ROM care plans were reviewed. The MDSC stated Resident 20's care plan included PROM for the left arm and left leg, application of the left-hand splint, and application of the left knee splint. The MDSC stated the Physician Orders for RNA to provide PROM to the left leg and application of the left knee splint was discontinued on 9/13/2024. The MDSC stated the care plan should have been revised when the Physician Orders were discontinued. During a review of the facility's Policy and Procedure (P&P) titled, Care Plan Comprehensive, dated 8/25/2021, the P&P indicated the facility's IDT in coordination with the resident, family, and/or representative must develop and implement a comprehensive person-centered care plan for each resident, including when there was a significant change in the resident's condition. The P&P indicated the comprehensive care plan would be developed within seven days of the resident's MDS completion and would include services provided to attain or maintain a resident's physical well-being.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Administer medications within one hour of their 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: 1. Administer medications within one hour of their prescribed time as per facility's policy and procedure (P&P) titled, Administering Medications, dated 04/2019, affecting two of five residents observed during medication administration (Resident 1 and 228). 2. Accurately account for the administration of a combination medication, hydrocodone (a controlled substance [a medication with a high potential for abuse used to treat pain] and acetaminophen (APAP - a medication used to treat fever and pain) on Controlled Drug Record (CDR- a log signed by the nurse with the date and time each time a controlled substance is given to a resident) affecting one resident (Resident 332) in one out of two inspected medication carts (Medication Cart 3). These failures have the potential to result in hypertension (HTN - high blood pressure), stroke (loss of blood flow to a part of the brain), venous thromboembolism (blood clots in veins) and hospitalization for Residents 1 and 228, and unintended use of Resident 332's hydrocodone-acetaminophen, placing the facility and residents at risk for medication errors, drug misuse and drug diversion. Findings: 1a. During a review of Resident 1's admission Record (a document containing demographic and diagnostic information), dated 11/13/2024, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, acute embolism (a blockage in blood vessel) and thrombosis (blood clotting) of unspecified deep veins of left lower extremity, personal history of transient ischemic attack (a brief episode where blood flow to the brain is temporarily blocked), and cerebral infarction (a condition where blood flow to the brain is blocked) without residual effects, hypertensive (high blood pressure) heart disease without heart failure, anemia (a condition where the body does not have enough healthy red blood cells) and paranoid schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 9/27/2024, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) was moderately impaired. The MDS indicated Resident 1 required setup or clean up assistance for eating and required partial assistance to supervision for some activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as showering, toileting, dressing and oral hygiene. During an observation of medication administration on 11/13/2024 at 10:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered following medications to Resident 1 by 10:46 a.m. 1. one tablet of amlodipine (a medication used to treat high blood pressure) 10 milligrams (mg - a unit of measure for mass) 2. one tablet of Eliquis (Generic name - apixaban, a medication used to prevent cerebrovascular accident [CVA] - stroke, loss of blood flow to a part of the brain) 2.5 miligram (mg unit of measurement). 3. one tablet of ferrous sulfate (a medication used to treat lack of iron) 325 mg 4. one tablet of folic acid (a vitamin B supplement used to treat lack of folic acid) 1000 microgram (mcg - a unit of measure for mass) 5. one tablet of hydralazine (a medication used to treat high blood pressure) 50 mg 6. 17 grams (gm - a unit of measure for mass) polyethylene glycol (a medication used to relieve constipation) dissolved in water 7. one tablet of multivitamin with minerals 8. one tablet of risperidone (a medication used to treat mental disorders) 0.5 mg 9. one tablet of senna S (a combination of sennosides 8.6 mg and docusate sodium 50 mg - used to treat constipation) During a medication reconciliation review on 11/13/2024 at 12:08 p.m., Resident 1's order entry details and Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 11/13/2024 were reviewed. The order details and MAR indicated the scheduled administration time for Resident 1's medications were 9 a.m., which indicated the medications were administered one hour and 46 minutes after the scheduled administration time. 1b. During a review of Resident 228's admission Record, dated 11/13/2024, the admission record indicated Resident 228 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses including but not limited to, end stage renal disease (ESRD - irreversible kidney failure), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) and recurrent major depressive disorder. During a review of Resident 228's MDS, dated [DATE], the MDS indicated Resident 228's cognition was intact. The MDS indicated Resident 228 required partial or moderate assistance for eating and oral hygiene. The MDS indicated Resident 228 was fully dependent or required maximal assistance for toileting, showering and dressing. During an observation of medication administration on 11/13/2024 at 10:57 a.m. with LVN 1, LVN 1 prepared and administered following medications to Resident 228: 1. one tablet of escitalopram (a medication used to treat depression and mood disorders) 10 mg 2. one tablet of multivitamin with minerals 3. one tablet of zinc 50 mg 4. one tablet of amlodipine 5 mg 5. one tablet of hydralazine 25 mg 6. one tablet of risperidone 0.25 mg 7. one milliliter (mL - a unit of measure for volume) or 5000 units of Heparin (a medication used to prevent blood clots) During a medication reconciliation review on 11/13/2024 at 12:08 p.m., Resident 228's order entry details and MAR dated 11/13/2024 were reviewed. The order details and MAR indicated the scheduled administration time for Escitalopram 10 mg was 7 a.m. and for the remaining medications, the scheduled administration time was 8 a.m., which indicated Escitalopram was administered four hours after scheduled administration time and other medications were administered three hours after their scheduled administration time. During an interview on 11/13/2024 at 3:00 p.m. with LVN 1, LVN 1 stated medications for Residents 1, 228 and other residents should have been administered at the prescribed time or within one hour before or one hour after prescribed administration time. LVN 1 stated she usually worked on the other side of the facility and was not completely familiar with residents on this side. LVN 1 stated that there was an increased risk of hypertension, deep venous thrombosis, blood clotting, mood change or agitation and hospitalization for residents when the medications were not administered on time. During an interview on 11/13/2024 at 1:29 p.m. and on 11/14/2024 at 4:41 p.m. with the Director of Nursing (DON), DON stated the medications should have been administered at prescribed time or within one hour before or one hour after prescribed administration time. DON stated if medications for Resident 1, 228 and other residents were administered outside of the one-hour timeframe, then they were considered as late administration. DON stated the facility staff would need to be retrained for order entry because the medication orders that were entered with 7 a.m. and 8 a.m. times were supposed to be entered with 9 a.m. scheduled administration. DON stated late administration of antihypertensive medications, Eliquis and psychotropic medications placed the residents at an increased risk for uncontrolled blood pressure, stroke, thrombosis, clotting, heart complications, mood and behavioral problems, and hospitalization. 2. During a review of Resident 332's admission Record, dated 11/14/2024, the admission record indicated Resident 332 was admitted to the facility on [DATE] with diagnosis including but not limited to, low back pain. During a review of Resident 332's Order Summary Report (a list of all currently active medical orders), dated 11/14/2024, the document indicated the following physician order: Norco Oral Tablet 10-325 mg (generic name - hydrocodone-acetaminophen) give 1 tablet by mouth every 4 hours as needed for severe pain 8-10 do not exceed more than 3 gm of APAP within 24 hours from all sources, hold for respiration rate (RR) less than (<) 12 or sedation, order date 11/7/2024, start date 11/7/2024. During a concurrent observation of Medication cart 3, interview and record review on 11/14/2024 at 1:03 p.m. with LVN 4, Resident 332's medication card / bubble pack for hydrocodone-APAP 10-325 mg, facility's CDR and the medication administration details were reviewed. Resident 332's medication card / bubble pack for hydrocodone-APAP 10-325 mg contained a quantity of 26 tablets remaining. The facility's CDR indicated a quantity of 27 tablets remaining with the last dose administered on 11/13/2024 at 10:22 a.m. The administration details indicated hydrocodone-APAP 10-325 mg for Resident 332 was administered on 11/14/2024 at 8:20 a.m. LVN 4 stated hydrocodone-APAP 10-325 mg was administered to Resident 332 on 11/14/2024 at 8:20 a.m. and the book (CDR) should have been documented and signed immediately after medication was administered. LVN 4 stated there was a possibility of medication error causing underdosing or overdosing of medication, drug misuse, and diversion if the medication was not documented accurately in the book after it was administered to resident. During an interview on 11/14/2024 at 4:31 p.m. with DON, DON stated it was important that LVN 4 documented the controlled drug record immediately after administering the hydrocodone-APAP to ensure that the medication was given. DON stated if the CDR was not documented, it would become questionable if the medication was administered. DON stated by not documenting controlled substances, it increased the risk for medication error, drug misuse, and diversion. During a review of the facility's P&P titled, Administering Medications, dated 04/2019, the P&P indicated, Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). During a review of the facility's P&P titled, Medication Errors, dated 6/28/2022, the P&P indicated, medication error means the administration of medication at the wrong time. During a review of the facility's P&P, titled, Controlled Substances, dated 11/2022, the P&P indicated, The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a) Records of personnel access and usage; b) Medication administration records; c) Declining inventory records; and d) Destruction, waste and return to pharmacy records. The P&P indicated, Controlled substance inventory is monitored and reconciled to identify loss or potential diversion loss/diversion and detection/follow-u

CONCERN (E)

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

Deficiency F0757 (Tag F0757)

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 two of three sampled resident (Resident 25 and 29) was free f...

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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 two of three sampled resident (Resident 25 and 29) was free from unnecessary medication. The facility failed to: a. Ensure Resident 25 continued use of antibiotic was reviewed when Resident 25 did not meet LOEB's criteria (set of guidelines used by healthcare providers in for long term care facilities to determine when a resident likely has a significant infection and needs antibiotics based on symptoms) indicating antibiotic use. This deficient practice of failing to ensure a continued need for antibiotics (medications that fight bacterial infections) increased the risk for Resident 25 to experienced antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) from unnecessary antibiotic use. b. Ensure Resident 29 Tramadol (pain medication) was given according to physician orders. c. Ensure Resident 29 Morphine sulfate (pain medication) was given according to physician orders. These failures had the potential to put Resident 29's safety at risk when not following the medication parameter (ensures medications are given correctly) orders for administering pain medications. Findings: a. During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility 4/19/2022 with diagnoses including diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing) and cerebral infarction (a part of the brain has been damaged because it wasn't getting enough blood supply). During a review of Resident 25's Minimum Data Set ([MDS]- a resident assessment tool), the MDS indicated Resident 25 had moderate cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent with bathing, toileting, and transferring. During a review of Resident 25's Antibiotic Surveillance Data Collection dated 10/17/2024, the Antibiotic Surveillance Data Collection indicated Resident 25 did not have the LOEB's criteria (set of guidelines used by healthcare providers in for long term care facilities to determine when a resident likely has a significant infection and needs antibiotics based on symptoms) indicating antibiotic use. During a concurrent interview and record review on 11/15/2024 at 9:32 a.m., with the Infection Prevention Nurse (IPN), the IPN stated Resident 25 was prescribed Ciprofloxacin (medication to treat a bacterial infection) but did not meet the LOEBS criteria. IPN stated Resident 25 was prescribed Keflex (medication to treat infection) from 10/17/24 to 10/24/2024 and then Ciprofloxacin from 10/29/2024 to 11/5/2024. IPN stated she spoke with Resident 25's primary physician that ordered the antibiotic and he still wanted the resident to receive the Ciprofloxacin despite not meeting the criteria. IPN stated she did not reach out to the facility's Medical Director (MD), and should have done so, to inform him Resident 25 did not meet the criteria for antibiotic use. During an interview on 11/15/2024 at 12:17 a.m., with the Director of Nursing (DON), the DON stated Resident 25 should not have been prescribed Ciprofloxacin because he did not meet the LOEBS criteria. The DON stated the MD should have been involved. The DON stated unnecessary medications like use of antibiotics can cause antibiotic resistance. During a review of the facility's policy and procedure (P&P) titled, Medication Utilization and Prescribing- Clinical Protocol, revised April 2018, the P&P indicated, When a medication is prescribed for any reason, the physician and staff will identify the indications, considering the residents age, medical conditions, risks, health status, and existing regimen. A diagnosis by itself may not be sufficient justification for prescribing a medication. The existence of a condition or risk does not necessarily require a treatment and the treatment may be something besides, or in addition to, medication. The physician will participate in the facility's antibiotic stewardship protocols, including documentation of the clinical criteria for infection and laboratory reports of susceptibility, if necessary, when an antibiotic is ordered. Cross Refernce F881 b. During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE] with the diagnoses including major depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), diabetes type 2 (DM a disorder characterized by difficulty in blood sugar control and poor wound healing), and anxiety (feels of worry or fear). During a review of Resident 29's MDS, dated [DATE] indicated Resident 29 has severe cognitive impairment. During a review of resident 29's History and Physical, dated 6/19/2024 indicated Resident 29 does not have the capacity to understand and make decisions. During a review of Resident 29's Physician Order Summary Report dated 11/15/2024 indicated Resident 29 had orders to monitor pain level every shift using the pain rating scale (a tool that helps people measure their pain so that doctors can plan treatment and monitor its effectiveness) one to four for mild pain, five to seven for moderate pain and eight to 10 for severe pain. Resident 29 had orders for acetaminophen 650 milligram (mg unit of measurement) insert one suppository rectally every six hours as needed for one to four for mild pain, do not exceed more than 3 grams of acetaminophen within 24 hours. Resident 29 had orders for Tramadol oral tablet 50 mg one tablet by mouth at bedtime for pain and tramadol oral tablet 50 mg one tablet by mouth every 6 hours as needed for five to seven for moderate pain. Resident 29 had orders for Morphine Sulfate oral solution 100mg/5 milliliter (ml-unit of measurement) give 0.25 ml sublingually (under the tongue every two hours as needed for moderate to eight to 10 for severe pain. During a review of Resident 29's Medication Administration Record (MAR) dated 11/15/24, the MAR indicated that on 11/2/2024 Resident 29 was given Tramadol 50 mg by mouth for a pain level of three (mild pain), and on 11/5/24 Resident 29 was given Tramadol 50mg by mouth for a pain level of four (mild pain). On 11/1/2024, 11/6/2024 ,11/7/2024 and 11/13/2024. Resident 29 received Morphine 0.25 ml sublingual on for a pain level of zero. On 11/12/24, and 11/13/24 Resident 29 was given Morphine 0.25 ml for a pain level of three (mild pain). On 11/8/24 Resident 29 received Morphine 0.25ml for a pain level of five (moderate pain). During a concurrent interview and record review on 11/15/2024. at 10:08 a.m., with Assistant Director of Nurses (ADON), reviewed Resident 29's MAR for 11/2024. The ADON stated Resident 29 should not have been given tramadol or morphine on 11/5/24, 11/1/2024, 11/6/2024 ,11/7/2024, 11/8/2024, 11/12/2024 and 11/13/2024. The ADON stated licensed nurses did not follow Resident 29's physician orders when Resident 29 received pain medication for the documented pain levels. The ADON stated resident was at risk for overdose when giving pain medication for the wrong indications. During a concurrent interview and record review on 11/15/2024 at 10:18 a.m., with the Director of Nurses (DON), reviewed Resident 19's MAR for 11/2024. The DON stated that licensed nurses should not have given the Tramadol or Morphine for those documented pain levels on those specific dates. The DON stated that licensed nurses did not follow Resident 29's physician orders when the pain medications were given not according to Resident 29 pain level. The DON stated that Resident 29 was at risk for possible adverse side effects of the medications when not following physician orders. During a review of the facilities policy and procedure (P&P) titled Administering Medications dated 4/2019, indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the 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

Based on observation, interview, and record review, the facility failed to: 1. Ensure Insulin Lispro prefilled pens [a type of insulin (a hormone that removes excess sugar from the blood, can be produ...

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Based on observation, interview, and record review, the facility failed to: 1. Ensure Insulin Lispro prefilled pens [a type of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) delivered via injection device] were stored and/or labeled in accordance with manufacturer's specifications and facility's policy and procedure (P&P) titled Medication Labeling and Storage, dated 02/2023 affecting two residents (Resident 4 and 62) in one of two inspected medication carts (Medication Cart 3). 2. Ensure a single dose vial of Retacrit (generic name - epoetin alfa-epbx, a medication used to treat anemia (a condition where the body does not have enough healthy red blood cells) was removed and/or discarded after being opened in accordance with manufacturer's specifications affecting one resident (Resident 50) in one of two inspected medication carts (Medication Cart 3). These failures have the potential to result in Residents 4, 50 and 62 receiving medications that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications such as hyperglycemia (high blood glucose [simple sugar- the body's primary source of energy from food]) and anemia. Findings: 1. During an observation and inspection on 11/14/2024 at 12:06 p.m. of Medication Cart 3 with Licensed Vocational Nurse (LVN) 4, the following medications were found stored under a different medication label and/or labeled with two different opened dates, which was not in accordance with manufacturer's requirements: 1a. Insulin Lispro 100 units (a unit of measurement for insulin) / milliliters (mL - a unit of measure for volume) prefilled pen for Resident 62 labeled with two different opened dates. The label on outer bag containing insulin lispro prefilled pen indicated opened date of 11/22/2024. The label on insulin lispro prefilled pen inside the bag indicated opened date of 11/12/2024. 1b. Two Insulin Lispro 100 units/mL prefilled pens for Resident 4 inside one bag that was labeled with a different medication name for Resident 4. The label on outer bag indicated Basaglar (Generic name - Insulin Glargine) KwikPen 100 units/mL for Resident 4 with an opened date of 10/23/2024. The bag contained two insulin lispro prefilled pens with two different opened dates: One insulin lispro prefilled pen inside the bag for Resident 4 indicated an opened date of 10/31/2024. One insulin lispro prefilled pen inside the bag for Resident 4 indicated an opened date of 10/30/2024. According to the manufacturer's product labeling, once opened / in-use or once stored at room temperature, below 86-degree Fahrenheit [(°F) is a unit of temperature] (30-degree Celsius [(°C) is a unit of temperature], insulin lispro and Basaglar prefilled pen must be used within 28 days or be discarded. During a subsequent interview on 11/14/2024 at 12:06 p.m. with LVN 4, LVN 4 stated the insulin lispro for Resident 62 was labeled with two different opened dates for insulin lispro prefilled pen. LVN 4 stated this could lead to confusion and misunderstanding, so should have been labeled better. LVN 4 stated she needed to take a break. During a subsequent interview on 11/14/2024 at 12:06 p.m. with Minimum Data Set Coordinator (MDSC) and LVN, MDSC stated, there was no risk for medication error for Resident 62 and Resident 4 because she would look at the electronic medical administration record (eMAR) not the outer bag label before administering medication. MDSC stated the LVNs were supposed to follow the order on eMAR and so did not see how this could lead to a medication error. During an interview on 11/14/2024 at 4:13 p.m., with Director of Nursing (DON), DON stated, the LVN was getting defensive, and it was a bad practice when the label on outer bag was labeled with a different medication name than the labels on the pens stored inside the bag. DON stated this practice could lead to a medication error causing abnormal blood glucose levels and hospitalization because different LVNs could interpret the medication labels and doses differently. 2. During an observation and inspection on 11/14/2024 at 12:30 p.m. of Medication Cart 3 with LVN 4, the medication cart contained an opened single dose vial of Retacrit 4,000 units/mL for Resident 50 with no open date and/or expiration date documented on the vial, which was not in accordance with manufacturer's requirements. According to the manufacturer's product labeling, Retacrit 4,000 units/mL single dose vial should be stored refrigerated at 2°C to 8°C (36°F to 46°F). During an interview on 11/15/2024 at 10:33 a.m. with LVN 4, LVN 4 stated the last administration of Retacrit to Resident 50 was on 11/11/2024. LVN 4 stated the single dose vial should have been discarded after it was opened and used otherwise Retacrit should be stored in the refrigerator if not in use. LVN 4 stated if the remaining medication from the opened vial was used, or if medication was not administered, there was a risk that Resident 50's hemoglobin (Hgb - a protein in red blood cells that carries oxygen throughout the body) could drop, leading to blood transfusion and hospitalization. During an interview on 11/15/2024 at 12:54 p.m. with DON, DON stated Retacrit single dose vial was supposed to be stored in the refrigerator until it was opened. DON stated single dose vial should be discarded after it was opened. DON stated there was a risk of anemia and would not improve Resident 50's hemoglobin if the improperly stored Retacrit was administered to the resident. During a phone interview on 11/15/2024 at 12:19 p.m. with pharmacist (RPH) 1 at pharmacy (PH) 1, RPH 1 stated pharmacy would not and did not store multiple different medications requiring refrigeration in one bag with a different medication's pharmacy label. RPH 1 stated if the product was an insulin vial and/or pen, there would be a separate small label on vial and/or pen indicating resident name and there would be a pharmacy label on the outer bag matching details of the product inside the bag. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 02/2023, the P&P indicated, Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received .only the issuing pharmacy is authorized to transfer medications between containers. The P&P indicated, labeling of medications and biologicals dispensed by the pharmacy is consistent with and currently accepted pharmaceutical practices. The P&P indicated, The medication label includes .expiration date, when applicable .precautions. The P&P indicated, multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days .shorter or longer date for the open vial.

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 implement infection control practices to prevent the s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement infection control practices to prevent the spread and transmission of infection. The facility failed to: a. Ensure hand hygiene was performed at appropriate times during a gastrostomy tube ([GT]- a tube inserted through the wall of the abdomen directly into the stomach) site dressing change for Resident 6. b. Observe Contact Precautions ( are set of safety measures used when a resident has a disease that can be spread thru contact with the patient or patient's environment) before entering Resident 22's room who had a methicillin resistant staphylococcus aureus ( MRSA-type of bacterial infection that is resistant to many antibiotics) and Candida Auris(C. Auris- type of yeast or fungus that can cause serios infections and are difficult to treat because it is resistant to many antifungal medications). c. Ensure laundry staff performed hand hygiene (any action of hand cleansing) and used Personal Protective Equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) including a gown, polyvinyl chloride (PVC) dipped gloves (gloves that offer more durability and chemical resistance), and eye protection with a face shield or goggles while handling soiled linen. d. Ensure clean linen was fully covered during transport to the clean linen carts located in the facility's hallways. These failures had the potential to result in the spread of diseases and infection to the facility staff, residents, and visitors. Findings: a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including epilepsy (abnormal electrical activity in the brain marked by sudden, recurrent episodes of loss of consciousness or uncontrolled body shaking), dementia (a progressive state of decline in mental abilities), dysphagia, contracture of muscles in both lower legs, and stiffness in the left shoulder, right elbow, wrist (unspecified), and right hand. During a review of Resident 6's Minimum Data Set (MDS- resident assessment tool), dated 10/16/2024, the MDS indicated Resident 6 did not have any speech, was never/rarely understood, never/rarely understood others, and was severely impaired for daily decision making. The MDS indicated Resident 6 was dependent (helper does all of the effort or the assistance of two or more helpers is required for the resident to complete the activity) for toileting, showering, dressing, personal hygiene, rolling to either side in bed, and chair/bed-to-chair transfers. During a review of Resident 6's Physician Order Summary Report, the Order Summary Report indicated an order was placed on 10/1/2020 for gastrostomy tube ([GT]- a tube inserted through the wall of the abdomen directly into the stomach) care, to cleanse daily with normal saline, pat dry and cover with a T-drain sponge (type of dressing) then secure with tape. During a review of Resident 6's care plan titled Risk for skin infection and skin breakdown initiated 9/17/2024, the care plan interventions for Resident 6 included monitoring for signs and symptoms (s/s) of infection. During an observation on 11/12/2024 at 2:46 p.m., in Resident 6's room, Treatment Nurse (TN) 1 was observed changing a GT dressing without performing hand hygiene after removing the dirty dressing and cleaning the site and before applying the clean dressing to the gastrostomy tube site. During an interview on 11/12/2024 at 3:08 p.m., with TN 1, TN 1 stated she did not perform hand hygiene after handling the dirty dressing and before applying the clean dressing to the gastrostomy tube site. TN 1 stated she should have performed hand hygiene for infection control and not doing so could cause Resident 6 to develop an infection. During an interview on 11/15/2024 at 12:15 p.m., with the Director of Nursing (DON), the DON stated hand washing should occur when changing a dressing, between handling the dirty and clean dressing. The DON stated, if hand washing does not occur, it could cause cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and lead to an infection for the resident. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 9/19/2023, the P&P indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors and the use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. b. During a review of Resident 22's admission Record, the admission Record indicated Resident 22 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease(COPD- group of lung diseases that block airflow and makes it difficult to breathe),end stage renal disease(ESRD-irreversible kidney failure), spinal stenosis( narrowing of spinal column that puts pressure on the spinal cord and nerve roots), and diabetes mellitus(DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 22's MDS dated [DATE], the MDS indicated Resident 22 had an intact cognition (ability to think, understand, learn, and remember) and required substantial/ maximal assistance (helper does more than half the effort) with toileting hygiene, chair/bed transfer. During a review of Resident 22's Care Plan titled Actual infection of multidrug resistant organism (MDRO-microorganism that is resistant to a lot of antibiotics and antifungals and difficult to treat) such as C. Auris and MRSA initiated on 8/2024 and revised on 11/15/2024, the Care Plan's interventions included maintaining Contact Precautions. During a review of Resident 22's General Acute Hospital Record (GACH) laboratory Results, GACH Records indicated Resident 22 had MRSA on the wound dated 10/17/2024 and C. Auris in the urine dated 4/17/2024. During a concurrent observation and interview on 11/14/2024, at 12:21 p.m., in Resident 22's room, observed Maintenance Supervisor (MS) and [NAME] President Resource (VPR) entered Resident 22's room without wearing a Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and practiced hand hygiene after leaving the room. VPR stated she did not look at the Contact Precaution signage posted on the door and was checking the curtains of Resident 22's room. VPR stated if the resident was on Contact Precautions, PPE should be worn. During an interview on 11/15/2024, at 12:27 p.m. with Director of Nursing (DON), the DON stated Resident 22 was on dialysis and had a dialysis catheter. The DON stated Resident 22 was on Vancomycin (antibiotic used to treat MRSA) during dialysis and verified through record review of Resident 22's electronic chart Resident 22 was on Contact Precautions. The DON stated the staff should practice hand hygiene, wear PPE such as gown, gloves, and mask before entering resident's room and then discard the PPE inside the room and wash hands before leaving the room to prevent spread of infection. During a concurrent interview and record review on 11/15/2024, at 2:13 p.m. with Infection Preventionist Nurse (IPN), reviewed Resident 22's GACH records. IPN stated Resident 22 was on Contact Precautions for an actual MRSA and extended spectrum beta-lactamase (ESBL- enzyme produced by some bacteria making them resistant to many antibiotics and are difficult to treat) infection. IPN verified thru record review Resident 22 had MRSA infection from a wound culture. IPN stated the staff should perform hand hygiene, wear gown, gloves, and mask before entering the resident's room and should remove the PPE inside the room and perform hand hygiene. IPN stated it was important to observe and practice contact precautions to prevent the spread of the infection throughout the facility. During a review of facility's P&P titled Isolation-Categories of Transmission -Based Precautions revised 9/2022, the P&P indicated Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. The P&P indicated staff and visitors wear gloves, disposable gowns upon entering the room and remove before leaving the room. c. During an observation on 11/15/2024 at 10:28 a.m., in soiled linen area of the laundry room, Laundry Assistant 1 (Laundry 1) wore a long-sleeve gown and nitrile gloves (typical medical gloves) to place soiled linen from a gray bin into the washer. Laundry 1 was observed removing dirty incontinence briefs from the soiled linen and placed them into the trash can. Laundry 1 did not wear any eye protection. Laundry 1 removed the long-sleeve gown overhead since it was fastened loosely around the neck and hung it on a hook next to the washer. Laundry 1 threw away both nitrile gloves into the trash can. Laundry 1 did not perform hand hygiene prior to putting on another pair of nitrile gloves. Laundry 1 left the soiled laundry area pushing the gray bin, which had wheels attached to the bottom, toward the back exit door. Laundry 1 exited the facility into the back parking lot where multiple soiled linen carts were observed. Laundry 1 removed the plastic bags from the soiled linen carts, tore the bags open, and dumped the soiled linen into the gray bin. Laundry 1 placed new plastic bags into the soiled linen cart. Laundry 1 did not perform hand hygiene after dumping the soiled linen into the gray bin and prior to placing new bags into the soiled linen carts. Laundry 1 pulled the gray bin back into the facility and entered the soiled linen area of the laundry. Laundry 1 removed both nitrile gloves and washed hands in the sink. Laundry 1 put on a new pair of nitrile gloves, placed the tied portion of the long-sleeve gown overhead, and placed both arms in the sleeves of the gown. Laundry 1 did not tie the back of the long-sleeve gown around the waist. Laundry 1 removed the soiled linen from the gray bin and placed them into the washer. Laundry 1 was observed removing incontinence briefs from the soiled linen and placed them in the trash can. Laundry 1's gown was observed moving forward from Laundry 1's body as Laundry 1 reached deeper into the gray bin. Laundry 1 removed the long-sleeved gown and placed it in the washer along with the soiled linen. Laundry 1 placed the nitrile gloves in the trash can and started the washing machine. During an interview on 11/15/2024 at 10:43 a.m. with Laundry 1, Laundry 1 stated the soiled linen was sorted inside the soiled linen room, including placing soiled incontinence briefs into the trash. Laundry 1 stated the long-sleeve gown was worn to prevent the soiled linen from touching Laundry 1's clothes. Laundry 1 stated she did not wear the long-sleeve gown in the back outside parking lot because the soiled linen was transferred from soiled linen bags into the gray bin. During an interview on 11/15/2024 at 2:24 p.m. with the Director of Nursing (DON), the DON stated the laundry staff needed to tie the gown around the waist to prevent the gown from moving. During an interview on 11/15/2024 at 2:26 p.m. with the Environment Services Supervisor (ESS) and the Environmental Services Regional Consultant (ESRC), the ESS stated Laundry 1 should have worn a long-sleeve gown when moving the soiled linen from the bags to the gray bin in the back outside parking lot. The ESS showed the PVC dipped gloves, eye goggles, and disposable face shields which were in plastic drawers in the soiled linen area. The ESRC stated the laundry staff needed to wear the eye protection, gown, and PVC dipped gloves to prevent injury from potentially sharp objects and for infection control while sorting soiled linen. During a review of the facility's P&P titled, Laundry Initiative Module 2: The Six-Step Laundry Process, revised 8/2024, the P&P indicated laundry staff should ensure use of the proper PPE while sorting soiled linen, including PVC dipped gloves, neoprene apron, and face shield. The P&P also indicated to always dump the [soiled linen] bag into a bin or barrel to sort the linen and remember to always use the proper PPE. d. During an observation on 11/15/2024 at 8:26 a.m. in the clean linen area of the laundry room, Laundry 1 placed folded blankets from the folding table and placed in them in a wired laundry basket with wheels and exited the clean laundry area to deliver them to the clean linen carts. During an observation on 11/15/2024 at 12:00 p.m., in the hallway, Laundry 1 was observed transporting clean linen to a linen cart in the hallway using the wired laundry basket. The wired laundry basket was observed to have a metal clothing rack with metal bars attached to both sides of the laundry basket. There was a sheet covering the clean linen, but the sides of the wired cart were not covered, allowing the clean linen to be visible. During an interview on 11/15/2024 at 2:26 p.m. with the ESS and ESRC, the ESS stated the laundry staff used the wired basket to deliver clean linen to carts in the hallway during the afternoon. The ESS stated the clean linen should be covered with a sheet during transport from the clean linen room to the hallway. The ESRC stated the sides of the wired cart would be exposed despite being covered with the sheet due to the presence of the metal bars. The ESRC stated the clean linen should be fully covered for infection control purposes. During a review of the facility's P&P titled, Laundry Initiative Module 2: The Six-Step Laundry Process, revised 8/2024, the P&P indicated All clean linen must be covered using a clean cover during deliver to prevent potential cross contamination.

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: a.Ensure an open container of apple sauce had an open date and a use by date on the container. b.Ensure an open container of be...

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Based on observation interview and record review the facility failed to: a.Ensure an open container of apple sauce had an open date and a use by date on the container. b.Ensure an open container of beef base had an open date and a use by date on the container. c.Ensure frozen chicken tenders that were stored in a Ziploc bag had an open date and a use by date on the bag. d.Ensure that pork was defrosted safely, when pork was left in a bowl of standing water while defrosting in the sink. These failures had the potential to expose residents to a food-borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites). Findings: a. During an interview on 11/15/2024 at 2:15 p.m., with the Dietary Aide (DA) the DA stated all opened food container must have an open date and use by date on the container, so staff would know when the food was no longer good to use. DA stated there was a potential for a food born illness if food was used after the expiration date. During a concurrent observation and interview on 11/12/2024. at 8:05 a.m., with Dietary Manager (DM), DM stated that the apple sauce, beef base and frozen chicken tenders did not have an open date or use by date on the containers. DM stated that all food that was opened must have an open date and use by date on the container. DM stated, staff need to know the correct open date, without that date the staff won't be able to know how old the food was. DM stated that there was a possibility for of a food born illnesses when expired foods are served to the vulnerable residents. During an interview on 11/15/2024 at 9:05 a.m., with the Director of Nurses (DON), the DON stated that open dates and use by dates must be on all food that was opened, to ensure food was fresh and not expired. The DON stated there was a possibility for bacteria to grow and that the residents are at risk for a food born illnesses when served with expired foods. b. During an interview on 11/15/2024 at 8:37 a.m., with the Cook, the [NAME] stated that when defrosting pork in the sink the cold water must be running on the meat until just before cooking it. The [NAME] stated that meat should never be left in standing water because there was a possibility for bacteria to grow on the food and the residents could get sick. During a concurrent observation and interview on 11/12/2024. at 8:05 a.m., with Dietary Manager (DM), the DM stated she put the pork in the sink in the morning (11/12/2020242024) to defrost it. DM stated that she had turned on the cold water and that someone must have turned the water off. The DM stated that when defrosting pork in the sink, cold water must always run on the pork. DM stated if there was no cold water running on the pork the meat could heat up to the food temperature danger zone were bacteria starts to grow. DM stated that residents are at risk for a food born illnesses when not defrosting meat properly. During an interview 11/15/2024 at 9:05 a.m., with the Director of Nurses (DON), the DON stated, that the right way to thaw out pork was to have cold water running on it while it was defrosting. The DON stated that bacteria could grow on the pork if not defrosted properly and the residents are at risk for a food born illnesses. During a review of the facilities policy and procedure (P&P) titled Receiving dated 2/2023 indicated, safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. All food items will be stored in a manner that ensures appropriate and timely utilization based on the principles of first in- first out (FIFO) inventory management. During a review of the facilities P&P titled Food Preparation dated 2/2023 indicated, All foods are prepared in accordance with the Food Drug Administration Food Code. The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: Thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross-contamination. Thawing the item in a microwave oven, then transferring immediately to conventional cooking equipment. Completely submerging the item under cold water (at a temperature of 70° For below) that is running fast enough to agitate and float off loose ice particles. Cooking directly from the frozen state, when directed.

Sept 2024 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Resident Rights (Tag F0550)

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 ensure a resident, who refused to be placed back to b...

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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 resident, who refused to be placed back to bed, did not sustain an injury, when a Certified Nursing Assistant (CNA 1) picked her up and placed her in bed against the resident wishes, for one of four sampled residents (Resident 2). The facility failed to: 1. Ensure CNA 1 honored Resident 1's decision not to go back to bed and did not force the resident against her wishes back to bed by holding her tightly, which resulted in Resident 1 becoming combative as she resisted CNA 1's attempt to place her back to bed. 2. Ensure CNA 1 and Registered Nurse Supervisor 1 (RNS 1) followed the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, which indicated if a resident resist or refuses care, staff will consider approaching the resident in a different way or at a different time or having another staff member speak with the resident. 3. Ensure CNA 1 and RNS 1 followed the facility's P&P titled, Requesting, Refusing and/or Discontinuing Care or Treatment, which indicated residents have the right to refuse and/or discontinue treatment and is not forced to accept any care or treatment. These failures resulted in Resident 2 becoming combative, when she was forced into bed against her wishes, while being held tightly by CNA 1, and sustaining bruises on her mid right forearm and right hand, and a skin tear on her right hand by the thumb, that measured approximately 2.0 centimeters ([cm] a unit of measurement) long. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included functional quadriplegia (the complete inability to move due to severe disability but without injury to the brain or spial cord), spinal stenosis (a narrowing of the spinal canal in the lower back that can put pressure on the spinal cord and nerves) of the lumbar region, a displaced traverse fracture of the shaft of the right tibia (a break in the shinbone where the bone pieces moved out of alignment, creating a gap), a displaced fracture of the lateral condyle of the left tibia (a break in the bone on the outside of the shin near the knee), and neuromuscular dysfunction of the bladder (when a problem in your brain, spinal cord, or central nervous system causes loss of bladder control). During a review of Resident 2's Minimum Data Set ([MDS] a Federal mandated assessment tool), dated 7/18/2024, the MDS indicated Resident 2's cognition (thinking) was intact, she had the ability to understand others, and could make herself understood. The MDS indicated Resident 2 required substantial maximum assistance rolling left to right, sitting to lying down, lying down to sitting and lying down to sitting on the side of the bed. During a review of Resident 2's History and Physical (H&P), dated 9/6/2024, the H&P indicated Resident 2 had a fluctuating capacity to make decisions. During a review of Resident 2's Progress Notes, dated 9/10/2024, the Progress Notes indicated, at 9:25 p.m., CNA 1 attempted to put Resident 2 into bed several times because it was getting late but Resident 2 refused to go to bed. The Progress Notes indicated Resident 2 did not want CNA 1 to use a sling (a device that is attached to a mechanical lift [a device operated by a motor used to move a client from one position or place to another] used to move a patient from one surface to another) to assist with putting her in bed. The Progress Notes indicated when CNA 1 carried Resident 2 to the bed, Resident 2 suddenly bit CNA 1 on his arm, yelled, pulled on her indwelling urinary catheter (a thin hollow tube that is inserted into the bladder to drain urine), and struggled not to go to bed, which was when a skin tear was found on Resident 2's right wrist. During an interview on 9/24/2024, at 3:50 p.m., CNA 1 stated Resident 2 was usually transferred to bed via a mechanical lift, and she had a behavior of screaming. CNA 1 stated on 9/10/2024 around 10:30 p.m., Resident 2 was soiled, she did not want to go to bed, and she did not want the mechanical lift used to put her in bed. CNA 1 stated, he picked up Resident 2 to put her into bed but acknowledges he could have left Resident 2 in the geriatric chair ([Geri chair] a large, padded reclining chair that provides support and comfort for people with limited mobility) she was sitting in, but his shift was almost over and he did not want to leave Resident 2 wet and sitting in the Geri chair, which would have made Resident 2's family upset. During an interview on 9/24/2024, at 4:32 p.m., RNS 1 stated after dinner, around 7 p.m., (9/10/2024) she told CNA 1 to put Resident 2 back to bed and Resident 2 yelled No, I don't want to go to bed. RNS 1 stated she again asked Resident 2 to go to bed at 8 p.m., 9 p.m., and 10 p.m., but Resident 2 yelled and screamed because she did not want CNA 1 to use the mechanical lift to transfer her to the bed. RNS 1 stated CNA 1 stood in front of Resident 2, who was sitting in a Geri chair, and picked her up to place her into bed, that was when Resident 2 bit CNA 1 on his arm. RNS 1 stated, she observed Resident 2 with a skin tear on her right hand by the thumb, that measured approximately 2.0 cm long, and bled a little bit. RNS 1 stated they should have left Resident 2 in the Geri chair and called Resident 2's family member (FM 1), who could have spoken to Resident 2 to convince her to go to bed, or they could have come back later to try again and documented Resident 2's refusal of care in the resident's Progress Notes and care plan. During an observation and concurrent interview on 9/25/2024, at 10:50 a.m., at the GACH where Resident 2 was transferred on 9/20/2024 for an unrelated event, Resident 2 was observed with a purple discoloration on her right hand and mid right forearm. Resident 2 stated, on 9/10/2024 CNA 1 lifted her from the Geri chair she was sitting in to put her in bed even though she did not want to go to bed. Resident 2 stated she kept telling CNA 1 No!! No!! Resident 2 stated she wanted CNA 1 to use the mechanical lift to transfer her back to bed. Resident 2 stated, CNA 1 would not listen to her and kept coming towards her. Resident 2 stated, she yelled at him, saying she did not want to go to bed, and finally she just gave up. Resident 1 stated when CNA 1 lifted her from the Geri chair he squeezed her arms really hard. Resident 2 stated RNS 1 was there and told CNA 1 to put her (Resident 2) into bed. Resident 2 stated she felt no protection from RNS 1 and could see people in the hallway pass by as she yelled for help, and no one stopped to see if she was ok or ask CNA 1 what was he doing? Resident 2 stated this went on for about 20 to 30 minutes, she stated she was afraid of CNA 1, she no longer felt safe at the facility, and did not want to return there because it was the worst thing that ever happened to her. During an interview on 9/25/2024, at 3:34 p.m., the Director of Staff Development (DSD) stated if a resident refused to use a mechanical lift or refused any care, the CNAs (in general) were expected to stop, explain to the resident the reason care was needed and if the resident still refused, CNAs were instructed to report the refusal of care to the charge nurse, come back later and try again. The DSD stated the nurses could have called the family member to ask them to talk to the resident. During an interview on 9/25/2024, at 4:54 p.m., the Director of Nursing (DON) stated, on 9/10/2024 at around 9 a.m., she checked on Resident 2 and saw that Resident 2 had discoloration on both of her hands, the discoloration had had always been there but stated it seemed more pronounced than usual, but stated there was no swelling, or complaints of pain, and Resident 2 had full range of motion (the amount of movement a joint can make when its flexed, extended, and rotated) to both of her wrist and hands. The DON stated, there was a dressing around Resident 2's right wrist that was not there before the skin tear that Resident 2 sustained. The DON stated, she was told that Resident 2 did not want to go to bed, and she (Resident 2) did not want to be transferred without the mechanical lift, and staff should have let Resident 2 remain in her Geri chair, come back later, call Resident 2's family and/or Resident 2's physician if she (Resident 2) continued to refuse care. During a review of the facility's P&P, titled, Activities of Daily Living (ADLs), Supporting, dated 3/2018, the P&P indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). The P&P appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). If a resident resist or refuses care, staff will attempt to identify the underlying cause of the behavior and consider approaching the resident in a different way or at a different time or having another staff member speak with the resident. The resident's response to interventions will be monitored, evaluated, and revised as appropriate During a review of the facility's P&P, titled Requesting, Refusing and/or Discontinuing Care or Treatment, dated 2/2021, the P&P indicated, residents and resident representatives have the right to refuse and/or discontinue treatment. The resident is not forced to accept any care or treatment and may refuse or discontinue care or treatment at any time. This includes care or treatment prescribed by a physician, care or treatment that has been administered previously, and/or care or treatment that the resident previously agreed to but has not yet been administered. Documentation pertaining to a resident's request, discontinuation or refusal of treatment includes at least the following, the date and time the care or treatment was attempted, the type of care or treatment, the resident's response and stated reasons for request, discontinuation or refusal, and that the resident is informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/ treatment.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan was developed that addressed the behaviors of ye...

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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 care plan was developed that addressed the behaviors of yelling, screaming and refusal of care for one of four sampled residents (Resident 2). This deficient practice resulted in Resident 2's care needs not being addressed and had the potential for non-continuity of care. Findings: During a review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included functional quadriplegia (the complete inability to move due to severe disability but without injury to the brain or spial cord), spinal stenosis (a narrowing of the spinal canal in the lower back that can put pressure on the spinal cord and nerves) of the lumbar region, a displaced traverse fracture of the shaft of the right tibia (a break in the shinbone where the bone pieces moved out of alignment, creating a gap), a displaced fracture of the lateral condyle of the left tibia (a break in the bone on the outside of the shin near the knee), and neuromuscular dysfunction of the bladder (when a problem in your brain, spinal cord, or central nervous system causes loss of bladder control). During a review of Resident 2's Minimum Data Set ([MDS] a Federal mandated assessment tool), dated 7/18/2024, the MDS indicated, Resident 2's cognition (thinking) was intact, she had the ability to understand others, and could make herself understood. The MDS indicated Resident 2 required substantial maximum assistance rolling left to right, sitting to lying down, lying down to sitting and lying down to sitting on the side of the bed. During a review of Resident 2's History and Physical (H&P), dated 9/6/2024, the H&P indicated Resident 2 had a fluctuating capacity to make decisions. During a review of Resident 2's Progress notes, dated 9/10/2024, the Progress notes indicated, at 9:25 p.m., Certified Nurse Assistant 1 (CNA 1) attempted to put Resident 2 into bed several times because it was getting late, but Resident 2 refused to go to bed. The Progress notes indicated Resident 2 did not want CNA 1 to use a sling (a device that is attached to a mechanical lift [a device operated by a motor used to move a client from one position or place to another] used to move a patient from one surface to another) to assist with putting her in bed, but instead wanted CNA 1 to carry her to the bed. The Progress notes indicated when CNA 1 carried Resident 2 to the bed, Resident 2 suddenly bit CNA 1 on his arm, yelled, pulled on her indwelling urinary catheter (a thin hollow tube that is inserted into the bladder to drain urine), and struggled not to go to bed, which was when a skin tear was found on Resident 2's left wrist. During a review of Resident 2's clinical record, the clinical record indicated there was no Care Plan developed that addressed Resident 2's behavior of yelling and screaming or her refusal to be transferred using a mechanical lift. During an interview on 9/24/2024, at 4:32 p.m., after reviewing the Care Plan section of Resident 2's clinical record, Registered Nurse Supervisor 1 (RNS 1) stated there was no Care Plan created to address Resident 2's behavior of yelling and screaming or her refusal to be transferred using a mechanical lift and a Care Plans should have been developed so that Resident 2's care needs were addressed During a concurrent interview and record review on 9/25/2024, at 4:54 p.m., with the Director of Nursing (DON), Resident 2's Care Plans were reviewed. The DON, after reviewing Resident 2's clinical records, stated there was no care plan available for Resident 2's behavior of yelling, and screaming and her refusal to use the mechanical lift. The DON stated the purpose of creating a care plan is to identify Resident 2's behaviors so that goals can be set, and interventions developed and implemented to assist with Resident 2's care. During a review of the facility's policy and procedure (P&P), titled, Care Plan Comprehensive, dated 8/5/2021, the P&P indicated, each resident's comprehensive care plan is designed to: a. incorporate identified problem areas, b. incorporate risk and contributing factors associated with identified problems, c. build on the resident's individualized needs, strengths, and preferences, e. reflect the resident's expressed wishes regarding care and treatment goals, f. reflect treatment goals, timetables, and objectives in measurable outcomes, h. aid in preventing or reducing declines in a resident's functional status and/or functional levels, i. enhance the optimal functioning of the resident by focusing on a rehabilitative program, and j. reflect currently recognized professional standards of practice for problem areas and conditions. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident are interdisciplinary processes that require careful data gathering, proper sequencing of events and systematic clinical decision making. No single discipline can manage the task in isolation. The resident's physician (or primary healthcare provider) is integral to this process.

May 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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure two of nine sampled residents (Resident 6 and 9) oxygen tubing (device that delivers oxygen [air e...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure two of nine sampled residents (Resident 6 and 9) oxygen tubing (device that delivers oxygen [air essential to living things to survive] through a tube to the nose) were labeled and dated. This failure has the potential for the oxygen tubing to lose patency that could negatively affect and delay delivery of care and services to Resident 6 and Resident 9. Findings: During a review of Resident 6's admission Record (Face sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (a common lung disease that causes restricted airflow and breathing problems) and chronic respiratory failure (a serious condition where the lungs cannot get enough oxygen in the blood making it difficult to breathe). During a review of Resident 6's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 2/26/2024, the MDS indicated Resident 6's cognition (ability to think, learn, remember, use judgement, and make decisions) was intact. The MDS indicated Resident 6 needed supervision with eating, oral hygiene, personal hygiene and dressing, and partial assistance where the helper does less than half the effort, with toilet hygiene and showering. During a review of Resident 6's Order Summary Report dated 6/8/2023, the Order Summary indicated Resident 17 had an order of Oxygen inhalation at 3 (three) Liters per minute through nasal cannula (a medical device used to deliver supplemental oxygen or increased airflow to a patient or person in need of a respiratory help) continuously and oxygen tubing change and labelling with date and initials every week. During a review of Resident 9's admission Records (Face sheet), the face sheet indicated Resident 9 was admitted to the facility with a diagnosis including heart failure (a condition that develops when the heart does not pump enough blood for the body's needs) and pulmonary hypertension (a condition that affects the blood vessels in the lungs). During a review of Resident 9's Order Summary Report dated 5/10/2024, the Order Summary report indicated Resident 9 had an order for Oxygen inhalation at 2 (two) liters per minute thru a nasal cannula as needed for shortness of breath and wheezing (a high pitched- sound made while breathing often associated with difficulty breathing). During an observation on 5/14/24/2024 at 12:24 p.m., Resident 6's oxygen tubing was not labelled and did not have a date. During a concurrent observation and interview on 5/14/2024 at 1:18 p.m., Resident 9 stated she does not know how long she has been using the oxygen and she does not know if it should have a label. During an interview on 5/14/2024 at 12:47 p.m., Licensed Vocational Nurse 1 (LVN 1) stated the oxygen tubing must be changed every week and should be labelled and/or dated to make sure the tubing is discarded accordingly. During an interview on 5/14/2024 at 1:22 p.m., Licensed Vocational Nurse 2 (LVN 2) stated undated/unlabeled oxygen tubing could be old and clogged that it could lose patency. During an interview on 5/14/2024 at 1:28 p.m., the Director of Nursing Services (DON) stated the oxygen tubing must be changed weekly, labelled, and dated to identify when to discard it to ensure the equipment is renewed and working properly. During a review of the facility's policy and procedure (P/P) titled Oxygen Administration revised in 10/2010, the P/P indicated the facility must ensure oxygen is safely administered by checking the oxygen tubing and discarding used and/ or soiled/outdated tubing as well as other respiratory supplies such as mask, tank, humidifying water, suction machine, and its related supplies.

Feb 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

Safe Environment (Tag F0584)

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 maintain the roof in good repair for one of one sampled residents (...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain the roof in good repair for one of one sampled residents (Resident 1), when Resident 1 ' s room had leaking water. This deficient practice resulted in Resident 1 being exposed to an unsanitary environment and violated Resident 1 ' s right to be provided with a safe, clean, and comfortable homelike environment. Findings: During a review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with polyneuropathy (damaged nerves), muscle wasting (decrease in size of muscle tissue) and Type 2 diabetes mellitus (disease where level of sugar in blood too high). During an interview on 2/8/2024, at 3 p.m., with Maintenance Supervisor (MS), the MS stated Resident 1 ' s room had water leaking from the ceiling vent during the recent rainstorm during the days between 1/29/2024 through 2/1/2024. The MS stated, Resident 1 could not stay in his room because of the leak. The MS stated the facility fixes leaks when the needs arise. The MS stated the facility does not keep track of a maintenance repair log documenting what materials were used to repair leaks nor where and when a repair has been completed. During a concurrent interview and record review, on 2/8/2024 at 4 p.m., with the Director of Nursing (DON), Resident 1 ' s Census List Report was reviewed. The report indicated on Resident 1 was admitted on [DATE] to the facility and on 2/1/2024 moved to another room within the facility. The DON stated, Resident 1 was moved because there was a leak in the resident's room and water was coming down from the ceiling vent. The DON stated, Resident 1 was at risk for from getting wet from the water which was unsanitary and unsafe. During an interview on 2/8/2024, at 4:45 p.m., with the DON stated it was the facility ' s policy to ensure residents ' have the right to safe, clean, and homelike environment. The DON stated, Resident 1 ' s rights were violated due to the leak in his room. During a review of the facility ' s policy and procedure (P/P) titled, Maintenance Service, revised 12/2009, the P/P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment; Maintaining the building in good repair and free from hazards. During a review of the facility ' s P/P titled, Homelike Environment, revised 2/2021, the P/P indicated residents were provided with a safe, clean, comfortable, and homelike environment. The facility staff and management will maximize to the extent possible, the characteristics of the facility that reflect a homelike setting including a clean, sanitary, and orderly environment.

Dec 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to provide necessary care and services for one of four sampled residents (Resident 1) when: a. The facility failed to immediately transfer Res...

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Based on interview and record review, the facility failed to provide necessary care and services for one of four sampled residents (Resident 1) when: a. The facility failed to immediately transfer Resident 1 to GACH (General Acute Care Hospital) after Resident 1 had a change of mental function on 11/26/2023. Resident 1 had an order to transfer to GACH at 12:37 p.m. Resident 1 was transferred to GACH at 3:23 p.m. b. The facility failed to ensure Licensed vocational nurse 1 (LVN 1) and Registered Nurse Supervisor (RNS 1) assessed Resident 1's neurological status (a series of tests that assesses mental status, reflexes, movements and more) immediately after the change of condition and frequently until Resident 1 was transferred to GACH three hours after the change of condition. c. The facility failed to ensure Resident 1's vital signs (temperature, respiration, heart rate and blood pressure measurement) was documented when Resident1's mental status changed at 12:37 p.m. and monitored frequently after the change of condition until Resident 1 was transferred to GACH three hours after the change of condition. These deficient practices resulted in inadequate and delayed care and services rendered to Resident 1. Findings: During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 11/22/2023 with a diagnosis that included malignant neoplasm (a malignant growth) of the rectum (end part of the intestine) and the left lung, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well they should), and epilepsy (a disorder of the brain characterized by repeated seizures). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/26/2023, the MDS indicated Resident 1 was dependent to 2-person assist to complete her ADLs (activities of daily living) such as bed mobility, toileting, hygiene, and bath/showering. During a review of Resident 1's medical record titled, History and Physical Examination dated 11/23/2023, the History and Physical Examination indicated Resident 1 was able to make her needs known but cannot make medical decisions. The History and Physical Examination indicated the plan for Resident 1 was to keep a close eye on Resident 1's vital signs and change in mental condition and to transfer Resident 1 to the emergency room immediately when Resident 1 experiences sudden and serious health issues. During a review of Resident 1's medical record titled, Progress Notes dated 11/26/2023 at 12:37 p.m., the Progress Notes indicated Resident 1 was awake, alert to self and able to communicate verbally with slight difficulty pronouncing some words, with stable vital signs (unspecified) and the doctor ordered for Resident 1 to be transferred to GACH for evaluation of change in mental status. During a review of Resident 1's medical record titled, Order Summary Report dated 11/26/2023, the Order Summary Report indicated a doctor's order for Resident 1 to be transferred to GACH for evaluation related to altered mental status. During a review of Resident 1's medical record titled, SNF/NF (Skilled Nursing Facility/ Nursing Facility) to Hospital Transfer Form dated 11/26/2023 at 3:00 p.m., the SNF/NF to Hospital Transfer indicated a report of Resident 1's health status was called to the GACH's emergency nurse and Resident 1 was transferred to GACH because of altered mental status. The SNF/ NF to Hospital Form indicated Resident 1's usual mental status before the change of condition was alert, disoriented but can follow simple commands. The record indicated the Resident 1 had the following vital signs: a. At 5:47 a.m., taken 6 hours before the change of condition, respirations (breathing) rate of 18, b. At 2:41 p.m., 2 hours after the change of condition, blood pressure of 120/68, heart rate of 60, oxygen saturation (oxygen level in the body) of 96% while on oxygen treatment of 2 liters per minute through a nasal cannula (a device that gives additional oxygen through the nose). During a review of Resident 1's medical record titled, Progress Notes dated 11/26/2023 at 3:23 p.m., the Progress Notes indicated Resident 1 was to be transferred to GACH and there was no specific assessment or monitoring documented such as vital signs and neurological assessment (neuro checks) conducted for Resident 1. During a telephone interview on 12/18/2023 at 3:31 p.m. with Emergency Contact 1 (EC1), EC 1 stated Resident 1 was visited by a friend on 11/26/2023 at 10:00 a.m. and the visitor found Resident 1 to have difficulty talking and Resident 1 looked like she had a stroke. EC 1 stated Resident 1 was transferred to the emergency late in the afternoon. During an interview on 12/19/2023 at 2:30 p.m., with the Restorative Nurse Assistant 1 (RNA 1), RNA 1 stated Resident was usually alert to self, forgetful but would talk to the staff in a few words and was understandable. During an interview on 12/19/2023 at 2:51 p.m., with the Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 was awake had some slight slurring of speech. LVN 1 stated he and the Registered Nurse Supervisor 1 (RNS 1) assessed Resident 1's vital signs initially, did not document the vitals signs and did not perform a continuous neurological assessment and monitoring of Resident 1's condition. During an interview on 12/19/2023 at 3:18 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she did not perform any assessment and monitoring for Resident 1 because there was never a report or endorsement from the previous shift regarding Resident 1's change of condition. During an interview on 12/19/2023 at 3:30 p.m., with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated if a resident has a change of condition of altered mental status it could indicate either neurological or even infection; therefore, the vital signs and neuro checks must be monitored and documented consistently to identify worsening of the resident's condition. During an interview and record review on 12/20/2023 at 12:32 p.m., with the Director of Nursing (DON), the DON stated it was necessary for the licensed nurses to perform consistent and/ or accurate neurological assessments, vital signs and monitoring for residents who have altered mental status to ensure identification of the resident's worsening condition. The DON confirmed there were missing assessments and monitoring for Resident 1, after Resident 1 was found to have altered mentation on 11/26/2023 at 12:37 p.m. During a telephone interview on 12/20/2023 at 1:52 p.m., with Resident 1's primary physician, represented by a nurse practitioner (NP), the NP stated he informed the licensed staff (Registered Nurse Supervisor 1) to perform assessments and monitoring such as vital signs and neuro checks to Resident 1 and transfer Resident 1 to GACH based on the severity of her condition. During a review of the facility's policy and procedure (P/P) titled, Resident Examination and Assessment revised 2/2014, the P/P indicated the purpose of the residents' examination and assessment was to identify any abnormalities in the residents' health status such as of neurological assessment which provides a basis and or deviation from their baseline for a residents' alertness, orientation, speech clarity, drooping eyelids, facial paralysis, asymmetry, strength and equality of the hand grasps and numbness or tingling of the extremities. During a review of the facility's policy and procedure (P/P) titled, Neurological Assessment revised 10/2010, the P/P indicated neurological assessments are indicated by a resident's condition, must always include frequent vital signs, and must be documented in the residents' medical record. During a review of the facility's job description of a licensed vocational nurse, revised 5/2022, the job description indicated a licensed vocational nurse must obtain and document the residents' vital signs as needed and must monitor the residents for and immediately report developments of acute changes of condition. During a review of the facility's job description of a registered nurse, revised 5/2022, the job description indicated a registered nurse must monitor the residents for and immediately report developments of acute changes of condition and provide nursing services to residents in accordance with scope of practice, facility policies and professional standards of practice. During a review of the facility's policy and procedure (P/P) titled, Change in a Resident's Condition or Status revised 2/ 2021, the P/P indicated the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Change in Condition form and must record in the residents' medical record information relative to changes in the residents' medical and/or mental condition or status.

Oct 2023 15 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 provide reasonable accommodations to meet the resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodations to meet the resident's needs by failing to ensure the resident room was not cluttered and the grab bar (a safety device attached to the wall designed to enable a person to maintain balance) was not easily within reach for Resident 18 who used a wheelchair. This deficient practice had the potential for delay of care in case of emergencies and not meet the Resident 28's daily needs. Findings: During a review of Resident 28's admission record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (insufficient insulin (a checmical that helps regulate blood sugar), end stage kidney disease, dependent on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and weakness, below knee right leg amputation (the loss or removal of a body part such as leg) During a review of Resident 28's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 03/26/2023, the MDS indicated Resident 1 had moderately impaired cognitive (ability to acquire knowledge through thought, experience and the five senses) skills for daily decision making. Resident 1 required limited assist for bed mobility, transfer, locomotion on unit, off unit, dressing, toilet use and personal hygiene. During an observation on 10/24/2023 at 3:47 p.m., of Resident 28's room, Resident 28's right side of the room was full of personal belongings, cluttered with plastic containers, cloths hanging on the TV stand with very little to no space for walkway between the wall and the bed. Resident 28's wheelchair obstructed the doorway. The dialysis emergency kit (a set of tools used to control accidental bleeding from the dialysis access point) was at the farthest right-side corner of the bedside table and not easily accessible in case of emergencies. During an interview on 10/24/2023 at 3:47 p.m., with Resident 28, Resident 28 stated it when he was in his wheelchair, and goes to the bathroom, it was difficult to reach the grab bar near the toilet to be able to stand up. Resident 28 stated he wanted a grab bar on the front wall so he can hold on to it to stand and then reach out to the other grab bar near the toilet. During a concurrent observation and interview on 10/26/2023 at 11:02 a.m., of Resident 28's room with the maintenance supervisor (MS), the MS described the room as cluttered and full of things obstructing the exit. During a concurrent observation and interview on 10/26/2023 at 11:05 a.m., of Resident 28's room with the director of staff development (DSD), the DSD described the room as cluttered with a lot of belongings. The DSD stated our rooms are tiny, space is limited, and it is not safe for Resident 28. All the clutter is a fall risk, that Resident 28 can trip and fall from. During an observation and measurements on 10/26/2023 at 11:14 a.m. of Resident 28's room, surveyor 's measurement of the room indicated distance between the door and the bed was 27.5 inches (a unit of measure of length) and the distance between the bed and the wall was 30.5 inches, while the width of the wheelchair is 25 inches, the door is blocked with the wheelchair; and the distance between the wheelchair and the door is 17 inches, there is no place for Resident 28's roommate's wheelchair to pass by. During a concurrent observation and interview on 10/26/2023 at 02:39 p.m., with registered nurse supervisor (RN), the RN stated the dialysis kit was on the side table behind hanging clothes. RD stated due to the clutter there would be a delay in care when trying to reach the emergency kit in case of emergency. During a review of the facility's revised policy and procedure titled Home like environment revised January 2020, the policy indicated Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible . During a review of the facility's revised policy and procedure titled Accommodation of Needs revised February 2021, the policy indicated the resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The policy indicated providing access to assistive devices, such as grab bars and toilet risers in the bathroom; Moving furniture or large items in rooms and common areas that may obstruct the path of a residents using a walker.

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

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 appropriately assess and monitor one of one sampled 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 appropriately assess and monitor one of one sampled resident (Resident 54) during the use of a concave mattress (a fall prevention mattress to minimize risks of falling out of the bed) to prevent the resident from sliding off the bed. This deficient practice had the potential for Resident 54 restricts freedom of movement or activity while in bed. Findings: During a review of Resident 54's Face Sheet (admission record), the Face Sheet indicated Resident 54 was admitted to the facility on [DATE] with diagnosis including, Parkinson's disease (chronic disorder that causes the brain to break down neurons that produce chemical messengers to the brain), hypertension (high blood pressure), and dementia without behavioral disturbance (impaired ability to think or make decisions without exhibiting behaviors such as agitation and depression). During a review of Resident 54's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 8/17/2023, the MDS indicated Resident 54's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired. The MDS indicated Resident 54 required extensive assistance for all aspects of activities of daily living (ADL's). The MDS indicated Resident 54 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 54 used a wheelchair and walker for mobility and have no impairments on both the upper and lower extremities (arms and legs). The MDS indicated Resident 54 did not have any physical restraints, which are any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. During review of Resident 54's untitled Care Plan (CP) initiated on 10/9/2023, the CP indicated Resident 54 had an actual fall. The CP intervention initiated on 10/9/2023 included Resident 54 having the bed in low position. The CP intervention initiated on 10/11/2023 included Resident 54 having bilateral floor mats. Additionally, an intervention initiated on 10/10/2023 indicated Resident 54 have a concave bed to prevent sliding off the bed. During a review of the Order Summary Report (Physician Order) as of 10/27/2023, there are no orders noted for a concave bed. During a review of Resident 54's Change of Condition (COC) Evaluation dated 10/9/2023, documented by a Licensed Vocational Nurse (LVN), the COC indicated on 10/9/2023, Resident 54 was found on the floor in front of the bed with the palms of her hands on the floor, sitting up facing the bathroom door. During a review of Resident 54's Interdisciplinary Team (IDT: department heads from various departments meet to discuss the plan for resident) Fall dated 10/9/2023, the IDT recommended a concave bed to prevent the resident sliding off the bed with bilateral mats. During a concurrent observation and interview on 10/24/2023 at 4:05p.m. with Registered Nurse Supervisor 2 (NS 2), NS 2 stated the wedge for offloading that is placed under the mattress of Resident 54's bed is positioned to prevent Resident 54 from falling off the bed. NS 2 stated it prevents Resident 54 from rolling out of bed since Resident 54 usually moves all over the bed. NS 2 stated it does not restrict the movement of Resident 54 and just stops the resident from rolling. NS 2 stated the wedge is normally used for position and does not require an doctors order to use the wedge. NS 2 stated the staffs get creative and does what needs to be done in order to keep residents from rolling out of the bed. During a concurrent observation and interview on 10/25/2023 at 10:44a.m. with Registered Nurse Supervisor 1 (NS 1), NS 1 stated restraints restrict the ability to move and has limitations on how a resident move. NS 1 stated Resident 54 is noncompliant, does not follow directions, and keeps going out of the bed. NS 1 stated the bed against the wall is for the safety of Resident 54. NS 1 stated despite Resident 54 being in bed, she will roll on to the other side NS 1 stated Resident 54 usually has bed rails on the side when she in bed. NS 1 stated side rails are not a form of restraint as it used to help the resident for mobility. NS 1 stated an order for restraint is required and is used as a last resort for safety. NS 1 stated once a consent is obtained and the restraint is initiated, they will check the resident every two hours based on the resident to prevent any strangulation. NS 1 stated residents with restraints are frequently checked and would reevaluate the resident to see if the restraint is necessary. NS 1 stated restraint documentation is in the progress notes. During a concurrent interview and record review on 10/26/2023 at 11:00a.m. with NS 1, NS 1 was showed a picture of the wedge that was under Resident 54's mattress. NS 1 stated Resident 54 is on a concave bed as an intervention and an order is needed for a concave bed. NS 1 stated the wedge placed under the mattress is not supposed to be like that as a wedge is supposed to be used for residents for repositioning. NS 1 stated the wedge under the mattress can affect residents safety and will have an increase for falls and injury. During a concurrent observation and interview on 10/26/2023 at 11:45a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she does not see the bed rails as a form of restraint as it is not always up. LVN 2 stated a restraint is when a bed is padded all the way to the edge of the bed so that the resident cannot move. LVN 2 stated for a restraint, an order from the doctor is obtained and once the restraint is implemented, it is important to ensure there is a finger width between the restraint and the resident, check circulation, and ensure the restraint is not on the rail and is placed on a secure location. LVN 2 stated resident with restraints are monitored every hour or two and will follow up with the doctor as a restraint cannot be kept on a resident for a long period of time. LVN 2 stated the assessment is documented in the progress notes, and an order for restraint is needed but is not sure if a consent form is needed. LVN 2 stated the bed against the wall is acceptable but does not know why. During a concurrent observation and interview on 10/26/2023 at 11:56a.m. with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated since Resident 54 is a fall risk, the bed is placed closer to the wall and the resident would have a bed rail while they are in bed. During an interview on 10/27/2023 at 11:07a.m. with Director of Staff Development (DSD), DSD stated restraints mean you are restricting the movement of the resident. DSD stated if a resident had restraints, an assessment is done, a consent from the family is obtained, and will receive an order from the doctor. DSD stated a cradle mattress is used for fall prevention to ensure the resident and does not slip and it does not restrict movement. DSD stated the mattress is used for residents who have a history of falls and would assess whether it is beneficial to the resident or not. DSD stated if a resident tends to stand up all the time, it will help them from sliding to the side of the bed. DSD stated the bed against the wall is a restraint as it impedes the movement of the resident. DSD stated the bed should be placed in the middle and should have landing pads on both sides of the bed. DSD stated the bed is low for safety and it should be care planned. DSD stated a consent to use the concave mattress is not needed. DSD stated they do not have bed alarms and Resident 54 tends to get up and can still get up. During a review of the facility's P&P titled Use of Restraints revised on April 2017, the P&P indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). Care plans shall also include the measures taken to systemically reduce or eliminate the need for restraint use. During a review of the facility's P&P titled Behavioral Assessment, Intervention and Monitoring revised on March 2019, the P&P indicated over time the staff will reduce the use or remove such devices, or will document why such attempts are not feasible.

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 observation, interview, and record review, the facility failed to accurately assess and code for Restorative Nursing Ai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess and code for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) for one of 19 sampled resident's (Resident 21) Minimum Data Set assessment (MDS, a standardized assessment and care-screening tool). This deficient practice had the potential to cause inaccurate care planning and inadequate provision of rehabilitation therapy and restorative nursing services for Resident 21. Findings: During a review of Resident 21's admission Record, the admission record indicated Resident 21 admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), left hand contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), left ankle and foot contracture, left elbow contracture. During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21 had severely impaired cognition (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS also indicated Resident 21 required extensive assistance (requires significant amount of assistance from another person to perform task) for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS also indicated Resident 21 had impairments in functional limitation in range of motion (ROM, full movement potential of a joint) on one side of the upper extremity (shoulder, elbow, wrist, hand) and lower extremity lower extremity (hip, knee, ankle, foot). The MDS also indicated, in Section O for Special Treatments, Procedures, and Programs under Restorative Nursing Programs, Resident 21 received five (5) days of passive range of motion (PROM, movement at a given joint with full assistance from another person) technique, 5 days of active range of motion (AROM, movement at a given joint when the person moves voluntarily) technique, and seven days of splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) or brace (an external device to support, align, or correct a movable part of the body) assistance technique. During a review of Resident 21's Order Summary Report dated 10/26/23, the report indicated a physician's order dated 6/9/22 for RNA for application of left pressure relief ankle foot orthosis (PRAFO, an orthotic device designed to correct or address problems with the ankle and foot and provide pressure relief at heels) four (4) hours as tolerated once a day five times a week (5x/wk); an order dated 6/9/22 for RNA for active range of motion on right left extremity (RLE) as tolerated once a day 5x/wk; an order dated 6/9/22 for RNA for PROM on left lower extremity (LLE) as tolerated once day 5x/wk; an order dated 8/28/23 for RNA for left elbow splint application for 4 hours as tolerated once a day 5x/wk; an order dated 8/28/23 for RNA for left resting hand splint application for 4 hours as tolerated once a day 5x/wk; an order dated 8/28/23 for RNA for PROM on left upper extremity (LUE) available planes as tolerated once a day 5x/wk. During a review of Resident 21's care plan revised 9/14/23, the care plan indicated Resident 21 was at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: decrease mobility. The care plan goal indicated to maintain LLE ROM and RLE strength and to maintain the highest capable level of ADL ability throughout the next review period as evidenced by his ability to perform ADLs and least level of support needed to perform. The care plan interventions included RNA for PROM all available joints and planes on LUE once a day 5x/wk as tolerated, RNA for application of left resting hand splint and left elbow splint as long as tolerated once a day 5x/wk for further contracture and skin breakdown prevention, RNA for PROM on LLE as tolerated once a day 5x/wk, RNA for application of L PRAFO 4 hours or as tolerated once a day 5x/wk. During a review of Resident 21's RNA October 2023 treatment record, the treatment record did not indicate the amount of minutes RNA spent completing each RNA treatment. On 10/24/23 at 10:02 AM, during an observation and interview, Resident 21 was laying in bed on the back with the head of bed up about halfway. Resident 21 had a cushion underneath the left arm, the left elbow was bent about halfway, the left wrist was bent forward, and the left fingers were bent. There was a hand splint noted at the resident's foot of the bed. Resident 21 stated he did not perform any exercises yet that day and did not have any splints put on yet. On 10/26/23 at 4:16 pm, during an interview and record review of Resident 21's MDS dated [DATE], the Regional MDS Nurse Consultant and interim MDS coordinator (MDSC) reviewed Resident 21's MDS dated [DATE] Section O under Restorative Nursing Programs and confirmed that the MDS indicated Resident 21 received 5 days of passive ROM technique, 5 days of active range of motion technique, and seven days of splint or brace assistance technique. MDSC stated Section O under Restorative Nursing Programs was assessed and coded inaccurately because the facility did not document the amount of minutes RNA spent on each treatment technique each day and could not verify that at least 15 minutes were spent each day. MDSC stated the MDS should be coded as zero days of RNA received. During a review of the facility's policies and procedures, revised 11/19, titled, MDS Assessment Coordinator: indicated a registered nurse shall be responsible for conducting and coordinating the development and completion of the resident assessment .each individual who completes a portion of the assessment must certify the accuracy of that portion of the assessment.

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 one out of five sampled residents (Resident 16) had an accur...

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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 one out of five sampled residents (Resident 16) had an accurate preadmission screening and annual resident review ([PASRR], is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) to determine the facility's ability to provide any special needs for the resident. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 16. Findings: During a review of Resident 16's admission record (face sheet), the face sheet indicated Resident 16 was admitted to the facility 3/16/2016 and readmitted [DATE] with diagnosis of schizoaffective disorder, bipolar type (a mental illness that affects our mood and thoughts), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive worry), and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). During a review of Resident 16's minimum data set (MDS, a standardized assessment and screening tool), the MDS indicated Resident 16 was able to make himself understood and was able to understand others. During a review of Resident 16's PASRR level 1 screening dated 12/5/2022, the PASRR level 1 screening was negative, and a level II screening was not required. The reason noted for Resident 16's negative PASRR level 1 screening was no serious mental illness. The PASRR indicated NO was checked on question number 10, does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? During an interview on 10/27/2023 at 12:49 p.m., registered nurse supervisor (NS) stated Resident 16 was diagnosed with schizoaffective disorder, major depression, bipolar, and anxiety. NS stated residents with psychiatric diagnoses usually qualify for PASRR, but he was never trained on the PASRR. During an interview on 10/27/2023 at 12:55 p.m., the Regional Clinical Resource-interim director of nursing/ registered nurse supervisor (CR) stated the PASRR was started in the hospital prior to transfer but it was the facility's responsibility to ensure the accuracy of the assessment. The CR stated if the facility found the PASRR to be inaccurate they were to create a new PASRR and update the information for submission. The CR confirmed Resident 16's psychiatric diagnoses and confirmed question 10 on the PASRR was inaccurate. The CR stated it was important to have an accurate PASSR so the residents could be properly screened for specialized services and treatment could be tailored to the resident's needs. During a review of the facility's policy and procedure (P/P) titled Behavioral Assessment, Intervention, and Monitoring dated 3/2019, the P/P indicated all residents were to receive a level PASRR screen prior to admission and if the level 1 screen indicated that the individual may meet the criteria for a mental disorder, he or she was to be referred to the state PASRR representative for the level II (evaluation and determination) screening process. The P/P indicated the level II evaluation report was to be used when conducting the resident assessment and developing the care plan.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

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 arrange for provision of vision services for three (3...

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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 arrange for provision of vision services for three (3) of four (4) sampled residents (Resident 4, Resident 26 and Resident 28). This deficient practice resulted in Resident 4 not having vision evaluated to prevent further decline, Resident 26 not having vision evaluated for new glasses to allow Resident 26 to read the daily chronicles, and Resident 28 not having the annual vision evaluation to maintain and/or improve his vision. Findings: a) During a review of Resident 4's admission record, the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (gradual loss of kidney function), seizures (uncontrolled electrical activity in the brain that causes temporary stiffness, twitching or limpness), hypoglycemia (low blood sugar), renal dialysis (blood purifying treatment given when kidney function is not optimal), legal blindness (minimal vision even with prescription glasses), Type II Diabetes Mellitus (insufficient insulin (hormone that helps regulate blood sugar) production), hypertension (high blood pressure), and unspecified glaucoma (damage to the nerve that is attached to the eye). During a review of Resident 4's Minimum Data Set (MDS a standardized assessment and care screening tool), dated 8/25/2023, the MDS indicated Resident 4's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were mildly impaired. The MDS indicated Resident 4 required extensive assistance for all activities of daily living (ADL activities related to self care). The MDS indicated Resident 4 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 4 used a wheelchair and walker for mobility and had no impairments on both the upper and lower extremities (arms and legs). During a review of Resident 4's untitled Care Plan (CP) initiated on 5/16/2023, the CP indicated Resident 4 has vision impairment related to diagnosed blindness in bilateral (both) eyes. The CP intervention indicated to consult with physician for vision evaluation. During a review of Resident 4's Order Summary Report (Physician's Orders) the report indicated, and order dated 7/14/2023, Resident 4 can have podiatry (medical specialty that treats feet), dental, and ophthalmology (medical specialty that treats eyes) consult, and treatment as needed for patient health and comfort. During an interview on 10/26/2023 at 11:30 a.m. with the Social Service Director (SSD), the SSD stated if a resident is admitted with visual impairment, depending on the assessment, the resident can have an eye health consultation quarterly (every three months) or annually and the CP would get updated with the resident's progress. During a concurrent interview and record review on 10/26/2023 at 4:29 p.m. with Registered Nurse Supervisor (RN), RN stated Resident 4 had gotten an Ear Nose and Throat (ENT) consultation with the doctor on 10/6/2023. RN stated they have an ophthalmologist, and the social worker is the one that does the scheduling. RN stated if a resident has issues with their eyes, facility staff will ask the resident's primary doctor to see if the resident can be seen by an ophthalmologist. RN stated he does not see any progress notes in Resident 4's chart that his eyes were seen by an ophthalmologist. RN stated if residents have visual impairment, they should be seen by the specialist to check the progression of the disease to ensure it does not progress as it may create more complications for the resident. b. During a review of Resident 26's admission record, the admission record indicated Resident 26 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including weakness, hemiplegia (severe weakness of one side of the body) and hemiparesis (weakness of one side of the body), history of falling, encephalopathy (a disease that damages the functions of the brain). During a review of Resident 26's MDS dated [DATE], the MDS indicated Resident 26 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident 28 had impaired vision and inability to see regular print in newspapers/ books. The MDS indicated Resident 26 required extensive assistance for bed mobility, transfers, walk in the room, walk in the corridor, locomotion on unit, off unit, dressing, toilet use and personal hygiene. The MDS indicated Resident 26 was not steady while walking moving from seated to standing position. The MDS indicated functional limitation of both upper and lower extremities (arms and legs). During the review of Resident 26's untitled care plan (CP), the CP indicated Resident 26 required assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, transfer, locomotion, and toileting. The care plan interventions included monitor conditions that could contribute to ADL decline including hearing and vision impairment. During the review of Resident 26's CP, the CP indicated Resident 26 stated it was important to engage in meaningful activities including reading and watching TV. During a concurrent observation and interview on 10/25/2023 at 03:39 p.m. with Resident 26, Resident 26 stated he does not have glasses and cannot read. Resident 26 had the daily chronicle at his bedside. Resident 26 stated he was not able to read, his glasses were broken. During an interview on 10/26/2023 at 10:33 a.m. with the SSD, the SSD stated all residents get dental and vison exams once a year unless they have any other issues that need to be taken care of. It will be documented on the resident's progress note. c.During a review of Resident 28's admission record, the admission record indicated Resident 28 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including diabetes mellitus (insufficient insulin (a chemical that helps regulate blood sugar), end stage kidney disease, dependent on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), and weakness, below knee right leg amputation (the loss or removal of a body part such as leg) During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 1 had moderately impaired cognitive (ability to acquire knowledge through thought, experience and the five senses) skills for daily decision making. Resident 1 required limited assist for bed mobility, transfer, locomotion on unit, off unit, dressing, toilet use and personal hygiene. The MDS indicated Resident 28 was unsteady but able to stabilize. During an interview on 10/24/2023 at 3:47 p.m., with Resident 28, Resident 28 stated he had never had his eyes checked since he had been at the facility. During an interview on 10/26/2023 at 10:33 a.m. with the SSD, the SSD stated all residents should have dental and vision exams once a year unless they have any other issues that need to be taken care. It will be documented on the resident's progress note. During a review of the facility's P&P titled Activities of Daily Living (ADLs), Supporting revised on March 2018, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident an in accordance with the plan of care. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognized standards of practice.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

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 physician's orders for Restorative Nursing...

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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 physician's orders for Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) to put on a right elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) and right resting hand splint included safe parameters (fixed time limits) for splint wearing time for one out of 17 sampled residents (Resident 19). This deficient practice had the potential for Resident 19 to develop pain and skin breakdown due to wearing splints for longer than Resident 19 could tolerate. CROSS REFERENCE F657 Findings: During a review of Resident 19's admission Record, the admission record indicated Resident 19 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, functional quadriplegia (weakness or paralysis to all four extremities), acquired absence of left leg above knee (surgical removal of a limb). During a review of Resident 19's Minimum Data Set (MDS) a standardized assessment and care planning tool dated 7/12/23, the MDS indicated Resident 19 was severely impaired with daily decision making, required extensive assistance (requires significant amount of assistance from another person to perform task) with bed mobility, dressing, and eating, and total dependence with transfer, toileting, personal hygiene. The MDS also indicated Resident 19 had functional limitation in range of motion (ROM, full movement potential of a joint) on one side of both the upper extremity (UE, shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). During a review of Resident 19's Order Summary Report dated 10/26/23, the report indicated an order dated 5/16/22 for RNA for PROM on right upper extremity (RUE) once a day five times a week (5x/wk), an order dated 5/16/22 for RNA for application of right elbow splint as long as tolerated once a day 5x/wk, and an order dated 5/16/22 for RNA for application of right resting hand splint as long as tolerated once a day 5x/wk. During a review of Resident 19's care plan dated 12/14/20 titled Restorative Splint and Brace Assistance, the care plan indicated a goal to prevent contractures and maintain skin integrity for 90 days. The care plan interventions included RNA for PROM to RUE once a day 5x/wk or as tolerated, RNA for right elbow splint application 5x/wk for four (4) hours as tolerated, RNA for right hand bulb application 5x/wk for 4 hours as tolerated, RNA for right resting hand splint application 5x/wk for 4 hours as tolerated. During a review of Resident 19's Occupational Therapy Treatment Encounter Note dated 5/12/22, the note indicated resident tolerated hand and elbow splint for three (3) hours no adverse response or discomfort noted. During a review of Resident 19's Restorative Nursing Weekly Summary - Splint - Hand Care dated 10/6/23, the restorative nursing weekly summary indicated a wearing schedule of 4 hours in the morning for the right hand/arm splint and the right leg splint. During a review of Resident 19's Restorative Nursing Weekly Summary - Splint - Hand Care dated 10/13/23, the restorative nursing weekly summary indicated a wearing schedule of 4 hours in the morning for the right hand/arm splint and the right leg splint. During a review of Resident 19's Restorative Nursing Weekly Summary - Splint - Hand Care dated 10/20/23, the restorative nursing weekly summary indicated a wearing schedule of 4 hours in the morning for the right hand/arm splint and the right leg splint. On 10/26/23 at 9:33 am, during an observation and interview in Resident 19's room, Restorative Nursing Assistant 2 (RNA 2) moved Resident 19's right arm up and down below the shoulder level. RNA 2 straightened Resident 19's right fully bent elbow a little bit, straightened the right wrist a little bit from a bent position, and opened the right fingers a little bit from a fisted position. Restorative Nursing Assistant 1 (RNA 1) assisted Resident 19 with wiping the right hand prior to RNA 2 putting on the right elbow splint and right resting hand splint. After completing Resident 19's RNA treatment session, RNA 2 stated he usually put the right elbow splint, right resting hand splint, and right knee splint on for about four to six hours because of the RNA orders. On 10/26/23 at 11:00 am, during an interview and record review of Resident 19's active physician's orders, the Occupational Therapist (OTR 1) stated Resident 19's RNA orders did not indicate a parameter for wearing time for the right elbow splint and for the right resting hand splint. OTR 1 stated the RNA order was open to allow the RNA to decide how long Resident 19 could tolerate wearing the elbow and resting hand splints. OTR 1 stated that an RNA did not have the training and education to assess whether a resident could tolerate a splint for a certain amount of time and OTR 1 should not have written an RNA order that allowed an RNA to put on a splint for more than what Resident 19 tolerated with Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) staff. OTR 1 stated it was the OT's professional responsibility to assess how long a resident could wear a splint. OTR 1 stated an OT would be able to determine if a resident could not tolerate a splint by assessing for skin integrity, monitoring a resident's behavior, and excessive pain. On 10/26/23 at 12:37 pm, during an interview and record review of Resident 19's Occupational Therapy Treatment records during the dates of service of 4/11/22 and 5/12/22, OTR 1 stated after review of the OT treatment service records, the maximum amount of time OT staff assessed Resident 19's tolerance for wearing the right elbow splint and right resting hand splint without any adverse outcome was 3 hours. OTR 1 stated there was no other documentation of the OT staff assessing Resident 19 for wearing tolerance of the right elbow and right resting hand splint for more than 3 hours. OTR 1 stated it was a mistake and OT staff should not have developed an RNA program for Resident 19 to wear the right elbow and right resting hand splint for more than 3 hours, because the OT staff did not assess and evaluate that Resident 19 could tolerate wearing the splints for more than 3 hours. OTR 1 stated that an RNA program order that did not indicate the maximum wearing time for a splint could put the resident at risk for skin breakdown, swelling, and pain. OTR 1 stated it was the OT's scope of practice and professional responsibility to establish the maximum tolerance and wearing time for splints and develop an RNA program to reflect a safe wearing time for splints. During a review of the facility's Occupational Therapist Job Description, revised 5/9/23, the job descrption indicated an occupational therapist's responsibility included, designs, fabricates, fits and/or applies adaptive devices, and trains patients in the use of adaptive devices including orthotics and prosthetics. During a review of the facility's policy and procedure (P/P), revised 4/12, titled, Guidelines for Charting and Documentation, the p/p indicated under content of orders that treatment orders: specify what is to be done, location and frequency, and duration of the treatment.

CONCERN (D)

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

Deficiency F0907 (Tag F0907)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide sufficient space for storage of non-therapy nursing items in order to provide adequate space for rehabilitative thera...

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Based on observation, interview, and record review, the facility failed to provide sufficient space for storage of non-therapy nursing items in order to provide adequate space for rehabilitative therapy services provided in the rehabilitation gym. This deficient practice had the potential to minimize the usable treatment space of the rehabilitation gym and create a cluttered, crowded environment for residents receiving therapy services. Findings: During an observation of the rehabilitation gym on 10/24/23 at 10:14 am, there was a white cabinet full of boxes of At-Home Coronavirus Disease 2019 (COVID-19, a highly contagious viral infectious disease) test kits (fast and individual tests that can detect the presence of COVID-19 in an individual), a crate of cardboard boxes (at least 4 large boxes) of a type of tube feeding (medical device that provides nutrition to people who cannot eat by mouth) formula, another cabinet with at least five more boxes of tube feeding formula, and underneath the cabinet were more cardboard boxes of multiple brands of tube feeding formula. During an observation and interview inside the rehabilitation gym, on 10/24/23 at 10:16 am, the Occupational Therapist (OTR 1) stated the rehabilitation gym was small and the therapy staff were used to working with little space. OTR 1 confirmed the gym had a crate of multiple boxes of tube feeding formula and a cabinet full of COVID-19 test kits. OTR 1 confirmed the open floor space in the rehabilitation gym did not have room for parallel bars (medical device with two parallel bars that can be used to help residents regain strength and mobility), training stairs (apparatus with multiple stairs of different heights used to help retrain individuals in progressive stepping up and down), or a therapy mat (wide treatment table). During an observation and interview of inside the rehabilitation gym, on 10/24/23 at 2:35 pm, the Director of Rehabilitation (DOR) confirmed the rehabilitation gym was used to store nursing items such as COVID-19 test kits and boxes of tube feeding formula. During an observation inside the rehabilitation gym on 10/25/23 at 12:15 pm, the office area of the rehabilitation gym had multiple cardboard boxes stacked on top of each other and therapy staff put a laptop on top of the stacked cardboard boxes to use as a table. There was a large clear bag of COVID-19 test kits on the floor at the end of the office area. Two residents sitting in wheelchairs were receiving therapy services from therapy staff in the open floor space in the gym. Therapy staff had to move one resident and one staff to one side of the room for the surveyor to move from the office area of the gym to the exit door of the gym. Another resident was sitting in a WC directly outside the rehab gym door and was receiving therapy with one staff member outside the therapy room. During an observation and interview inside the rehabilitation gym, on 10/25/23 at 2:56 pm, DOR stated that the rehabilitation gym was cluttered before. DOR confirmed the rehabilitation gym still had multiple cardboard boxes underneath the cabinet area that were full of boxes of different brands of tube feeding formula and COVID-19 test kits inside the cabinet doors. DOR confirmed there was a large bag of COVID-19 test kits on the ground in the office area. During an observation and interview in the rehabilitation gym, on 10/25/23 at 3:01 pm, the Central Supply staff (CS) stated the rehabilitation gym was used to store all the newly delivered boxes of some nursing items such as the different brands of tube feeding formula. CS stated once the other boxes were used and removed from the utility room, the boxes from the gym were then moved to the utility room, but then more boxes are delivered and then stored on a pallet in the gym CS stated he was not sure if there was sufficient space in the facility to store the items in another area. During an interview on 10/26/23 at 4:05 pm, the interim Director of Nursing (CR) stated the rehabilitation gym should not be cluttered and it should not be used as a storage space for non-therapy items. During a review of the facility's policies and procedures (P/P), revised 12/09, titled, Therapy Rooms, Equipment and Supplies, the P/P indicated, adequate space for Therapeutic Services is provided and meets the independent and group activity needs of the residents.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to address the following for three of seventeen sampled r...

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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 address the following for three of seventeen sampled residents (Resident 40 and Resident 10), including: 1. failed to develop and implement a comprehensive and resident-centered care plan regarding Resident 40's communication needs, visual deficits, and visual deficits. 2. failed to ensure there was a care plan developed to monitor and address resident's behavior related to the use of a psychotropic, for one (1) of 31 sampled residents (Resident 10). These deficient practices have the potential to delay care or services provided for Resident 40 and Resident 10. Findings: 1. During a review of Resident 40's admission assessment (face sheet), the face sheet indicated Resident 40 was admitted to the facility on [DATE] with diagnosis of diabetes mellitus (a disease that causes inappropriate levels of blood sugar) and paraplegia (can not move the legs and lower body). The face sheet indicated Resident 40's primary language was Spanish. During a review of Resident 40's minimum data set (MDS, a standardized assessment and screening tool) dated 7/20/2023, the MDS indicated Resident 40 was able to understand others and make himself understood. The MDS indicated Resident 40 had minimal difficulty with hearing and used corrective lenses. During a review of Resident 40's exam report from a hearing aid center dated 7/21/2023, the exam report indicated Resident 40 had moderate to severe hearing loss and bilateral ear hearing aids were recommended. During an observation and concurrent interview on 10/26/2023 at 11:20 a.m., Resident 40 stated he mainly speaks Spanish but could semi communicate in English. Resident 40 stated he had bilateral ear hearing aids, but he had not put them on yet for the day and they were in his bedside drawer. An observation of Resident 40 indicated he wore glasses. During an interview on 10/27/2023 at 12:39 p.m., certified nursing assistant (CNA) 5 stated Resident 40 spoke some English, but his primary language was Spanish. CNA5 stated Resident 40 was able to answer and understand simple questions in English but if it was something more complex, she would grab a Spanish speaking nurse for translation. CNA5 stated Resident 40 wore glasses and hearing aids. During an interview and concurrent record review on 10/27/2023 at 12:42 a.m., the registered nurse supervisor (NS) stated a resident should have a care plan for communication if their primary language was something other than English and a vision and hearing care plan if a resident had any issues with vision or hearing. The NS reviewed the care plans for Resident 40 and stated there was not a care plan for communication, vision, or hearing. The NS stated the importance of care plans was to provide proper care to the resident and meet their needs. During an interview on 10/27/2023 at 1:01 p.m., the Regional Clinical Resource-interim director of nursing/ registered nurse supervisor (CR) stated a communication care plan was required for a resident whose primary language was not English. The CR state a vision and hearing care plan was required if a resident had hearing or vision deficits. The CR stated care plans were important to tailor care to the resident's needs. During a review of the facility's policy and procedure (P/P) titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P/P indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was to be developed and implemented for each resident. 2. During a review of Resident 10's admission Record, the admission record indicated Resident 10 was originally admitted to the facility on [DATE], with diagnoses including anemia (condition in which the body does not have enough healthy red blood cells, coronary artery disease(CAD-caused by plaque buildup in the wall of the arteries that supply blood to the heart), hypertension( high blood pressure) During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 impaired vision. Resident 10 able to understand others and able to be understood. The MDS indicated Resident 10 required set up on eating, supervision on oral hygiene, maximal assistance on rolling left to right, sit to stand and unable to ambulate. During a record review of Resident 10 physician orders indicated resident had the following psychotropics (medications that affect a person's mental state): 1. Bupropion (generic for Wellbutrin) 75 milligram (mg, an unit of weight used in measuring the strength of medication) 1 tablet every night at bedtime for major depression disorder as evidence by persistent refusal of care. 2. Duloxetine (generic for Duloxetine) 60 mg 2 capsules daily for neuropathic pain (nerve pain). On 10/27/23 at 11:20 AM during an interview with a concurrent review of Resident 10's care plan, the Clinical Resource nurse (CR, who was acting as the interim Director of Nursing) stated Resident 10's care plan addressed resident's mood of sadness, but the care plan did not address the behavioral of care refusal. CR stated the care plan goal to achieve improved mood as evidenced by happier demeanor was incorrect. A review of the facility policy and procedure, Behavioral Assessment, Intervention and Monitoring (dated 2019), indicated . The care plan will include, as a minimum: a description of the behavioral symptoms .

CONCERN (E)

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

Deficiency F0657 (Tag F0657)

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 a. revise one of 17 sampled residents' (Resident 19) ...

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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 a. revise one of 17 sampled residents' (Resident 19) care plan to reflect Resident 19's current Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) orders and treatment plan. b. implement the comprehensive care plan for one of one sampled resident (Residents 54) who sustained a fall on 10/9/2023. This deficient practice had the potential for Resident 19 to not receive the most current RNA treatment plan and staff may not know the correct services to provide the resident. This deficient practice had the potential to place Resident 54 at risk for recurrent falls. Findings: a. During a review of Resident 19's admission Record , the admission record indicated Resident 19 initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting right dominant side, functional quadriplegia (weakness or paralysis to all four extremities), acquired absence of left leg above knee (surgical removal of a limb). During a review of Resident 19's Minimum Data Set (MDS) a standardized assesment and care planning tool, dated 7/12/23, the MDS indicated Resident 19 was severely impaired with daily decision making, required extensive assistance (requires significant amount of assistance from another person to perform task) with bed mobility, dressing, and eating, and total dependence with transfer, toileting, personal hygiene. The MDS also indicated Resident 19 had functional limitation in range of motion (ROM, full movement potential of a joint) on one side of both the upper extremity (UE, shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). During a review of Resident 19's Order Summary Report dated 10/26/23, the report indicated an order dated 2/28/22 for RNA to apply right knee splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) four (4) to five (5) hours or as tolerated once a day 5 times a week (5x/wk), an order dated 2/28/22 for RNA for PROM (PROM, movement at a given joint with full assistance from another person) on right lower extremity (RLE) as tolerated once a day 5x/wk, an order dated 3/7/22 for RNA for PROM on left lower extremity (LLE) as tolerated once a day 5x/wk, an order dated 5/16/22 for RNA for PROM on right upper extremity (RUE) once a day 5x/wk, an order dated 5/16/22 for RNA for application of right elbow splint as long as tolerated once a day 5x/wk, an order dated 5/16/22 for RNA for application of right resting hand splint as long as tolerated once a day 5x/wk. During a review of Resident 19's care plan dated 12/14/20 titled Restorative Splint and Brace Assistance. the care plan indicated a goal to prevent contractures and maintain skin integrity for 90 days. The care plan interventions included RNA for PROM to R and L LE once a day 5x/wk or as tolerated, RNA for PROM to RUE once a day 5x/wk or as tolerated, RNA for right knee splinting for two (2) hours as tolerated, RNA for right elbow splint application 5x/wk for 4 hours as tolerated, RNA for right hand bulb application 5x/wk for 4 hours as tolerated, RNA for right resting hand splint application 5x/wk for 4 hours as tolerated. During a review of Resident 19's care plan dated 8/7/21 titled Resident/Patient requires assistance/is dependent for activities of daily living (ADL, basic activities such as eating, dressing, toileting) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to history of Cerebral vascular accident (CVA, blood flow stops to a part of the brain, brain damage due to blocked blood flow), functional quadriplegia (extreme weakness of arms and legs), history below knee amputation, limited mobility, mood symptoms the care plan indicated a goal for resident's ADL care needs will be anticipated and met through the next review period. The care plan interventions included RNA for PROM right UE 5x/wk as tolerated, RNA for PROM RLE 2 sets of 10 as tolerated, RNA for R knee splinting for 2 hours as tolerated, RNA for right elbow splint application 5x/wk for 4 hours as tolerated. On 10/26/23 at 3:25 pm, during an interview and concurrent record review of Resident 19's care plans and Resident 19's active physician's orders, the Registered Nurse Supervisor (NS 1) confirmed that Resident 19's care plan titled Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: history of CVA, functional quadriplegia, history BKA, limited mobility, mood symptoms and the care plan titled Restorative splint and brace assistance: patient cannot apply and remove splint/brace functional deterioration, CVA, functional quadriplegia did not reflect Resident 19's current RNA orders. NS 1 stated the MDS coordinator, any nurse completing a change of condition, and registered nurse supervisors were responsible for updating care plans when any orders, including RNA orders, were revised. NS 1 stated care plans should be revised when orders were changed to reflect the treatments and services the resident was currently receiving from the facility and so that staff would know what to do with the resident. During an interview on 10/26/23 at 4:05 pm, the interim Director of Nursing stated all resident care plans should reflect the current physician's orders so that the care plan reflected what the resident was currently receiving at the facility. b.During a review of Resident 54's admission record, the admission record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses including diffuse traumatic brain injury with loss of consciousness, Parkinson's disease (chronic disorder that causes the brain to break of production of the chemical messengers to the brain), abnormal gait and mobility, hypertension (high blood pressure), neuromuscular dysfunction of bladder (lack of bladder control), epilepsy (seizure [abnormal electrical activity in the brain that causes muscle twitching, or jerking]), and dementia without behavioral disturbance (impaired ability to think or make decisions without exhibiting behaviors such as agitation and depression). During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired. The MDS indicated Resident 54 required extensive assistance for all aspects of activities of daily living (ADLs personal care). The MDS indicated Resident 54 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 54 used a wheelchair and walker for mobility and had no impairments on both the upper and lower extremities (arms and legs). During review of Resident 54's untitled Care Plan (CP) initiated on 10/9/2023, the CP indicated Resident 54 had an actual fall. The CP intervention initiated on 10/9/2023 included setting Resident 54's bed in a low position. The CP intervention initiated on 10/11/2023 included Resident 54 having bilateral (both sides) floor mats. Additionally, an intervention initiated on 10/10/2023 indicated Resident 54 have a concave (curved inwards) bed to prevent sliding off the bed. During a review of Resident 54's Nursing Document Evaluation, the Fall risk Factor on 2/17/2023 indicated Resident 54 had a history of falls in the last 6 months, poor safety judgement, required assistance for toileting, had an unsteady gait, and utilized cardiac (heart) medications. During a review of Resident 54's Change of Condition (COC) Evaluation dated 10/9/2023, documented by a Licensed Vocational Nurse (LVN), the COC indicated on 10/9/2023, Resident 54 was found on the floor in front of the bed with the palms of her hands on the floor, sitting up facing the bathroom door. During a review of Resident 54's Interdisciplinary Team (IDT: Resident's health care team members from various medical specialties) Fall document dated 10/9/2023, the IDT recommended Resident 54 a concave bed to prevent the resident sliding off the bed with bilateral mats. During a concurrent observation and interview on 10/24/2023 at 4:05p.m. with Registered Nurse Supervisor 2 (NS 2), of a wedge (a device made of foam that is used to position the resident) NS 2 stated the wedge for offloading that is placed under the mattress of Resident 54's bed is positioned to prevent Resident 54 from falling off the bed. NS 2 stated it prevents Resident 54 from rolling out of bed since Resident 54 usually moves all over the bed. NS 2 stated the staff does what needs to be done in order to keep residents from rolling out of the bed. During a concurrent observation and interview on 10/25/2023 at 10:44 a.m. with Registered Nurse Supervisor 1 (NS 1), NS 1 stated Resident 54 is noncompliant, does not follow directions, and keeps getting out of the bed. NS 1 stated the bed against the wall is for the safety of Resident 54. NS 1 stated despite Resident 54 being in bed, she will roll onto the other side, so when a Certified Nursing Assistant (CNA) tends to Resident 54, the resident can safely roll so she does not fall. During a concurrent interview and record review on 10/26/2023 at 10:53 a.m. with NS 1, NS 1 stated Resident 54 fell on [DATE] and was found on the floor. NS 1 stated Resident 54 should have a fall mat on one side (intervention states bilateral fall mats) and interventions need to be implemented if it is on the CP for resident safety and to prevent further injuries. NS 1 stated Resident 54 needs a CP regarding her behavior of constantly getting out of bed. NS 1 stated interventions are goals and are provided to prevent Resident 54 from falling and having any other injuries. NS 1 stated Resident 54 should have fall mats and indicated at times the housekeeper will take the fall mats to wash, dry, and bring it back. NS 1 stated fall mats are for fall risk residents or for residents who keep falling out of bed. NS 1 stated fall risk assessments are done upon admission and if a resident fell, another fall risk assessment is done. NS 1 stated Resident 54 does not have a fall risk assessment but has an initial fall risk factor that was done on 2/17/2023. During an interview on 10/26/2023 at 12:06p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated fall risk assessments are done at admission and does not know how often the fall risk assessments are done. LVN 2 stated Resident 54 is supposed to have a fall risk assessment at admission. During an interview on 10/27/2023 at 11:07a.m. with Director of Staff Development (DSD), DSD stated if there was a fall, there would be an inservice and is not aware of any recent falls for the month of October. DSD stated if a resident fell, she would communicate with the Charge Nurse (CN), ask about the COC, and discuss the incident in the morning. DSD stated if none of the staff members are aware of the fall, they will not know what happened to the resident. DSD stated the facility does not use stars to indicate that a resident is a fall risk and since all of the residents are fall risk, they use low beds for the safety of the residents. A review of the facility's policy and procedures(P&P), revised 7/17, titled, Resident Mobility and Range of Motion, indicated the care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. During a review of the facility's P&P titled Falls and Fall Risk, Managing revised on March 2018, the P&P indicated the staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falls. If interventions have been successful in preventing falls, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (dizziness or weakness) has resolved. During a review of the facility's P&P titled Care Plans-Comprehensive Person-Centered revised on March 2022, the P&P indicated care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area and their causes, and relevant clinical decision making. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. During a review of the facility's P&P titled Dementia revised on 6/1/2021, the P&P indicated resident's showing signs of problematic behavior will be identified and managed appropriately. The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: Number and frequency of episodes, preceding or precipitating factors .interventions attempted .and outcomes associated with interventions.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one (1) hour of their prescribed time for Resident 3, one of 31 sampled residents. On 10/25/23, Resident 3 received 10 oral medications 2 hour after the prescribed time. Also, Resident 3 were scheduled to receive 71 doses intravenous (IV, to the vein) Zyvox (a potent antibiotic medication to treat severe systemic infection) administrations as of 10/26/2023; however, and 18 of those 71 doses were documented more than 1 hour late. (Also see F760) 2. Nurses documented in MAR after administering medications, and /or reason it was missed for 2 of 31 sampled residents (Residents 3 and 470). For Resident 3, there was no administration documentations for 12 doses of IV Zyvox. For Resident 470, there was no administration documentation on 2 doses of IV ceftriaxone (a potent antibiotic medication to treat severe systemic infection), out of 5 scheduled doses. These deficient practices had the potential for medication omission, that may worsen infection and affect residents. Findings: During an observationon 10/25/23 at 11:07 AM in the hallway of South nursing station, there was a medication cart blocking the entrance of Resident 3's room. A look inside the room revealed a licensed vocational nurse (LVN 2) was passing oral medications to Resident 3. At 11:10 AM, LVN 2 exited the room and proceeded to document at a computer on the medication cart. During a concurrent interview, LVN 2 stated she administered 10 medications to Resident 3, and those medications were due at 9 AM. LVN 2 stated she was aware Resident 3 received medications late. LVN 2 stated medication administration should be done within 1 hour of the due time, from 1 hour before to 1 hour after the due time. LVN 2 explained she was behind schedule because there were a couple new admissions in the morning that required her attention, thus, the resident received the medications late. During a review of Resident 3's Face Sheet (admission record), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (disease that makes your immune system attack your own nerve cells), osteomyelitis (bone infection), severe protein calorie malnutrition, functional quadriplegia (complete immobility), idiopathic peripheral autonomic neuropathy (nerves that control the automatic body functions are damaged), hypertension (high blood pressure), and neuromuscular dysfunction of bladder (urinary bladder issues). During a review of Resident 3's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/4/2023, the MDS indicated Resident 3's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 3 required total dependence to perform most of activities of daily living (ADL) and required extensive assistance for dressing and bed mobility. The MDS indicated Resident 3 have impairments on both the upper and lower extremities (arms and legs). The MDS indicated Resident 3 had an indwelling catheter (helps drain urine from your body). During a record review of Resident 3's physician orders indicated 10 medications were scheduled at 9 AM, including carvedilol (a medication to treat high blood pressure), a multiple vitamin with mineral, ascorbic acid (a form of vitamin C supplement), cranberry tablet (a form of diet supplement), ferrous sulfate (iron supplement), folic acid (a form of vitamin supplement), oyster shell with vitamin D (a supplement for bone health), cholecalciferol (a form of vitamin D), enulose solution (a form of laxative and also a medication to prevent complications of liver disease). During an observation on 10/26/23 at 8:49 AM at Resident 3's room, IV medication was connected to the resident. A review of the attached label indicated the medication was Zyvox 600 milligram (mg, unit to measure weight) in 300 milliliters (ml, an unit to measure volume) to infuse over 60 minutes, also included was an initial, written date of 10/26/23, and the time of 6 AM. During a concurrent interview, the registered nurse supervisor (NS 1) stated that he administered medication. NS 1 stated he reported to work at 7 AM and administered Resident 3's IV Zyvox upon arrival due to the lack of a night shift registered nurse. NS 1 stated after administering the IV medications, he documented on the medication administration record (MAR) electronically. A concurrent review of Resident 3's MAR indicated the Zyvox was due at 6 AM and the medication was administered at 7:58 AM. NS 1 stated there is a 1 hour window to administer scheduled medications. NS 1 stated he administered Resident 3's IV Zyvox after arrival to work and confirmed the time on MAR was accurate. During a record review of Resident 3's eMAR indicated there were 18 documented administrations of IV Zyvox that were more than an hour late. Nine of the late administrations were at least 6 hours late, and one of those administration had a delay of 9 hours and 27 minutes after the scheduled dose. The late administrations were as follow: 9/21/23 scheduled at 9 AM, administered at 1:12 PM 9/22/23 scheduled at 9 AM, administered at 1:13 PM 9/25/23 scheduled at 9 AM, administered at 1:09 PM 9/28/23 scheduled at 9 AM, administered at 1:10 PM 9/29/23 scheduled at 9 AM, administered at 1:08 PM 9/30/23 scheduled at 6 AM, administered at 7:44 AM 10/1/23 scheduled at 6 PM, administered at 4:11 PM 10/6/23 scheduled at 6 AM, administered at 8:05 AM 10/7/23 scheduled at 6 AM. administered at 7:33 AM 10/7/23 scheduled at 6 AM, administered at 7:17 AM 10/13/23 scheduled at 6 AM, administered at 3:27 PM 10/14/23 scheduled at 6 AM, administered at 7:36 AM 10/15/23 scheduled at 6 AM, administered at 7:38 AM 10/20/23 scheduled at 6 AM, administered at 2:11 PM 10/22/23 scheduled at 6 AM, administered at 7:10 AM 10/24/23 scheduled at 6 AM, administered at 10:01 AM 10/26/23 scheduled at 6 AM, administered at 7:58 AM During an interview on 10/26/23 at 11:12 AM with the Clinical Resource nurse (CR, who was acting as the interim Director of Nursing), CR stated Resident 3's total doses given as of 10/26/23 were 71 doses. During a concurrent review of Resident 3's eMAR, CR stated there were 12 doses did not have administration documentation (the boxes that nurses initial were blank). CR stated if the dose was refused, there should be a R at the box with initial and the box should not be blank. During an interview on 10/26/23 at 4 PM with NS 1,NS1 stated he sometimes worked double shifts overseeing two stations and the morning shifts were always very busy. NS 1 stated he sometimes got sidetracked and forgot to document in eMAR until later. During a review of Resident 470's face sheet, the face sheet indicated Resident 3 was admitted to the facility 10/21/2023 with diagnosis of hypertension, atrial fibrillation( an irregular and often very rapid heart rhythm), and hyperlipidemia . During a review of Resident 470's MDS, dated [DATE], the MDS indicated Resident 470 was able to make himself understood and was able to understand others. During a concurrent interview on 10/27/23 at 12:47 PM and record review of Resident 470's MAR, 2 out of 5 scheduled doses of ceftriaxone (an antibiotic medication to treat systemic infection) were blank. CR acknowledged the nurse did not document medication administration. During a record review of the facility's policy and procedure(P&P), Administering Medications (dated 2019), indicated . Medications are administered within one (1) hour of their prescribed time . The individual administering the medication initials the resident's MAR on the appropriated line after giving each medication and before administering the next ones .

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure antipsychotic (medications that treat psychosis [a severe m...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure antipsychotic (medications that treat psychosis [a severe mental condition that affects thoughts and emotions and causes a break with reality]-related conditions and symptoms) and psychotropic (medications that affect a person's mental state) medication orders for three (3) of 31 sampled residents (Residents 26,10, and 12). For Resident 26, the antipsychotic medications did not have documented rationale for the use of Abilify (an antipsychotic) to treat a specific, diagnosed, and documented behavior. The facility also failed to ensure there was a monthly report of consolidated behavioral data available to the prescribersFor Resident 10, resident's psychotic medication order did not have an indication (a reason) of use or treat a specific and documented behavior. For Resident 12, the facility failed to indicate rationale for use of psychotropic medication and no care plan was developed. These deficient practices had the potential of misuses of medications and unnecessary medication for Resident 26, Resident 10 and Resident 12. Findings: a. During a review of Resident 26's admission Record, the admission record indicated Resident 26 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including weakness, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body), history of falling, encephalopathy (a disease damaged the functions of the brain) During a review of Resident 26's Comprehensive Minimum Data Set (MDS- a standardized assessment and screening tool) dated March 21, 2023, the MDS indicated Resident 26 had moderately impaired cognitive skills for daily decision making. The MDS indicated impaired vision and has inability to see regular print in newspapers/ books. The MDS indicated Resident 26 required extensive assistance for bed mobility, transfer, walk in the room, walk in the corridor, locomotion on unit, off unit, dressing, toilet use and personal hygiene. The MDS indicated Resident 26 was not steady while walking moving from seated to standing position. The MDS indicated functional limitation of both upper and lower extremity. On 10/27/23 at 8:55 AM during an interview, the Registered Nurse Supervisor (RNS 1) stated Resident 26 had an order for Abilify 2 milligram (mg, unit to measure weight) daily for mood stabilizer. During a concurrent interview at 9:07 AM, RNS 1 stated the order did not contain a specific behavior that would indicate the use. On 10/27/23 at 11:12 AM during an interview, the Clinical Resource nurse (CR, who was acting as the interim Director of Nursing) reviewed Resident 26's order for Abilify and confirmed the order did not contain a targeted behavior for monitoring. During a concurrent review of Resident 26's progress notes, CR stated there was no documentation of a clinical rationale for the start of Resident 26's Abilify. During a review of Resident 26's order to monitor episodes of psychotic feature as evidenced by irritability, CR stated the description was not specific. During a review of Resident 26's admission record, CR stated Resident 26's admission diagnoses did not include behavioral issues. b. During a review of Resident 10's admission Record, the admission record indicated Resident 10 was originally admitted to the facility on [DATE], with diagnoses including anemia (condition in which the body does not have enough healthy red blood cells, coronary artery disease(CAD-caused by plaque buildup in the wall of the arteries that supply blood to the heart), hypertension( high blood pressure) During a review of Resident 10's MDS dated [DATE], the MDS indicated Resident 10 impaired vision. Resident 10 able to understand others and able to be understood. The MDS indicated Resident 10 required set up on eating, supervision on oral hygiene, maximal assistance on rolling left to right, sit to stand and unable to ambulate. A review of Resident 10 physician orders indicated resident had the following psychotropics: 1. Bupropion (generic for Wellbutrin, a psychotropic that treats depression) 75 mg 1 tablet every night at bedtime for major depression disorder as evidence by persistent refusal of care. 2. Duloxetine (generic for Duloxetine, a psychotorpic that treats depression and neuropathic, or nerve, pain) 60 mg 2 capsules daily for neuropathic pain (nerve pain). A review of Resident 10's psychiatrist progress notes and psychologist notes did not indicate behavioral issues nor documentation of care refusal. On 10/27/23 at 11:37 AM, during an interview, CR stated the facility did not have the record of reporting consolidated monthly behavioral data summary to prescribers for both Residents 10 and 26. During a review of Resident 12's admission record, the admission record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance (impaired ability to think or make decisions accompanied by behaviors such as agitation and depression), lack of coordination, neurocognitive disorder (group of conditions that affect cognitive performance in various areas), depression (persistently low mood, that interferes with daily life). During a review of Resident 12's Minimum Data Set (MDS a standardized assessment and care screening tool), dated 8/26/2023, the MDS indicated Resident 12's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were severely impaired. The MDS indicated Resident 12 required extensive assistance for all activities of daily living (ADL). The MDS indicated Resident 12 was not steady transferring from sit to standing position and surface to surface transfers and is able to only stabilize with staff assistance. The MDS indicated Resident 12 used a wheelchair and walker for mobility and have no impairments on both the upper and lower extremities (arms and legs). The MDS indicated Resident 12 did not exhibit any behavioral symptoms or potential indicators of psychosis. During a review of Resident 12's Order Summary Report (Physician's Orders) the report indicated an order for Risperdal (antipsychotic medication used to treat mental or mood disorders) 0.5 mg oral tablet at bedtime for psychosis (combination of symptoms resulting in an impaired relationship with reality) manifested by visual hallucinations (seeing something that does not exist) on 8/24/2023. Resident 12 additionally had Venlafaxine (an antidepressant used to treat depression) 37.5mg one tablet once a day for depression manifested by feeling by crying. During a concurrent interview and record review on 10/27/2023 at 11:46 a.m. with the CR, the CR stated the order for Risperdal should identify specific visual hallucinations Resident 12 had. The CR stated Resident 12 does not have a CP for Risperdal and indicated it is important to know whether the medication is affective or not. If the resident is not properly monitored, we would not know if the medication would have to be increased or decreased. During a concurrent interview and record review on 10/27/2023 as 12:22 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated antipsychotic medications are monitored daily and should indicate why the resident is getting the medication. LVN 1 stated Resident 12 was admitted on [DATE] and started taking Risperdal 0.5mg on 8/24/2023 for visual hallucinations but did not indicate anywhere what the visual hallucinations Resident 12 was seeing. LVN 1 stated it does not specify what Resident 12 saw and it should be documented more specifically as they do not know what exactly they were monitoring for the visual hallucinations. LVN 1 stated there are no CPs for Risperdal and Venlafaxine and there should be specific CP's for the medications as a CP has specific goals and provides a guide for accurate monitoring to see if the goal has been met. LVN 1 stated there should be evaluations for psychotropic medications to reassess and identify if the dose can be decreased, increased, or discontinued. LVN 1 stated if a resident continued to get medications that are not appropriate for them, it may have long term effects. A review of the facility policy and procedure, Behavioral Assessment, Intervention and Monitoring (dated 2019), indicated . The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes . When medications are prescribed for behavioral symptoms, documentation will include: rationale for use, potential underlying causes of the behavior, . specific target behaviors, . monitoring for efficacy .

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure: 1. Medications were administered within one (1) hour of their prescribed time for Resident 3, one of 31 sampled residents. On 10/25/23, Resident 3 received 10 oral medications 2 hour after the prescribed time. Also, Resident 3 were scheduled to receive 71 doses intravenous (IV, to the vein) Zyvox (a potent antibiotic medication to treat severe systemic infection) administrations as of 10/26/2023; however, and 18 of those 71 doses were documented more than 1 hour late. (Also see F760) 2. Nurses documented in MAR after administering medications, and /or reason it was missed for 2 of 31 sampled residents (Residents 3 and 470). For Resident 3, there was no administration documentations for 12 doses of IV Zyvox. For Resident 470, there was no administration documentation on 2 doses of IV ceftriaxone (a potent antibiotic medication to treat severe systemic infection), out of 5 scheduled doses. These deficient practices had the potential for medication omission, that may worsen infection and affect residents. Findings: During an observationon 10/25/23 at 11:07 AM in the hallway of South nursing station, there was a medication cart blocking the entrance of Resident 3's room. A look inside the room revealed a licensed vocational nurse (LVN 2) was passing oral medications to Resident 3. At 11:10 AM, LVN 2 exited the room and proceeded to document at a computer on the medication cart. During a concurrent interview, LVN 2 stated she administered 10 medications to Resident 3, and those medications were due at 9 AM. LVN 2 stated she was aware Resident 3 received medications late. LVN 2 stated medication administration should be done within 1 hour of the due time, from 1 hour before to 1 hour after the due time. LVN 2 explained she was behind schedule because there were a couple new admissions in the morning that required her attention, thus, the resident received the medications late. During a review of Resident 3's Face Sheet (admission record), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (disease that makes your immune system attack your own nerve cells), osteomyelitis (bone infection), severe protein calorie malnutrition, functional quadriplegia (complete immobility), idiopathic peripheral autonomic neuropathy (nerves that control the automatic body functions are damaged), hypertension (high blood pressure), and neuromuscular dysfunction of bladder (urinary bladder issues). During a review of Resident 3's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/4/2023, the MDS indicated Resident 3's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 3 required total dependence to perform most of activities of daily living (ADL) and required extensive assistance for dressing and bed mobility. The MDS indicated Resident 3 have impairments on both the upper and lower extremities (arms and legs). The MDS indicated Resident 3 had an indwelling catheter (helps drain urine from your body). During a record review of Resident 3's physician orders indicated 10 medications were scheduled at 9 AM, including carvedilol (a medication to treat high blood pressure), a multiple vitamin with mineral, ascorbic acid (a form of vitamin C supplement), cranberry tablet (a form of diet supplement), ferrous sulfate (iron supplement), folic acid (a form of vitamin supplement), oyster shell with vitamin D (a supplement for bone health), cholecalciferol (a form of vitamin D), enulose solution (a form of laxative and also a medication to prevent complications of liver disease). During an observation on 10/26/23 at 8:49 AM at Resident 3's room, IV medication was connected to the resident. A review of the attached label indicated the medication was Zyvox 600 milligram (mg, unit to measure weight) in 300 milliliters (ml, an unit to measure volume) to infuse over 60 minutes, also included was an initial, written date of 10/26/23, and the time of 6 AM. During a concurrent interview, the registered nurse supervisor (NS 1) stated that he administered medication. NS 1 stated he reported to work at 7 AM and administered Resident 3's IV Zyvox upon arrival due to the lack of a night shift registered nurse. NS 1 stated after administering the IV medications, he documented on the medication administration record (MAR) electronically. A concurrent review of Resident 3's MAR indicated the Zyvox was due at 6 AM and the medication was administered at 7:58 AM. NS 1 stated there is a 1 hour window to administer scheduled medications. NS 1 stated he administered Resident 3's IV Zyvox after arrival to work and confirmed the time on MAR was accurate. During a record review of Resident 3's eMAR indicated there were 18 documented administrations of IV Zyvox that were more than an hour late. Nine of the late administrations were at least 6 hours late, and one of those administration had a delay of 9 hours and 27 minutes after the scheduled dose. The late administrations were as follow: 9/21/23 scheduled at 9 AM, administered at 1:12 PM 9/22/23 scheduled at 9 AM, administered at 1:13 PM 9/25/23 scheduled at 9 AM, administered at 1:09 PM 9/28/23 scheduled at 9 AM, administered at 1:10 PM 9/29/23 scheduled at 9 AM, administered at 1:08 PM 9/30/23 scheduled at 6 AM, administered at 7:44 AM 10/1/23 scheduled at 6 PM, administered at 4:11 PM 10/6/23 scheduled at 6 AM, administered at 8:05 AM 10/7/23 scheduled at 6 AM. administered at 7:33 AM 10/7/23 scheduled at 6 AM, administered at 7:17 AM 10/13/23 scheduled at 6 AM, administered at 3:27 PM 10/14/23 scheduled at 6 AM, administered at 7:36 AM 10/15/23 scheduled at 6 AM, administered at 7:38 AM 10/20/23 scheduled at 6 AM, administered at 2:11 PM 10/22/23 scheduled at 6 AM, administered at 7:10 AM 10/24/23 scheduled at 6 AM, administered at 10:01 AM 10/26/23 scheduled at 6 AM, administered at 7:58 AM During an interview on 10/26/23 at 11:12 AM with the Clinical Resource nurse (CR, who was acting as the interim Director of Nursing), CR stated Resident 3's total doses given as of 10/26/23 were 71 doses. During a concurrent review of Resident 3's eMAR, CR stated there were 12 doses did not have administration documentation (the boxes that nurses initial were blank). CR stated if the dose was refused, there should be a R at the box with initial and the box should not be blank. During an interview on 10/26/23 at 4 PM with NS 1,NS1 stated he sometimes worked double shifts overseeing two stations and the morning shifts were always very busy. NS 1 stated he sometimes got sidetracked and forgot to document in eMAR until later. During a review of Resident 470's face sheet, the face sheet indicated Resident 3 was admitted to the facility 10/21/2023 with diagnosis of hypertension, atrial fibrillation( an irregular and often very rapid heart rhythm), and hyperlipidemia . During a review of Resident 470's MDS, dated [DATE], the MDS indicated Resident 470 was able to make himself understood and was able to understand others. During a concurrent interview on 10/27/23 at 12:47 PM and record review of Resident 470's MAR, 2 out of 5 scheduled doses of ceftriaxone (an antibiotic medication to treat systemic infection) were blank. CR acknowledged the nurse did not document medication administration. During a record review of the facility's policy and procedure(P&P), Administering Medications (dated 2019), indicated . Medications are administered within one (1) hour of their prescribed time . The individual administering the medication initials the resident's MAR on the appropriated line after giving each medication and before administering the next ones .

CONCERN (E)

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

Medical Records (Tag F0842)

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 maintain complete and accurate medical records by fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records by failing to ensure the following: a. Resident 21's Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment provided on 10/25/23 was accurately documented by Restorative Nursing Aide 2 (RNA 2), the RNA who performed the RNA treatment session. b. Resident 47's Interdisciplinary Therapy Screens (facility's resident's functionality screening documentation) dated 6/23/23 was included in Resident 47's medical record. c. Resident 28's Interdisciplinary Therapy Screens dated 9/29/23 and 10/25/23 was included in Resident 28's medical record. These failures had the potential for the residents to have inaccurate medical records and could affect their care planning and services received at the facility. Findings: a. During a review of Resident 21's admission Record, the admission record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body), left hand contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), left ankle and foot contracture, left elbow contracture. During a review of Resident 21's Minimum Data Set (MDS) a standardized screening and care planning tool dated 8/2/23, the MDS indicated Resident 21 had severely impaired cognition (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). The MDS also indicated Resident 21 required extensive assistance (requires significant amount of assistance from another person to perform task) for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS also indicated Resident 21 had impairments in functional limitation in range of motion (ROM, full movement potential of a joint) on one side of the upper extremity (UE, shoulder, elbow, wrist, hand) and lower extremity (LE, hip, knee, ankle, foot). The MDS also indicated, in Section O for Special Treatments, Procedures, and Programs under Restorative Nursing Programs, Resident 21 received five (5) days of passive range of motion (PROM, movement at a given joint with full assistance from another person) technique, 5 days of active range of motion (AROM, movement at a given joint when the person moves voluntarily) technique, and seven days of splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) or brace (an external device to support, align, or correct a movable part of the body) assistance technique. During a review of Resident 21's Order Summary Report dated 10/26/23, the summary report indicated a physician's order dated 6/9/22 for RNA for application of left pressure relief ankle foot orthosis (PRAFO, an orthotic device designed to correct or address problems with the ankle and foot and provide pressure relief at heels) for four (4) hours as tolerated once a day five times a week (5x/wk); an order dated 6/9/22 for RNA for AROM on right left extremity (RLE) as tolerated once a day 5x/wk; an order dated 6/9/22 for RNA for PROM on left lower extremity (LLE) as tolerated once day 5x/wk; an order dated 8/28/23 for RNA for left elbow splint application for 4 hours as tolerated once a day 5x/wk; an order dated 8/28/23 for RNA for left resting hand splint application for 4 hours as tolerated once a day 5x/wk; an order dated 8/28/23 for RNA for PROM on left upper extremity (LUE) all available planes as tolerated once a day 5x/wk. During a review of Resident 21's care plan revised 9/14/23, the care plan indicated Resident 21 was at risk for decreased ability to perform activities of daily living (ADL, basic activities such as eating, dressing, toileting) bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to decreased mobility. The care plan goal indicated to maintain LLE ROM and RLE strength and to maintain the highest capable level of ADL ability throughout the next review period as evidenced by his ability to perform ADLs and least level of support needed to perform. The care plan interventions included RNA for PROM all available joints and planes on LUE once a day 5x/wk as tolerated, RNA for application of left resting hand splint and left elbow splint as long as tolerated once a day 5x/wk for further contracture and skin breakdown prevention, RNA for PROM on LLE as tolerated once a day 5x/wk, RNA for application of L PRAFO 4 hours or as tolerated once a day 5x/wk. During a review of Resident 21's RNA October 2023 treatment record, the treatment record indicated RNA staff initials for each day RNA treatment was completed. On 10/25/23, RNA 1 initialed Resident 21's RNA treatment record. There was no comment or circle around the initials on 10/25/23 to indicate Resident 21 did not wear or tolerate splints for less than 4 hours. On 10/24/23 at 10:02 am, during an observation and interview, Resident 21 was lying in bed on the back with the head of the bed up around 45 degrees. Resident 21 had a cushion underneath the left arm, the left elbow was bent about halfway, the left wrist was bent forward, and the left fingers were bent. There was a hand splint noted at the resident's foot of the bed. Resident 21 stated he did not perform any exercises yet that day and had not had any splints put on yet. On 10/25/23 at 3:07 pm, during an observation and interview in Resident 21's room, Resident 21 was in bed wearing a t-shirt. Resident 21 did not have any splints on the upper or lower extremities. During an interview on 10/25/23 at 3:09 pm, RNA 1 stated she did not complete the RNA session for Resident 21 today. RNA 1 stated RNA 2 completed the RNA session with Resident 21 today. During an interview on 10/26/23 at 9:28 am, RNA 2 stated he completed the RNA ROM exercises with Resident 21 yesterday (10/25/23) and Resident 21 wore the left elbow, left resting hand splints, and left PRAFO for about two (2) hours. RNA 2 stated he did not have time to complete the RNA documentation yesterday. On 10/26/23 at 10:41 am, during an interview and record review of Resident 21's October 2023 RNA treatment record, RNA 2 stated he completed the RNA treatment session with Resident 21 on 10/25/23. RNA 2 reviewed Resident 21's October 2023 RNA treatment record and confirmed it was RNA 1's initials on 10/25/23 indicating that RNA 1 completed the RNA treatment session on that day. RNA 2 stated he did not initial and complete the documentation on 10/25/23 in the RNA treatment record. RNA 2 stated he asked RNA 1 to help him complete the documentation for the RNA treatment on 10/25/23. RNA 2 stated that he should have initialed and completed the documentation because he was the staff member that completed the RNA treatment on 10/25/23. RNA 2 stated because he did not document for the RNA treatment that day, he also did not document in the RNA treatment record that Resident 21 tolerated the left elbow, left resting hand splint and L PRAFO for only 2 hours. RNA 2 stated he would document the resident's response to the splints by circling the initial on that day and writing a comment on the back of the RNA treatment record. RNA 2 stated that staff should always document if the resident could not tolerate the recomended amount of time wearing the splint that was ordered and inform the charge nurse so that the nurse could assess the resident. During an interview on 10/26/23 at 4:05 pm, the interim Director of Nursing (CS) stated that all documentation should be accurate and complete. CS stated that staff who complete the RNA treatment should be the only staff that can document the treatment was completed. CS stated the RNAs should document how long a resident tolerated the splint that day so that staff would have accurate information and monitor a resident's health correctly. During a review of the facility's Job Descriptions for Long-Term Care Facilities, revised 10/20, titled, Restorative Nursing Assistant, the job description indicated an essential function of an RNA's duties and responsibilities included, ensure that all restorative care notes are information and descriptive of the treatment provided and the resident's response to the care. During a review of the facility's policy and procedure (P/P), revised 4/12, titled, Guidelines for Charting and Documentation, the P/P indicated, the purpose of charting and documentation is to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress of the resident's care .the facility as well as other interested parties, with a tool for measuring the quality of care provided to the resident . It indicated as a general for charting and documentation to chart all pertinent changes in the resident's condition, reaction to treatments, medication, etc., as well as routine observations. Be concise, accurate, and complete. b. During a review of Resident 47's admission Record, the admission record indicated Resident 47 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side and contracture left lower leg. During a review of Resident 47's MDS dated [DATE], the MDS indicated Resident 47 had moderate cognitive impairment, required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene. The MDS also indicated the activities of transferring, walking, locomotion did not occur. The MDS also indicated Resident 47 had functional limitations in range of motion on one side of both the upper and lower extremities. During a review of Resident 47's paper and electronic medical record, the record did not indicate any rehabilitation therapy screenings for Resident 47. During an interview on 10/24/23 at 2:35 pm, the Director of Rehabilitation (DOR) stated therapy staff completed an Interdisciplinary Therapy Screen for Resident 47 but was not sure when the screen was completed and had to locate the therapy screen on the contracted rehabilitation company's system. DOR confirmed Resident 47's Interdisciplinary Screen was not located in Resident 47's paper or electronic medical records and had to be retrieved separately from the rehabilitation company's Google Docs (a web-based application offered by Google, a technology company). During a review of Resident 47's Interdisciplinary Therapy Screen dated 6/23/23, the Interdisciplinary Therapy Screen indicated the DOR screened Resident 47 and indicated a change in status due to pain and requested Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) evaluation orders. c. During a review of Resident 28's admission Record, the admission record indicated Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to, Type 2 Diabetes Mellitus (a chronic disease that affects how the body processes sugar) with diabetic chronic kidney disease (gradual loss of kidney function to filter waste and excess fluid from the blood), acquired absence of right leg below knee (surgical removal of limb). During a review of Resident 28's MDS dated [DATE], the MDS indicated Resident 28 was cognitively intact, required limited assistance with bed mobility, transfer, locomotion, dressing, toileting, and personal hygiene. The MDS also indicated the activity of walking did not occur. During a review of Resident 28's paper and electronic medical record, the records did not indicate any rehabilitation therapy screenings for Resident 28. During an observation and interview on 10/24/23 at 9:15 am, Resident 28 was laying on the left side in the bed. Resident 28 stated he had an amputation in his right leg about five years ago and stated he was able to move around himself with the wheelchair in the facility. Resident 28 was able to move all available extremities without limitations. During an interview on 10/25/23 at 2:56 pm, the DOR stated therapy staff completed therapy screens for Resident 28 and the therapy screens indicated that Resident 28 was offered RNA and PT to work on ambulation (walking), but declined due to personal reasons. DOR confirmed that the therapy screens were not located anywhere in Resident 28's paper or electronic medical records because it was located on the therapy company's own system on Google Docs. DOR stated that facility staff, health providers, or surveyors could not access the therapy screens from the resident's medical records. During a review of Resident 28's Interdisciplinary Therapy Screen dated 9/29/23 and 10/25/23, indicated the DOR screened Resident 28 on 9/29/23 and indicated no change in status in cognition, communication, self-care, mobility, pain, and bed/chair positioning. The DOR indicated that DOR offered to try to use Resident 28's RLE prothesis (artificial part of the body) for functional use but Resident 28 refused at this time. A review of Resident 28's Interdisciplinary Screen dated 10/25/23 indicated Resident 28 no change in status in cognition, communication, mobility, pain, and bed/chair positioning. The DOR indicated updates on Resident 28's prosthetist appointment and agreeability to work with PT when a new prosthesis arrived. During an interview on 10/24/23 at 2:35 pm, the DOR stated therapy staff completed quarterly screens for all residents, but the therapy screens were not located in the resident's medical records. DOR stated the therapy screens were located in the rehabilitation company's own separate system. DOR stated that if the facility staff wanted to review the therapy screens, then the staff would have to ask for each one specifically. DOR stated that every now and then, if staff had time, they would print out the therapy screens and file them in the resident's paper chart. During an interview on 10/27/23 at 8:22 am, the Rehabilitation Resource Support (RRS) and the interim Administrator (ADM 1) confirmed that the current practice was therapy staff did not include the completed Interdisciplinary Therapy Screens in each resident's paper or electronic medical records. RRS stated the information in the Interdisciplinary Therapy Screens were considered medical records and could be included in each resident's medical records where all staff and health providers could access the document. During a review of the facility rehabilitation therapy contracted provider's P/P, revised 2/14/23, titled Therapy Screenings, the P/P indicated the purpose of the therapy screenings were to gather information about an individual's physical/cognitive/functional performance using an accepted screening process and tool, for the purpose of identifying the individual's care needs and/or for facilitation of interprofessional team collaboration and care planning .to determine the need for more comprehensive evaluation/assessment and/or referral for additional services.

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 implement its infection prevention and control progra...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program for two of two sampled residents (Resident 3 and Resident 30) by failing to: 1. Ensure the Certified Nursing Assistant 8 (CNA 8) and two visitors followed Resident 3's transmission-based precautions (TBP- residents who are known or suspected to be infected or colonized with infectious agents) to prevent spread of infections. 2. Offer personal protective equipment(PPE- equipment worn to minimize exposure to hazards) and inform the visitor why Resident 30 is on enhanced barrier precaution. These deficient practices had the potential to result in the spread of diseases and infection to the facility residents, staff, and the community. Findings: a. During a review of Resident 3's Face Sheet (admission record), the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including multiple sclerosis (disease that makes your immune system attack your own nerve cells), osteomyelitis (bone infection), idiopathic peripheral autonomic neuropathy (nerves that control the automatic body functions are damaged) and hypertension (high blood pressure). During a review of Resident 3's Minimum Data Set [(MDS) a standardized assessment and care screening tool], dated 9/4/2023, the MDS indicated Resident 3's cognitive skills (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) were moderately impaired. The MDS indicated Resident 3 required total dependence to perform most of activities of daily living (ADL) and required extensive assistance for dressing and bed mobility. The MDS indicated Resident 3 have impairments on both the upper and lower extremities (arms and legs). The MDS indicated Resident 3 had an indwelling catheter (helps drain urine from your body). During review of Resident 3's untitled care plan CP initiated on 9/21/2023, the CP indicated Resident 3 has a urinary tract infection with Vancomycin-Resistant Enterococci (VRE: an infection with bacteria that are resistant to the antibiotic called Vancomycin) on contact precaution (prevent spread of bacteria, parasites, and viruses) during duration of antibiotic therapy. The CP intervention initiated on 9/21/2023 indicated for contact precautions, use gown and gloves when performing high-contact activities and educate patient/family and visitors regarding precautions. During a review of the Order Summary Report (Physician Order) indicated Resident 3 is on contact precautions related to VRE in the urine on 10/20/2023 and enhanced standard precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) related to C-Auris on 9/8/2023. During an observation on 10/24/2023 at 12:51p.m. of Resident 3's room, it indicated Resident 3 is on EBP and on contact precautions, and a visitor was in the room feeding Resident 3 without donning proper PPE. During an observation on 10/24/2023 at 4:20p.m., Resident 3 was requesting assistance. Registered Nurse Supervisor NS 1 (NS 1) was informed about Resident 3 requiring assistance and asked CNA 8 if Resident 3 was assigned to her. CNA 8 went inside the room and started assisting Resident 3 NS1 walked into Resident 3's room NS 1 began informing CNA 8 that Resident 3 was an isolation room and a gown was needed. CNA 8 came back towards the door and grabbed a gown from the cart outside the door. During an interview on 10/24/2023 at 4:23p.m. with CNA 8, CNA 8 stated prior to re-entering Resident 3's room, CNA 8 does not know why Resident 3 is on isolation, this was the first time she was assigned to Resident 3 and was instructed by NS 1 what Resident 3 is on isolation for. During an interview on 10/24/2023 with CNA 8, CNA 8 stated rooms that are on isolation required individuals entering the room wear PPE. CNA 8 stated the importance to check the door to see if a resident has any isolation signs prior to entering. CNA 8 stated a report was not given on Resident 3 due to assisting another resident that required showering and was unable to receive a report prior to the previous CNA leaving. CNA 8 stated it is important to receive a report prior to providing care to know what is going on with your assigned residents CNA 8 stated PPE's should be completely removed, and hands should be washed prior to exiting the isolated resident's room. CNA 8 stated she uses the restrooms in the resident's rooms to wash her hands before exiting. CNA 8 stated visitors are educated regarding PPE requirements if they are observed in an isolation room without proper PPE and explained why a PPE is required. CNA 8 stated PPE is important to prevent spreading germs to other residents and to protect ourselves. During an observation on 10/25/2023 at 12:59p.m., Resident 3 had a visitor in the room without PPE. Resident 3 is actively on contact isolation and the family member was informed by CNA 7 with instructions to don PPE while visiting Resident 3. Resident 3's visitor reluctantly stepped out of the room without performing hand hygiene, removed a gown from the cart, applied the gown, and continued with his visit. During an interview on 10/26/2023 at 9:52a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated Resident 3 is on contact precautions for C-Auris and urinary tract infection (UTI). CNA3 stated visitors don and doff the PPE but at times, the family is noncompliant. CNA 3 stated the Infection Preventionist Nurse (IPN) is notified, the family is re-educated but if they continue to remain noncompliant we talk to the family member. CNA 3 stated visitors should wear PPE to protect themself and the resident as you do not know what you can bring to them and can possibly get the infection. During an interview on 10/26/2023 at 11:48a.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated resident's with C-Auris will be on contact isolation for a lifetime. LVN 2 stated Resident 3 is on contact for VRE in the urine with an end date for antibiotics on 10/27/2023. LVN 2 stated visitors are educated and encouraged to wear gowns. LVN 2 stated PPE should be worn to prevent spreading the infection to other residents. b. During a review of Resident 30's Face Sheet, the Face Sheet indicated Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD: progressive lung disease that limit airflow) with acute exacerbation, acute and chronic respiratory failure with hypoxia (lungs and blood cannot exchange enough oxygen causing low oxygen levels in the blood and tissues), hypertensive heart with disease with heart failure (high blood pressure that damages the heart and blood vessels contributing to the heart not being able to pump enough blood. During a review of Resident 30's MDS dated [DATE], the MDS indicated Resident 30's cognitive skills (were cognitively intact. The MDS indicated Resident 30 is dependent for lower body dressing and putting/taking off footwear. The MDS indicated Resident 30 required maximal assistance for personal hygiene, toileting, bathing, and upper body dressing. The MDS indicated Resident 30 used a walker for mobility and have no impairments on both the upper and lower extremities . During review of Resident 30's untitled CP initiated on 6/9/2023, the CP indicated Resident 30 has an actual infection with MDRO Carbapenem-resistant Enterobacterales (CRE: bacteria that is resistant to a strong antibiotic Carbapenems) with EBP. The CP intervention initiated on 6/9/2023 indicated to educate patient/family and visitors regarding precautions. During a review of the Physician Order indicated Resident 30 is on enhanced standard precautions related to CRE on 10/6/2023. During a concurrent observation and interview on 10/25/2023 at 2:58p.m, Resident 30 stated she is on isolation for CRE. Resident 30 had a visitor in the room without any PPE. The visitor stated she sees the staff coming in with yellow gowns, but she has never been informed of needing to wear PPE. The visitor stated she visits Resident 30 regularly and over several weeks, no requirement or education was provided from the staff about PPE. The visitor stated today (10/25/2023) was the first day she was ever informed of needing to wear a gown while in Resident 30's room. During an interview on 10/27/2023 at 4:46p.m. with LVN 3, LVN 3 stated Resident 30 is on contact precaution due to bacteria in her urine. LVN 3 stated visitors are advised to wear the PPE. LVN 3 stated due to Resident 30 being on contact precautions, required antibiotics, PPE should be worn to ensure non one gets the infection Resident 30 has. During a review of the facility's Policy and Procedure (P&P) titled Isolation-Notice of Transmission-Based Precautions revised on August 2019, the P&P indicated notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. When transmission-based precautions are implemented, the Infection Preventionist (or designee) determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions. During a review of the facility's P&P titled Enhanced Standard/Barrier Precautions revised on 2/1/2023, the P&P indicated enhanced standard/barrier precautions (ESP/EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. Residents, families and visitors are notified of the implementation of EBPs/ESP throughout the facility. During a review of the facility's P&P titled Title: Infection Prevention and Control Program Precautions dated 9/18/2023, the P&P indicated The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified. Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store and prepare food in a sanitary manner to preven...

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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 store and prepare food in a sanitary manner to prevent growth of microorganisms (An organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for 60 out 66 total residents in the facility by not: a. ensuring facility staff changed gloves and washed their hands between tasks in the kitchen. b. ensuring facility staff with a beard used a beard cover while handling food in the kitchen. c. ensuring food stored in the resident refrigerator was stored for the correct time frame. These deficient practices had the potential to affect all residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: a. During a review of Resident 49's admission assessment (face sheet), the face sheet indicated Resident 49 was admitted to the facility on [DATE] with diagnoses of depressive episodes (feelings of sadness) and irritable bowel syndrome (IBS, a common disorder that affects the stomach and intestines). During a review of Resident 49's history and physical (H&P) report dated 7/1/2023, the H&P indicated Resident 49 did not have the capacity to understand or make decisions. During an observation on 10/26/2023 at 9:14 a.m., in the presence of the dietary supervisor (DS) and director of operations (DOO), the cook (CK) was standing at the sink testing the sanitation bucket used for cleaning and was wearing gloves. The CK then went to the food preparation area with the same gloves on and began whisking salad dressing for the tomato salad. The DOO asked the CK to remove his gloves and perform hand hygiene, the CK did so and then went back to preparing the salad dressing. b. During and observation on 10/26/2023 at 9:17 a.m., the CK was noted to be wearing a surgical mask, but facial hair (a beard and mustache) was exposed outside of the surgical mask. The CK was not wearing a beard mask in the kitchen. During an observation on 10/26/2023 at 12:01 p.m., the CK was plating food during tray line and was seen without a beard cover. c. During an observation and concurrent interview on 10/26/2023 at 4:21 p.m., in the presence of the dietary supervisor, the resident refrigerator in the staff lounge was noted to have a plastic bag inside with Resident 49's name on it and the dates 10/20/2023 through 10/28/2023. Inside the plastic bag were multiple paper bags with different food items in them from [NAME] in the Box. The DS took the entire plastic bag and threw it inside the trash. Certified Nursing Assistant (CNA) 2 stated Resident 49's family was going to be very upset because they come in at the beginning of the week and bring food for Resident 49 for the entire week. The DS stated food was not to be held in the resident refrigerator more than 3 days because it comes in hot and then staff are placing it in the refrigerator. During an interview on 10/26/2023 at 5:20 p.m., the DS stated the facility was going to reeducate the family of Resident 49 about the personal food policy and how long food was able to be stored in the refrigerator. The DS stated the potential outcome for storing perishable food for extended periods of time was the potential of food borne illness. During an interview on 10/27/2023 at 8:54 a.m., the DS stated the facility's policy and procedure for hand hygiene in the kitchen was to change gloves and wash hands between tasks including when working with chemicals. The DS stated it was important to do proper hand hygiene to prevent cross contamination in the kitchen. The DS stated all hair and facial hair was required to be covered in the kitchen and she needed to check their supply to check if they had beard covers available. The DS stated hair covers and beard covers were important to prevent hair from falling in resident's food. During an interview on 10/27/2023 at 2:10 p.m., the infection prevention nurse stated hand hygiene was important in the kitchen due to the potential for food contamination. The IPN stated kitchen staff were required to have all hair and facial hair covered due to the possibility of food contamination because organisms could live on the hair and get into the food. During a review of the facility's policy and procedure (P/P) titled Preventing Food Borne Illness-Employee Hygiene and Sanitary Practices, undated, the P/P indicated facility staff were to wash their hands after engaging in activities that contaminate the hands and during food preparation, as often as necessary. The P/P indicated gloves were considered single-use items and were to be discarded after completing a task for which they were used. The P/P indicated gloves were to be removed, hands were to be washed and then replaced with another clean pair of gloves. The P/P indicated beard restraints were to be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linen. During a review of the facility's P/P titled Safe Handling of Foods from Visitors dated 8/25/2021, the P/P indicated the responsible facility staff would determine whether food was for immediate consumption or to be stored for later use. The P/P indicated if food was stored for later use it was to be sealed in a container to prevent cross contamination and was to be used by 2 days from when the food was brought in. The P/P indicated the refrigerator was to be properly maintained and there was to be daily monitoring for refrigerated storage duration and discard of any food items that have been stored for greater than 2 days.

Sept 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to safe guard the personal clothing of two of two sample...

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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 safe guard the personal clothing of two of two sampled residents(Resident 1 and 2). These deficient practices violated Residents 1 and 2's rights and caused Resident 1 to feel sad and Resident 2 to feel angry because their personal clothing were not available for use. Findings: a. During a review of Resident 1's admission Record , the admission record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (mental illness causing persistent fear and/or worry). During a review of Resident 1's History and Physical (H/P), dated 4/1/2023, the H/P indicated, Resident 1 had the capacity to make needs known but did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 7/13/2023, The MDS indicated, Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) from staff with at least one person assisting with bed mobility and extensive assistance (resident involved in activity, staff provide weight-bearing support) with transferring, dressing, toilet use, personal hygiene and had utilized a wheelchair as a mobility (ability to move) device. During an interview on 9/28/2023, at 3:40 p.m., with Resident 1's Responsible Party (RP), RP stated she and her family brought Resident 1 clothing and underwear throughout her stay at the facility. RP stated she was frustrated and angry because the facility lost Resident 1's clothes and Resident 1 does not have any clothes that were hers but shared by other residents in the facility. During a concurrent observation and interview on 9/29/2023, at 11:50 a.m., with Resident 1, in Resident 1's room, Resident 1 was observed looking through her closet. Resident 1 stated she does not know where her clothes were and felt sad because she was wearing someone else's clothes. During a concurrent observation and interview on 9/29/2023, at 11:52 a.m., with Certified Nurse Assistant (CNA) 2, in Resident 1's room, Resident 1's closet was observed to have the following , one pair of black pants with a name other than Resident 1's and one striped black and white sweater with no name. CNA 2 stated these clothes do not belong to Resident 1. CNA 2 stated she did not know who the clothes in Resident 1 ' s closet belonged to. CNA 2 stated Resident 1 did not have any other clothes in her closet or drawers. CNA 2 stated, I will have to go to the donation section in the laundry room to get her more clothes. During a concurrent observation and interview on 9/29/2023, at 12:00 p.m., with Housekeeping Manager (HM) 2, in the laundry room, several racks of clothing were observed. HM stated Resident 1 did not have any clothing in the clean clothes section. HM stated residents ' belongings were inventoried immediately by the admitting nurse or CNA upon admission and when family brings in new items. HM stated it was the residents' rights to have their belongings with them. HM stated it was important to inventory residents' belongings when admitted in order to ensure residents items can be tracked if lost. HM stated if residents do not have clothes, CNAs will choose clothing from the donation (clothes donated to the facility )rack to give to the residents. During a concurrent interview and record review, on 10/3/2023, at 10:55 a.m., with the Director of Nursing (DON), Resident 1's inventory of personal effects forms dated 8/29/2021, 9/11/2021, 11/10/2021 were reviewed. The forms indicated Resident 1 had numerous articles of clothing as verified by Resident 1, Resident 1's RP and facility staff. The DON stated the facility should ensure the personal effects listed on the forms were accessible to Resident 1 as it was her right to have her belongings with her. b. During a review of Resident 2's admission Record , the admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including hypertension (force of blood pushing on the blood vessels is too high) , colostomy (opening in the belly done in surgery) and surgical aftercare (care after surgery). During a review of Resident 2's H/P, dated 12/7/2022, the H/P indicated, Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive (ability to learn, reason, remember, understand, and make decisions) impairment. The MDS indicated Resident 2 required at least one-person limited to extensive assistance with bed mobility, walking in the corridor, dressing, toileting, and personal hygiene. During a concurrent observation and interview on 9/29/2023, at 1:00 p.m., with the DON, in Resident 2's room, Resident 2 ' s closet was observed to have several articles of clothing. The DON stated the clothes in Resident 2's closet did not have Resident 2's name on them. During an interview on 9/29/2023, at 1:10 p.m., with Resident 2, Resident 2 stated she was angry because she does not know where her clothes went. Resident 2 stated she has not bought any clothes since her admission to the facility and would like her own clothes back. Resident 2 stated she does not like wearing other people's clothing. During a concurrent interview and record review, on 10/3/2023, at 10:56 a.m., with the DON, Resident 2's inventory of personal effects forms dated 12/5/2022 and 5/2/2023 were reviewed. The forms indicated Resident 2 had numerous articles of clothing as verified by Resident 1 and the facility staff. The DON stated upon observing Resident 2's closet he did not see the clothing listed on the forms. The DON stated the facility should ensure the personal effects listed on the forms were accessible to Resident 2 as it was their right to have their belongings. During a concurrent interview and record review on 10/3/2023, at 11:00 a.m., with the DON, the facility's policy and procedure (P&P) titled, Resident's Personal Property, dated 8/25/2021, was reviewed. The P&P indicated the purpose of the P&P was to protect the residents ' right to retain his/her personal belongings and preserve the residents' individuality and dignity, all possessions or clothing must be marked with resident name upon admission. All items brought to the facility will be listed on the inventory of personal effects form and kept in the resident clinical chart, additional items brought into the facility after admission must be added to the list. The DON stated the staff should have ensured that Residents 1's and 2's clothes were labeled, and their inventory lists up to date. The DON stated the facility failed to ensure Resident 1's and Resident 2's rights which can negatively affect their mental health.

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

Accident Prevention (Tag F0689)

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 a resident, who had a history of elopement ( when a resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident, who had a history of elopement ( when a resident who is not capable of protecting or caring from themselves leaves the facility unsupervised) on 1/5/2022 and wandering (a person that roams around and becomes lost or confused about their location) had adequate supervision and monitoring (staff that are immediately at hand to redirect a resident from dangerous situations) for one of one sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was monitored for elopement and wandering behavior when the facility's front door was remodeled, and the wander guard sensor ( alarm to signal if a resident at risk for elopement tries to exit the facility) was disabled on 9/19/2023. 2. Ensure Resident 1's Care Plan (CP) was revised to reflect interventions to prevent elopement and wandering after the facility's front door was remodeled and the wander guard sensor was disabled on September 19,2023. 3. Ensure staff followed the facility's policy and procedure (P&P), titled, Safety and Supervision to ensure resident's safety. These deficient practices resulted in Resident 1's elopement on 9/27/2023. Resident 1 was missing from the facility for 8 hours and had the potential to sustain injury, harm, and death. Findings: During a review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (mental illness causing persistent fear and/or worry). During a review of Resident 1's History and Physical (H/P), dated 4/1/2023, the H/P indicated, Resident 1 had the capacity to make her needs known but did not have the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and screening tool], dated 7/13/2023, The MDS indicated, Resident 1 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) of staff with at least one person assisting with bed mobility and extensive assistance (resident involved in activity, staff provide weight-bearing support), transferring, dressing, toilet use, personal hygiene and had utilized a wheelchair as a mobility (ability to move) device. During a review of Resident 1's Change of Condition (COC) form, dated 1/5/2022, the COC indicated on 1/5/2022 at approximately 12:00 p.m., Resident 1 could not be located in the facility. During a review of Resident 1's Progress Notes (PN), dated 1/5/2022, the PN indicated on 1/5/2022 at approximately 2:50 p.m., Resident 1 was located by the police and was returned to the facility. During a review of Resident 1's Care Plan (CP) form, initiated 1/5/2022, the CP indicated Resident 1 is at risk for elopement related to Resident has made one or more attempts to leave the facility during this stay with impaired decision due to dementia, schizophrenia diagnosis. The CP goals indicated Resident 1 will not attempt to leave the facility without an escort by next review. The CP interventions indicated the following, Wander Guard due to poor safety awareness, check for placement and function every shift, monitor the nature and circumstances (triggers) of attempted elopement during specific activities, involvement of others with resident, patterns of behavior. During a review of Resident 1's Progress Notes (PN) form, dated 9/27/2023, the PN indicated on 9/27/2023 at approximately 11:15 a.m., Resident 1 could not be located in the facility. During a review of Resident 1's PN dated 9/27/2023 at 7:07 p.m., the PN indicated Resident 1 was located by the police department and would be returned to the facility escorted by the Administrator (ADM) and Director of Nursing (DON). During a concurrent observation and interview on 9/28/2023, at 2:45 p.m., with Resident 1, in Resident 1's room, Resident 1 was noted to be sitting on her bed with a sitter at her bedside. Resident 1 stated she went out yesterday to her parents' house but does not remember how she got there or how she got back to the facility. Resident 1 was observed to have a Wander Guard bracelet on her left wrist. Resident 1 stated she did not know what that bracelet is for or who put it on her. During an interview on 9/28/2023, at 3:00 p.m., with Certified Nurse Assistant (CNA 1), CNA 1 stated Resident 1's daily routine is to walk around the facility with her bags and states my dad is coming to pick me up. CNA 1 stated, Resident 1's has a Wander Guard bracelet on her left hand but the sensor on the front door was removed as of 9/19/2023. CNA 1 stated the morning of 9/27/2023, Resident 1 stated she was waiting for her father to pick her up and was seen walking into the front entrance lobby. CNA 1 stated she redirected Resident 1 into the patio where she remained until 10 a.m. CNA 1 stated, she could not locate Resident 1 during her 11:00 check. CNA 1 stated Resident 1 has eloped from the facility in the past and must be closely monitored. CNA 1 stated the front lobby was very busy that morning and Resident 1 could have walked out of the front door entrance as there was no alarm to sound as she exited. CNA 1 stated Resident 1 was at risk injury and or death. During an interview on 9/29/2023 at 1:37 p.m., with the receptionist (R1) , R1 stated I am a CNA and was working as the receptionist during the time Resident 1 eloped on 9/7/27/2023. R1 stated I know Resident 1 has a history of eloping from the facility before and needs a lot of redirection to keep her safe. R1 stated Resident 1 must be monitored closely especially because the Wander Guard sensor does not work on the front door. R1 stated the morning of 9/27/2023 the front lobby was very hectic. R1 stated she was attending to many visitors and answering phone calls. R1 stated she should have asked for a partner to sit at the front desk with her to ensure Resident 1 did not walk out of the front door. During an interview on 10/3/2023, at 11:00 a.m., with the DON, the DON stated Resident 1 was placed on 1:1 monitoring (staff at resident's side 24 hours 7 days a week) 9/27/2023 when she returned to the facility. The DON stated when the Wander Guard sensor was removed on 9/19/2023, Resident 1 was at an even higher risk for elopement due the lack of sensor at the front door. The DON stated the facility should have revised Resident 1's care plan for appropriate monitoring to ensure Resident 1 did not elope. The DON stated the facility should have reevaluated the Resident 1's interventions to ensure safety. The DON stated Resident 1 could have been hit by a car, assaulted, hospitalized , or killed during the time of her elopement. During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered , dated December 2016, the P&P indicated the following the comprehensive person centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being, incorporate identified problem areas, incorporate risk factors associated with identified problems, assessments of residents are ongoing and care plans revised as information about the residents and the resident's conditions change. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision, dated July 2017, the P&P indicated the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk, resident supervision is 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, the type and frequency of resident supervision may vary among residents and over time for the same resident. The P&P due to their complexity and scope, certain resident risk factors and environment hazards are addressed in dedicated policies and procedures. These risk factors and environment hazards include the following unsafe wandering.

Aug 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

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 interview and record review, the facility failed to ensure one of three sampled resident's ( Resident 1), who presented...

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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 one of three sampled resident's ( Resident 1), who presented with a new onset left lower extremity weakness and inability to stand, signs and symptoms (s/s) of a possible stroke (when something blocks supply to part of the brain or when a blood vessel in the brain bursts) was continuously monitored and transferred to a General Acute Care Hospital (GACH) in a timely manner. The facility failed to: 1. Monitor Resident 1's vital signs (measurements of the body's most basic functions), and continuously assess for s/s of a possible stroke for approximately five hours until Resident 1 was transferred to the GACH. 2. Immediately inform the physician (MD) of Resident 1's change of condition (COC) on 7/24/2023 at 12:33 p.m. This deficient practice resulted in Resident 1 being unmonitored for 5 hours and a delay in Resident 1's evaluation and treatment at GACH which potentially increased the risk of harm to the resident's well-being. Resident 1 was transferred to GACH approximately 5 hours after the COC. Findings: During a review of Resident 1's admission (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including subdural hematoma (collection of blood on brain ' s surface), muscle weakness and myocardial infarction (MI- heart attack- lack of blood flow to the heart). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making showed no impairment. MDS further indicated Resident 1 required extensive assistance from one staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review or Resident 1's Progress notes dated 7/24/2023 at 12:33 p.m., the notes indicated the physical therapist (PT) reported Resident 1 was unable to stand/walk, left leg was very weak, and resident was unable to transfer. During a review of Resident 1's Change of Condition (COC) note, dated 7/24/2023 and timed at 3:16 p.m., the COC indicated, during the morning of 7/24/2023, Resident 1 needed more assistance with activities of daily living (ADLs- dressing, bathing, grooming, eating), the resident displayed general weakness with a decrease in mobility/ambulation, and Resident 1 had left side weakness. The COC indicated Licensed Vocational Nurse (LVN) 1 notified Resident 1's primary care clinician on 7/24/2023 at 1:40 p.m. During a review of Resident 1's Skilled Nursing Facility (SNF) to hospital transfer form, dated 7/24/2023, the form indicated Resident 1 was transferred to GACH on 7/24/2023 at 5:30 p.m. During an interview with LVN 1 on 8/14/2023 at 2:07 p.m., LVN 1 stated, on 7/24/2023 approximately before 12:00 p.m., the Physical therapist assistant (PTA) informed LVN 1 Resident 1 had a COC, was unable to put weight on his left leg, and was unable to stand during the resident ' s morning therapy session. LVN 1 stated Resident 1 might have had a stroke. LVN 1 stated LVN 1 did not perform or document any neurological assessments or vitals sign measurements after completing the COC form. LVN 1 stated she should have followed up with Registered Nurse 1(RN1) to make sure the MD was contacted and performed neurological assessments / vital signs to properly assess and detect any worsening of Resident 1's condition. During a concurrent record review and interview on 8/14/2023, at 2:30 p.m., with Registered Nurse (RN) 2, Resident 1's Progress notes dated on 7/24/2023 were reviewed. The progress notes indicated no documented evidence of assessments or monitoring for signs and symptoms of stroke, which may include sudden onset of confusion, difficulty speaking, difficulty understanding speech, sudden loss of vision in one eye, sudden difficulty walking, severe dizziness, loss of balance or coordination, sudden numbness or one sided weakness of the face, arm or leg, sudden severe headache were noted in the chart after the COC was initiated on 7/24/2023 at 1:40 p.m. RN 2 stated Resident 1 should have been monitored for signs and symptoms of a stroke per facility policy. During an interview with RN 1 on 8/15/2023 at 10:09 a.m., RN 1 stated he was notified by Resident 1's PTA that Resident 1 was unable to complete the scheduled therapy due to weakness in the left lower leg. RN 1 stated he texted Resident 1's MD regarding Resident 1's COC and did not follow up to see if the MD received the text. RN 1 stated he did not perform any assessments on Resident 1. RN 1 stated it was the RN ' s responsibility to ensure documentation and follow up care for Resident 1 was complete. RN 1 stated Resident 1 was at risk for stroke and should have been monitored for facility stroke policy. During an interview with Resident 1's MD on 8/15/2023 at 11:18 a.m., the MD stated he was notified by text message of Resident 1's COC (unable to recall time). MD stated Resident 1 needed to be evaluated for another subdural bleed hematoma or a stroke and required a transfer to the GACH. MD stated Resident 1 should have been monitored closely per facility stroke protocol until transfer. MD stated the nursing staff should have been assessing, monitoring, and documenting for any changes in mental status, level of consciousness, signs of bleeding and changes in vital signs. MD stated he expected to be called for any changes assessed in Resident 1. During a concurrent record review and interview on 8/15/2023, at 3:30 p.m., with the Director of Nursing (DON), Resident 1's Weights and Vitals Summary (VS) Reports and progress notes dated 8/15/2023 were reviewed. The VS reports indicated on 7/24/2023 Resident 1 had no blood pressure (BP, how much force it takes for blood to circulate in the body) measurement, and a pulse (heartbeat) rate documented from 12:30 p.m. until 5:30 p.m. The DON stated Resident 1's vital signs were not checked after the COC occurred and resident was not assessed or monitored for changes after the incident. The DON stated the documents indicated the facility failed to monitor Resident 1 as dictated on the stroke policy and put Resident 1 at risk for a delay in evaluation, care, or transport. During a review of the facility's Policy and Procedure (P&P), titled Stroke/ Transient ischemic attack (TIA- blood flow to brain is briefly interrupted) Clinical protocol, revised 11/2018, the P&P indicated the staff will identify and report individuals with symptoms that could indicate TIA or stroke. Signs and symptoms of stroke may include sudden onset of confusion, difficulty speaking, difficulty understanding speech, sudden loss of vision in one eye, sudden difficulty walking, severe dizziness, loss of balance or coordination, sudden numbness or unilateral weakness of the face, arm or leg, sudden severe headache without identifiable cause. The P/P further indicated the nurse shall assess and document/report the following: vital signs, neurological abnormalities, change in mental status and level of consciousness, resident ' s age and sex, onset, duration, severity and scope of abnormality, history of stroke, other neurological disorders all active diagnosis and all current medications, the physician will identify whether symptoms could represent a stroke or another condition or problem. During a review of the facility's P&P, titled Change of Condition: Notification of, effective 8/25/2023, the P&P indicated a facility must immediately consult with the resident's physician and or nurse practitioner where there is a significant change in the resident's physical, mental. or psychosocial status.

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

Medical Records (Tag F0842)

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 one of one resident's (Resident 1) medical records reflected ...

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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 one of one resident's (Resident 1) medical records reflected resident was turned and repositioned every two hours, as needed, and as tolerated. This deficient practice placed Resident 1 at risk for not receiving the appropriate care or services which could lead to a pressure injury (PI -result of skin damage after prolonged periods of exposure to moisture and pressure). Findings: A. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including subdural hematoma (collection of blood on brain ' s surface), muscle weakness and myocardial infarction (MI- heart attack- lack of blood flow to the heart). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making showed no impairment. The MDS indicated Resident 1 required extensive assistance from one staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS further indicated Resident 1 was at risk for developing pressure injuries. During a concurrent interview and record review on 8/15/2023, at 3:35 p.m., with the Director of nursing (DON), Resident 1 ' s care plan, dated 7/19/2023 was reviewed. The care plan indicated Resident 1 will be repositioned every two hours, as needed, and as tolerated. The DON stated the care plan indicated Resident 1 was at risk for skin breakdown and was to be turned every two hours and as needed to prevent any complications. During a concurrent interview and record review on 8/15/2023, at 3:40 p.m., with the DON, Resident 1's Point of Care (POC) Response History document, dated 8/14/2023 was reviewed. The POC indicated Resident 1 was turned and repositioned during the following times: a. 7/18/2023 at 10:00 p.m., b. 7/19/2023 at 1:53 a.m., 11:05 a.m., 10:41 p.m., c. 7/20/2023 at 00:21 a.m., 10:59 a.m., 5:06 p.m., 11:43 p.m., d. 7/21/2023 at 2:59 p.m., 8:42 p.m., e. 7/22/2023 at 00:33 a.m., 2:59 p.m., 8:42 p.m., f. 7/23/2023 at 2:20 a.m., 2:32 p.m., 8:46 p.m., and g. 7/24/2023 at 00:28 a.m., 10:54 a.m. and 6:49 p.m. The DON stated, the POC did not indicate Resident 1 was turned and repositioned every two hours. The DON stated failure to turn and reposition per Resident 1's placed the Resident 1 at risk for pressure injuries. During a review of the facility's Policy and Procedure (P/P), titled Charting and Documentation, revised 11/2017, the P/P indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. The P/P further indicated documentation in the medical record will be objective, complete, and accurate.

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

Comprehensive Care Plan (Tag F0656)

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 develop and implement a comprehensive care plan for t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for two out of three sampled residents (Resident 1 and 2). The facility failed to A. Develop and implement a care plan for Resident 1 after the resident presented with a new onset left lower extremity weakness and inability to bear weight on the left leg on 7/24/2023. B. Develop and implement a care plan for Resident 2 addressing incontinence (lack of voluntary control over urination) and risk for pressure injury (PI -result of skin damage after prolonged periods of exposure to moisture and pressure). These deficient practices had the potential to negatively affect the delivery of necessary care and services for the residents. Findings: A. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including subdural hematoma (a buildup of blood on the surface of the brain), muscle weakness and myocardial infarction (MI- heart attack- lack of blood flow to the heart). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 7/21/2023, the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision-making showed no impairment. The MDS indicated Resident 1 required extensive assistance from one staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 1's Change of Condition (COC) note, dated 7/24/2023 and timed at 3:16 p.m., the COC indicated, during the morning of 7/24/2023, Resident 1 needed more assistance with activities of daily living (ADLs- dressing, bathing, grooming, eating), had left side weakness and presented with decreased mobility/ambulation. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 8/14/2023 at 2:07 p.m., LVN 1 stated the Physical Therapist Assistant (PTA) informed LVN 1 regarding Resident 1's change of condition and new onset of weakness on 7/24/2023 approximately before 12:00 p.m. LVN 1 stated she did not create a care plan for Resident 1 after completing the COC. During a concurrent record review and interview on 8/15/2023, at 3:30 p.m., with the Director of Nursing (DON), Resident 1's care plans were reviewed. The DON stated a care plan was not created to address Resident 1's change of condition reflecting left sided weakness. The DON stated Resident 1 was at risk for stroke and a care plan should have been created to address interventions that included monitoring for signs and symptoms of a stroke. The DON stated failure to create a care plan for Resident 1 could cause a delay in evaluation and care. B. During a review of Resident 2's AR, the AR indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including surgical after care following surgery, colostomy (operation that creates an opening the belly that allows stool/feces to pass) and unsteadiness on feet. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision-making showed mild impairment. The MDS further indicated Resident 2 required extensive assistance from one staff with bed mobility, transfer, dressing, toilet use, and personal hygiene. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's was frequently incontinent and high risk for developing pressure injuries. During a concurrent record review and interview on 8/15/2023, at 3:30 p.m., with the DON, Resident 2's care plans were reviewed. The DON stated, Resident 2's documents do not indicate a care plan addressing Resident 2's urinary incontinence and risk for pressure injury. The DON stated Resident 2 was at risk for skin breakdown such as pressure injuries and moisture associated skin damage (MASD- skin damage caused by prolonged exposure to a source of moisture such urine). The DON stated failure to create a care plan for Resident 2's incontinence and risk for pressure injury caused a delay in interventions. During a review of the facility's policy and procedure (P&P), titled the Care Plan Comprehensive, revised 8/25/2021, the P&P indicated each resident's comprehensive care plan was to be developed for each resident. The care plan was designed shall incorporate identified problem areas, incorporate risk and contributing factors associated with the problems, reflect the resident's expressed wishes regarding care and treatment goals, aid in preventing and reducing declines in resident's functional status or functional levels and reflect currently recognized professional standards of practice for problem areas and conditions. The P&P indicated each resident's comprehensive care includes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Jul 2023 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0726 (Tag F0726)

Someone could have died · 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 licensed vocational nurse (LVN) 1was train...

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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 licensed vocational nurse (LVN) 1was trained and had knowledge on how to operate an automated medication machine (AMM) Emergency Kit (E-KIT) during emergencies to retrieve emergency medication for 1 of 6 sampled residents (Resident) 1. The facility failed to: 1. Ensure LVN 1 was able to retrieve Glucagon (medication to reverse low blood sugar levels) from the AMM E-KIT, to administer to Resident 1 when the resident was found unresponsive with a blood sugar (BS) of 59 milligrams per deciliter [(mg/dl) - a unit of measurement]. The BS reference range is 80 mg/dl to 130 mg/dl). This deficient practice resulted in Resident 1's blood sugar level dropping to 25 mg/dl upon paramedic's arrival to the facility, who administered needed Glucagon to increase Resident 1's blood sugar level to prevent the resident from having seizures (uncontrolled, abnormal electrical activity of the brain that may cause changes in the level of consciousness, behavior, memory, or feelings), going into a coma (a state of unconsciousness where a person is unresponsive and cannot be woken), and possible death. Paramedics transferred Resident 1 to a general acute care hospital (GACH) for an acute (severe and sudden onset) hypoglycemic episode. On 07/28/2023 at 3:55 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADMIN) and the Director of Nursing (DON) due to LVN 1's lack of knowledge and ability to operate the AMM to get an access to emergency medication to administer in case of emergencies The facility submitted an acceptable IJ removal plan [(IJRP) an interventions to immediately correct the deficient practices). After verification of the IJRP implementation through observation, interviews, and record review, the IJ was removed on 7/29/2023 at 3:36 p.m., in the presence of the ADMIN, Regional [NAME] President of Operations (VP) and the Regional Quality Assurance Registered Nurse (QA RN). The IJRP included the following immediate actions: 1. On 7/29/2023, the ADMIN and DON followed up with the Facility pharmacist to schedule a Train-the-trainer in-service (staff education on a specific subject) to make the DON and Director of Staff Development (DSD) the facility superusers. As superusers, the DON and DSD can enroll new licensed nurses, reset passwords, and train licensed nurses on AMM functionality and usage. 2. The DON and/or Designee will review Electronic Medication Administration Records (EMAR) of diabetic (a condition where the body is not able to process and use sugar for functioning without medication) residents, including new admissions, five times a week. On Saturdays and Sundays Registered Nurse (RN) supervisor will review EMAR of new diabetic residents admitted to the facility to verify that Physician Orders are correct, and the facility has medications in stock to be provide to residents according to Physician's Orders. 3. Newly hired licensed nurses will be in-serviced by the DON and/or designee during initial orientation; 1) To understand the significance of correctly accessing medication from the AMM and 2) To Demonstrate the proper steps to access medication safely and efficiently, including emergency medications such as glucagon. 4. Return demonstration of knowledge and competency will be assessed on five facility licensed nurses each week by the DON and/or designee for the next eight weeks. All new hires (licensed nurses) will be assessed for knowledge and competency by the DON and/or Designee on a weekly basis for a period of eight weeks. Each licensed nurse assessed must achieve a competency score of 100 percent (%). 5. During an emergency such as when a resident experiences a hypoglycemic event, licensed nurses can access emergency glucagon injections and other emergency medications such as Epinephrine (medication to treat many sudden life-threatening conditions) and Narcan (medication to treat a drug overdose) at these locations. Locations were discussed with facility pharmacist on 07/29/2023. DON and/or Designee will keep inventory of these medications and will order from Pharmacy if/when used, to maintain supply stock in: a. Nurse Medication Carts (two in each cart for a total of six). b. Crash Cart (an organized mobile container of medications for life threatening conditions) (two total). c. Medication Room (two total). d. AMM E-Kit. e. For non-emergent medications, licensed nurses will notify the assigned physician and will order required medications from the Facility Pharmacy. f. Facility will initiate huddles (a short, stand-up meeting) at the start of each shift to routinely check emergency medication supplies such as glucagon and contact AMM agency to replenish emergency medication supplies after each use. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease to filter out toxins from the blood, leading to the need for a regular course of long-term mechanical filtering or a kidney transplant to maintain life), hypoglycemia, seizures, diabetes mellitus, and hypertension (high blood pressure). A review of Resident 1's Minimum Data Set [(MDS), a standardized assessment and care screening tool] dated 5/17/2023, indicated Resident 1's cognitive (process of thinking) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required extensive assistance with bed mobility, toilet use, bathing, personal hygiene, and eating. The MDS indicated that Resident 1 was usually understood and was able to understand others. A review of Resident 1's physician's orders (PO) dated 7/14/2023, indicated the following: 1. Administer Glucagon 1 milligram [(mg) unit of measurement] from Emergency Kit intramuscular [(IM) a technique used to deliver a medication deep into the muscles] every 15 minutes as needed for hypoglycemic symptoms, difficult to arouse or unconsciousness. Administer immediately, repeat BS in 15 minutes, if no response to first dose administrated, repeat Glucagon 1 mg, if no response to second dose administered in 15 min repeat blood glucose test and start intravenous [(IV) method of delivering medications and fluids through a vein) access, if not presently established, and go to the next step based on BS results. 2. Insulin Glargine (a long-acting medication used to control blood sugars that lasts in the body for 24 hours) subcutaneous [(SQ) beneath all the layers of the skin] solution with concentration of 100 units per milliliter [(u/ml) medication concentration], inject 20 units SQ at bedtime for diabetes mellitus (DM). 3. Insulin Lispro (a fast-acting medication used to control blood sugars) injection solution 100 u/ml, inject SQ before meals and at bedtime based on a sliding scale (amount of medication depends on results of BS) as follows: A. For blood sugar level 70-150 mg/dl-administer zero units. B. For blood sugar level 151-200 mg/dl- administer three units. C. For blood sugar level 201-250 mg/dl-administer six units. D. For blood sugar level 251-300 mg/dl-administer nine units. E. For blood sugar level 301-350 mg/dl-administer 12 units. F. For blood sugar level 351-400 mg/dl-administer 15 units. G. For blood sugar level >401 18 units and call Medical Doctor (MD) During a review of the facility's AMM inventory list dated 7/22/2023 and timed at 8:22 a.m., the inventory list indicated the AMM had four Glucagon medication pens in stock. A review or Resident 1's electronic medical record (eMAR), dated 7/21/2023 indicated Resident 1 received 3.0 units of Insulin Lispro and 24 units of Insulin Glargine at 9:00 p.m. A review of Resident 1's change of condition (COC - a documentation of vital medical information of a resident's sudden change of condition from baseline) report dated 7/22/2023 at 5:00 a.m., indicated Resident 1 was found unresponsive with a BS of 59 mg/dl. A review of Resident 1's PO dated 7/22/2023, timed at 5:09 a.m., indicated to transfer Resident 1 to emergency room (ER) for further evaluation due to Resident 1 unresponsiveness and low blood sugar. A review of Resident 1's Transfer Form (TF) dated 7/22/2023 and timed at 5:15 a.m., indicated that Resident 1 was transferred to the GACH via ambulance. A review of Resident 1's GACH's History of Present Illness (HPI) dated 7/22/20223 and timed at 5:18 a.m., indicated Resident 1's BS was 25, and Resident 1's Glasgow Coma Scale ([GCS] a clinical scale used to reliably measure a person's level of consciousness after a brain injury, severe=8 or less, moderate=9-12, mild=13-15) was a 3. According to the HPI paramedic administered Glucagon 1 mg IM to Resident 1 at the skilled nursing facility and upon Resident 1's arrival to GACH the resident returned to the baseline (normal state of being). During a concurrent observation and interview with Registered Nurse (RN) 1 on 7/26/2023 at 2:43 p.m., RN 1 stated that the AMM is the facility's 'E-kit and it is where staff can obtain the necessary medications that they need during an emergency. RN 1 stated that all residents with diagnosis of diabetes have a standing order (permanent physician's orders in place, to avoid a delay in care during emergencies) for Glucagon and can get the medication by either going into the resident's profile (information stored in the AMM about a resident's medication, dosage and frequency) or overriding (taking manual control of the AMM to access medication) the system in the event of an emergency. During an interview with LVN 4 on 7/26/2023 at 2:56 p.m., LVN 4 stated if a resident had a hypoglycemic episode, first he would check the resident's blood sugar, see if there is a Glucagon order, then go to the AMM to retrieve it, administer Glucagon to a resident and follow the physician's order. The physician's order might indicate to repeat the process if the resident did not respond to the first dose of Glucagon, just depends on what the order states. During an interview with LVN 1 on 7/27/2023 at 6:24 a.m., LVN 1 stated that when Resident 1 was found unresponsive and had a low blood sugar, he came to the AMM to retrieve Glucagon, while LVN 2 was calling 911. LVN 1 stated that he was not able to retrieve the medication because the medication indicated it was out of stock. LVN 1 stated that he did not know about the 'override' function at that time, that would have allowed him to access the emergency Glucagon. During an interview with LVN 2 on 7/27/2023 at 7:10 a.m., LVN 2 stated that LVN 1 asked her to call 911 while he (LVN 1) was retrieving the Glucagon from AMM. LVN 2 stated that LVN 1 was struggling to retrieve the Glucagon and that he (LVN 1) went back to Resident 1 without the medication. LVN 2 stated she was aware of the override function but did not help LVN 1 because, I was gathering documents so it can be ready for the paramedics. During a concurrent observation and interview with LVN 3 on 7/27/2023 at 7:28 a.m., LVN 3 was able to demonstrate the AMM override function. LVN 3 stated that before working on the floor licensed staff usually get training on how to use the AMM and the override function. During an interview with DON on 7/27/2023 at 9:20 a.m., the DON stated that LVN 1 should have accessed stock medications to retrieve the emergency Glucagon. The DON stated that LVN 1 panicked, and his main concern was being with Resident 1 at that time. The DON stated LVN 1 was trained on how to use the AMM and the override function right after the incident. The DON stated that if the resident does not receive the Glucagon in a timely matter, the outcome could be fatal. A review of the facility's document titled LVN Job Description, revised May 2022, indicated the LVN must attend and participate in continuing education programs. The document also indicated that LVNs must demonstrate the knowledge and skills necessary to provide care appropriate to the age-related needs of the residents serve and the LVN must be able to cope with mental and emotional stress of the position. A record review of the facility's undated document titled Facility Assessment Tool (a tool for the facility to evaluate its resident population and identify the resources needed to provide necessary person-centered care and services the facility residents require), indicated that nursing staff are checked for competency skills and if they are deemed competent then they are assigned to the unit that they meet qualifications for. The document also indicated that competency skills evaluations are checked upon hiring and annually thereafter. Performance evaluations are performed annually to ensure staff is meeting the facility's standards of performance and conduct.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the physician ' s order of applying bilater...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the physician ' s order of applying bilateral floor mats (high-impact foam mats placed next to resident ' s bed designed to prevent injury during fall) for one of three sampled residents (Resident 2) who had a history of fall with injury (nasal bridge [part of nose] fracture [broken bone]), on 5/25/2023. This deficient practice placed Resident 2 at risk for sustaining another fall and placed Resident 2 at risk for another serious injury. Findings: During a review of Resident 2 ' s admission Record (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (CHF, the heart is unable to pump enough blood the body needs), kyphosis (excessive curve of the back) and unsteadiness on the feet. During a review of Resident 2 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 4/22/2023, the MDS indicated, Resident 2 had severe cognitive (ability to clearly think, learn, and remember) impairment. The MDS indicated, Resident 2 required one-person extensive (resident involved in activity, staff provided weight-bearing support) physical assistance for bed mobility, walking, toilet use, and transferring. The MDS indicated, Resident 2 used a walker and wheelchair for ambulation. During a review of Resident 2 ' s Change of Condition (COC) note, dated 5/25/2023, the COC indicated, Resident 2 had a fall on 5/25/2023 after he got up from bed without assistance. The COC indicated, Resident 2 was found on the floor near his (Resident 2) bed laying down on his left side facing the door with fresh blood coming out from a laceration (a deep cut or tear in skin) on the nasal bridge and his forehead (part of the face above the eyes). During a review of Resident 2 ' s Order Summary Report (OSR), dated 6/2023, the OSR indicated, a STAT (immediate) facial and nasal X-Ray (a test that produces images of bones and organs) was ordered on 5/25/2023. The OSR indicated, an order for Resident 2 was placed on 5/25/2023 for: low bed and to apply bilateral floor mats for safety precautions. During a review of Resident 2 ' s X-Ray results (XRR), dated 5/25/23, the XRR indicated, Resident 2 had an acute (new onset) nasal bone fracture with minimal displacement (bone moved from its place) and angulation (bone turned from its normal position). During a review of Resident 2 ' s Follow-up Documentation (FUD, post fall monitoring), dated 5/25/2023 to 5/29/2023, the FUD documentation had not indicated bilateral (both) floor mats were placed on either side of Resident 2 bed for safety precautions as ordered by Resident 2 ' s physician (MD 1). During an observation on 6/6/2023 at 12:42 p.m., a scab was noted on Resident 2 ' s nose and an observation of Resident 2 ' s room indicated there was no floor mats seen on either side of Resident 2 ' s bed. During a concurrent observation and interview on 6/6/2022 at 3:08 p.m., with Licensed Vocational Nurse (LVN 1), in Resident 2's room, LVN1 stated there was no floor mats in Resident 2 ' s room. LVN 1 stated, Resident 2 had fallen recently and part of the facility ' s fall precautions included lowering the resident ' s bed height and placing floor mats next to the bed but there was no floor mats placed for Resident 2. During a concurrent interview and record review on 6/6/2023 at 3:18 p.m., Resident 2 ' s active OSR (6/2023) was reviewed with Registered Nurse (RN 1). The OSR indicated, there was an active order for Resident 2 for the facility to apply bilateral floor mats in Resident 2 ' s room. RN 1 stated, if there was an order for bilateral floor mats, the order should have been carried out and implemented and there should be floor mats in Resident 2 ' s room. RN 1 stated, it was important to follow physician orders to prevent injuries. During an interview on 6/6/2023 at 3:32 p.m., the Director of Nursing (DON) stated, it was very important for licensed nurses to follow physician orders. The DON Stated implementation of floor mats for safety precautions was a useful intervention if a resident was not ambulatory but was at risk of rolling out of bed. The DON stated floor mats prevented the residents from sustaining serious injuries if a fall occurred. The DON stated floor mats being implemented for Resident 2 could have possibly prevented Resident 2 ' s fracture. During a review of the facility ' s policy and procedure (PP) titled Fall Management and dated 5/26/2021, the PP indicated, the facility was to assess patients for falls risk and those patients determined to be at fall risk was to receive appropriate interventions to reduce risk and minimize injury.

May 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively manage a residents' pain for one of five sampled reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively manage a residents' pain for one of five sampled residents (Resident 1) by: 1. Failing to properly monitor and assess Resident 1's pain as ordered by the physician 2. Failing to ensure a resident centered pain care plan (CP) was created at admission, and not 10 days later 2. Failing to ensure Resident 1's pain management was consistent with the comprehensive person-centered CP and resident's goals and preferences. This deficient practice had the potential to result in unrelieved pain for Resident 1 and placed Resident 1 at risk of suffering unnecessary pain. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility 5/5/2023 and readmitted [DATE] with diagnoses of encounter for surgical aftercare following surgery on the skin and subcutaneous (under the skin) tissue and sepsis (a life-threatening medical emergency, the body's extreme response to an infection). During a review of Resident 1's modified data set ([MDS] a standardized assessment and care screening tool), dated 5/12/2023, the MDS indicated Resident 1 had the ability to be understood and to understand others. The MDS indicated Resident 1 was not in pain or hurting within the past five days of assessment but had received or been offered pain medication in the facility within the past five days of assessment. The MDS indicated the full pain assessment interview was not done because section J0300 was marked No for pain presence which ended the pain assessment. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated on 5/5/2023 an order was placed for acetaminophen (Tylenol, a pain-relieving medication) 325 milligrams (mg, a unit of measurement of weight), give two (2) tablets by mouth every four (4) hours for mild pain. The OSR indicated on 5/5/2023 an order was placed for acetaminophen with codeine ([Tylenol #3] an opioid, a powerful pain-reducing medication) 300-30mg give 2 tablets by mouth every 4 hours as needed (PRN) for pain level 7 out of 10 (pain scale, tool utilized to assess pain with 0 meaning no pain and 10 being the worst pain of your life). The OSR indicated on 5/6/2023 an order was placed for wound treatment: change abscess wound dressing twice daily with packing (special dressing inserted in a deep wound to promote healing), premedicate (give pain medication prior to wound care) for packing change for pain and to document the pain level for treatments, before, during, and after treatment and administer PRN pain medications if pain was present. During a review of Resident 1's Treatment Administration Record (TAR) for the month of 5/2023, the TAR indicated Resident 1 received her first dressing and packing change of the abscess surgical wound site on 5/6/2023. The TAR indicated the pain scale was being charted daily in the TAR at 7 a.m. and 7 p.m. (TAR did not indicate the pain level before, during and after treatment as indicated in the OSR) and the nurses charted a pain scale of 0 (no pain) for every assessment except for on 5/7/2023 at 7 a.m., the nurse (unknown) charted 7 out of 10 pain (severe pain) for Resident 1. During a review of Resident 1's Medication Administration Record (MAR) for the month of 5/2023, the MAR indicated Resident 1 first received pain medication (order: Tylenol #3, 300-30mg give 2 tablets by mouth every 4 hours PRN for pain scale 7 out of 10) on 5/7/2023 (2 days after admission). The MAR indicated Resident 1 received Tylenol #3 on: 5/7/2023 at 9:55 a.m., 5/8/2023 at 2:14 p.m. and 8 p.m., 5/10/2023 at 2:30 a.m. and 8:21 a.m., 5/12/2023 at 5 a.m., 5/13/2023 at 8:45 a.m., 5/14/2023 at 8:59 a.m., and 5/15/2023 at 9 p.m. (a pain assessment or the pain scale was not documented in MAR or TAR during these times). During a review of Resident 1's Care Plans (CP), the CP initiated on 5/15/2023 (10 days after admission) indicated Resident 1 was at risk for alterations in comfort related to her abscess (painful collection of puss, usually caused by a bacterial infection) wound (surgical removal of the abscess), goals for Resident 1 indicated Resident 1 was to achieve acceptable levels of pain control, and interventions included, evaluation of pain characteristics, quality of pain, severity of pain, location of pain, precipitating (the cause) and relieving (what makes it better) factors for pain, the nurse was to utilize the pain scale, and the pain assessment was to be completed per protocol. During a review of Resident 1's General progress notes (GPN) dated 5/15/2023 and 5/16/2023, the GPN indicated Resident 1 was sent to general acute hospital (GACH 1) by recommendation of Resident 1's physician (MD 1) for evaluation of uncontrolled pain. The GPN indicated Resident 1 returned from GACH 1 on 5/16/2023. During an interview on 5/25/2023 at 4:10 p.m., Resident 1 stated, when she was admitted to the facility (5/5/2023) following a surgery to remove an abscess on her butt and she was in excruciating pain for 16 hours prior to receiving pain medication post admission. Resident 1 stated she kept calling her family member (FM1) because she was so upset, they had not given her anything for the pain and she needed someone to talk to. During an interview on 5/26/2023 at 9:55 a.m., FM1 stated since the day Resident 1 was admitted to the facility Resident 1 was calling her and stated they had not given her anything for pain. FM1 stated, Resident 1 informed her she was upset because the facility did not care how much pain she was in during wound care. FM1 stated upon Resident 1's admission, she was not given pain medication for 16 hours. During subsequent interviews on 5/26/2023 at 1:47 p.m. and 5/30/2023 at 2:19 p.m., the director of nursing (DON) stated Resident 1 did not have full pain assessments charted in the resident's medical record and in the nursing world, if it was not charted, it was not done. The DON stated the only place the nurses had to document a daily pain assessment was in the MAR or TAR depending on the order and it only included the numbered pain scale. The DON stated based on what was charted in Resident 1's medical record, it was unclear if Resident 1 was experiencing pain. The DON stated there was nowhere in Resident 1's chart where the staff documented the type of pain, location of pain, or what caused and relieved Resident 1's pain, the DON stated a full pain assessment included all those characteristics of pain and the numbered pain scale was not a full pain assessment. During an interview on 5/26/2023 at 3:10 p.m., the minimum data set nurse (MDS1) stated the facility's electronic medical record (EMR) software did not have pain assessments embedded for the full characteristics of pain, the only pain assessments they had was an admission pain assessment and the pain scale charted in the MAR. During an interview on 6/1/2023 at 9:35 a.m., Licensed Vocational Nurse (LVN3) stated when a resident was admitted the admitting nurse would assess the resident's pain and then create a care plan regarding pain. LVN3 stated the only place nurses had to chart their daily pain assessments was the numbered pain scale in the MAR. LVN3 stated nurses created pain care plans based on the Resident's needs, such as ordered pain medications, current pain or potential for pain based on their diagnoses. LVN3 stated it was very important for pain care plans to be developed and followed because pain needed to be treated as a priority because residents were admitted to the facility to get better and when a resident was in pain it could hinder their recovery. LVN3 stated unresolved pain could affect the resident's ability to perform activities of daily living (ADLs, activities related to personal care). During a review of the facility's policy and procedure (P/P) titled Pain Management and dated 8/25/2021, the P/P indicated the policy's purpose was for residents to maintain their highest possible level of comfort by providing a system to identify, assess, treat, and evaluate pain. The P/P indicated the facility was to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with resident directed goals. The P/P indicated the facility was to create a person-centered pain CP that used strategies that prevented and minimized different levels or sources of pain or pain related symptoms. During a review of the facility's P/P titled Pain- Clinical Protocol undated, the P/P indicated pain was to be reassessed at regular intervals and at least every shift (three shift daily) for acute pain. The pain review was to include the pain frequency, the duration of pain, the intensity of pain, and the resident's ability to perform ADLs, resident's sleep pattern, mood, behavior, and participation in activities. During a review of the facility's P/P titled Care Plan-Baseline and dated 8/25/2021, the P/P indicated the base line CP was to be created within 48 hours of a resident's admission and should include the minimum information necessary to properly care for a resident. During a review of the facility's P/P titled Care Plan- Comprehensive and dated 8/25/2021, the P/P indicated the CP was to incorporate identified problem areas and incorporate risk and contributing factors associated with the identified problems

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 F0697 (Tag F0697)

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 effectively manage a residents' pain for one of five sampled reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively manage a residents' pain for one of five sampled residents (Resident 1) by: 1. Failing to properly monitor and assess the Resident 1's pain as ordered by the physician 2. Failing to ensure a pain care plan (CP) was created at admission, and not 10 days later 2. Failing to ensure Resident 1's pain management was consistent with the comprehensive person-centered CP and resident's goals and preferences. This deficient practice had the potential to result in lack of detection of unrelieved pain for Resident 1 and placed Resident 1 at risk to suffer unnecessary pain. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility 5/5/2023 and readmitted [DATE] with diagnoses of encounter for surgical aftercare following surgery on the skin and subcutaneous (under the skin) tissue and sepsis (a life-threatening medical emergency, the body's extreme response to an infection). During a review of Resident 1's Order Summary Report (OSR), the OSR indicated on 5/5/2023 an order was placed for acetaminophen (Tylenol, a pain-relieving medication) 325 milligrams (mg, a unit of measurement), give two (2) tablets by mouth every four (4) hours for mild pain. The OSR indicated on 5/5/2023 an order was placed for acetaminophen with codeine ([Tylenol #3] an opioid, a powerful pain-reducing medication) 300-30mg give 2 tablets by mouth every 4 hours as needed (PRN) for pain level 7 out of 10 (pain scale, tool utilized to assess pain with 0 meaning no pain and 10 being the worst pain of your life). The OSR indicated on 5/6/2023 an order was placed for wound treatment: change abscess wound dressing twice daily with packing (special dressing inserted in a deep wound to promote healing), premedicate (give pain medication prior to wound care) for packing change for pain and to document the pain level for treatments, before, during, and after treatment and administer PRN pain medications if pain was present. During a review of Resident 1's Treatment Administration Record (TAR) for the month of 5/2023, the TAR indicated Resident 1 received her first dressing change and packing change of the abscess surgical wound site on 5/6/2023. The TAR indicated the pain scale was being charted daily in the TAR at 7 a.m. and 7 p.m. (TAR did not indicate the pain level before, during and after treatment as indicated in the OSR) and the nurses charted a pain scale of 0 (no pain) for every assessment except for on 5/7/2023 at 7 a.m., the nurse (unknown) charted 7 out of 10 pain (severe pain) for Resident 1. During a review of Resident 1's Medication Administration Record (MAR) for the month of 5/2023, the MAR indicated Resident 1 first received pain medication (order: Tylenol #3, 300-30mg give 2 tablets by mouth every 4 hours PRN for pain scale 7 out of 10) on 5/7/2023 (2 days after admission). The MAR indicated Resident 1 received Tylenol #3 on: 5/7/2023 at 9:55 a.m., 5/8/2023 at 2:14 p.m. and 8 p.m., 5/10/2023 at 2:30 a.m. and 8:21 a.m., 5/12/2023 at 5 a.m., 5/13/2023 at 8:45 a.m., 5/14/2023 at 8:59 a.m., and 5/15/2023 at 9 p.m. (a pain assessment or the pain scale was not documented in MAR or TAR during these times). During a review of Resident 1's modified data set ([MDS] a standardized assessment and care screening tool), dated 5/12/2023, the MDS indicated Resident 1 had the ability to be understood and to understand others. The MDS indicated Resident 1 was not in pain or hurting within the past five days of assessment but had received or been offered pain medication in the facility within the past five days of assessment. The MDS indicated the full pain assessment interview was not done because section J0300 was marked No for pain presence which ended the pain assessment. During a review of Resident 1's Care Plans (CP), the CP initiated on 5/15/2023 (10 days after admission) indicated Resident 1 was at risk for alterations in comfort related to her abscess (painful collection of puss, usually caused by a bacterial infection) wound (surgical removal of the abscess), goals for Resident 1 indicated Resident 1 was to achieve acceptable levels of pain control, and interventions included, evaluation of pain characteristics, quality of pain, severity of pain, location of pain, precipitating (the cause) and relieving (what makes it better) factors for pain, the nurse was to utilize the pain scale, and the pain assessment was to be completed per protocol. During a review of Resident 1's General progress notes (GPN) dated 5/15/2023 and 5/16/2023, the GPN indicated Resident 1 was sent to general acute hospital (GACH 1) by recommendation of Resident 1's physician (MD 1) for evaluation of uncontrolled pain. The GPN indicated Resident 1 returned from GACH 1 on 5/16/2023. During an interview on 5/25/2023 at 4:10 p.m., Resident 1 stated, when she was admitted to the facility (5/5/2023) following a surgery to remove an abscess on her butt and she was in excruciating pain for 16 hours prior to receiving pain medication post admission. Resident 1 stated she kept calling her family member (FM1) because she was so upset, they had not given her anything for the pain and she needed someone to talk to. During an interview on 5/26/2023 at 9:55 a.m., FM1 stated since the day Resident 1 was admitted to the facility Resident 1 was calling her and stated they had not given her anything for pain. FM1 stated, Resident 1 informed her she was upset because the facility did not care how much pain she was in during wound care. FM1 stated upon Resident 1's admission, she was not given pain medication for 16 hours. During subsequent interviews on 5/26/2023 at 1:47 p.m. and 5/30/2023 at 2:19 p.m., the director of nursing (DON) stated Resident 1 did not have full pain assessments charted in the resident's medical record and in the nursing world, if it was not charted, it was not done. The DON stated the only place the nurses had to document a daily pain assessment was in the MAR or TAR depending on the order and it only included the numbered pain scale. The DON stated based on what was charted in Resident 1's medical record, it was unclear if Resident 1 was experiencing pain. The DON stated there was nowhere in Resident 1's chart where the staff documented the type of pain, location of pain, or what caused and relieved Resident 1's pain, the DON stated a full pain assessment included all those characteristics of pain and the numbered pain scale was not a full pain assessment. The DON stated the facility was not addressing the interventions indicated in Resident 1's CP due to the fact the facility's electronic medical record (EMR) did not have that option with their EMR software (no option to chart characteristics of pain, just the pain scale). During an interview on 5/26/2023 at 3:10 p.m., the modified data set nurse (MDS1) stated the facility's EMR software did not have pain assessments embedded for the full characteristics of pain, the only pain assessments they had was an admission pain assessment and the pain scale charted in the MAR. During an interview on 6/1/2023 at 9:35 a.m., Licensed Vocational Nurse (LVN3) stated when a resident was admitted the admitting nurse would assess the resident's pain and then create a care plan regarding pain. LVN3 stated the only place nurses had to chart their daily pain assessments was the numbered pain scale in the MAR. LVN3 stated nurses created pain care plans based on the Resident's needs, such as ordered pain medications, current pain or potential for pain based on their diagnoses. LVN3 stated it was very important for pain care plans to be developed and followed because pain needed to be treated as a priority because residents were admitted to the facility to get better and when a resident was in pain it could hinder their recovery. LVN3 stated unresolved pain could affect the resident's ability to perform activities of daily living (ADLs, activities related to personal care). During a review of the facility's policy and procedure (P/P) titled Pain Management and dated 8/25/2021, the P/P indicated the policy's purpose was for residents to maintain their highest possible level of comfort by providing a system to identify, assess, treat, and evaluate pain. The P/P indicated the facility was to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with resident directed goals. The P/P indicated the facility was to create a person-centered pain CP that used strategies that prevented and minimized different levels or sources of pain or pain related symptoms. Duringa review of the facility's P/P titled Pain- Clinical Protocol undated, the P/P indicated pain was to be reassed at regular intervals and at least every shift (three shift daily) for acute pain. The pain review was to include the pain frequency, the duration of pain, the intensity of pain, and the residents ability to perform ADLs, resident's sleep pattern, mood, behavior, and participation in activities. During a review of the facility's P/P titled Care Plan-Baseline and dated 8/25/2021, the P/P indicated the base line CP was to be created within 48 hours of a resident's admission and should include the minimum information necessary to properly care for a resident. During a review of the facility's P/P titled Care Plan- Comprehensive and dated 8/25/2021, the P/P indicated the CP was to incorporate identified problem areas and incorporate risk and contributing factors associated with the identified problems.

Dec 2022 17 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect the rights of the residents to be treated with ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to protect the rights of the residents to be treated with dignity and respect and provide care in a manner that promotes the resident's quality of life for two of eight (8) sampled residents (Resident 3 and 32) by: 1. Failing to change and clean Resident 3 after a bowel movement for 25 minutes and failing to answer Resident 3's call light for over one hour when he was in pain. 2. Failing to answer the call light of Residents 32 and provide incontinent (lack of voluntary control over urination or defecation) care when the resident requested assistance with changing his soiled incontinence brief (diaper) in a timely manner. These deficient practices had the potential to cause psychosocial harm and affect resident's sense of self-worth and self-esteem for Resident 3 and 32. Findings: 1.During an observation on 12/5/22 at 10:20 a.m., observed Resident 3 call light had been ringing for 25 minutes before a staff member went in to assist Resident 3. During the initial tour of the facility on 12/5/22 at 11:14 a.m. at Resident 3 bedside, observed Resident 3 lying in bed, wearing glasses, and turned to his side. He stated that it takes two staff to clean him up and it takes a while for staff to come in and help but it depended on the staffing for that day. During a record review of the admission record dated 9/21/2021, the admission record indicated that Resident 3 was admitted to the facility for muscle weakness, repeated falls, vertigo (dizziness) and difficulty in walking. During a record review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated October 2, 2022, the MDS indicated, Resident 3 was alert and oriented. It also indicated, Resident 3 needed one-to-two-person physical assistance with toileting and personal hygiene. MDS indicated, Resident 3 used a walker and wheelchair for mobility. During a record review of Resident 3 care plan revised 4/4/2022, the care plan indicated, Resident 3 requires assistance and was dependent for activities of daily living including bathing, transfers, and toileting. The care plan also indicated; Resident 3 requires extensive assistance with two staff members for transfers out of bed. Care plan indicated, Resident 3 was at risk for falls, a history of falls and vertigo. During an interview on 12/6/22 at 9:20 a.m. with Resident 3, Resident 3 stated, he had to wait for over 20 minutes on 12/5/2022 for help after his bowel movement to get cleaned up. Resident 3 stated, sometimes it takes the staff about an hour and half to come and answer his call light and it makes him feel like a dog. He stated when he had his bowel blockage, he was in so much pain and put on the call light for help and it took over an hour for a staff member to come and check on him. Resident 3 stated, he felt miserable and felt like the elderly are the new oppressed population. During an interview on 12/7/22 at 12:11 p.m. with Certified Nurse Assistant (CNA) 4, CNA 4 stated, Resident 3 complained to her that he had to wait a long time to get help when he puts on the call light. CNA 4 stated, Resident 3 usually complains about the overnight shift staff and on weekends when they get sick calls. During an interview on 12/7/22 at 6:05 p.m. with Licensed Vocational Nurse (LVN) 8, LVN 8 stated, CNAs on the evening shift take care of 10-12 residents. LVN 8 stated, the call light should be answered in three (3) minutes. LVN 8 stated, if the call light was not answered in a timely manner, resident could be on the floor, fall or stop breathing. Lastly, LVN 8 stated, if the resident needed to go to the restroom, they could have an accident on themselves and become frustrated and feel horrible. During an interview on 12/07/22 at 7:03 p.m. with the Registered Nurse (RN) 1, RN 1 stated, some of the residents stated it takes a long time for the call light to be answered. RN 1 stated, a resident should be changed right away if they are wet and if a CNA was busy, she will ask the resident if they can wait till the CNA was done with the other resident. RN 1 stated, the call light should be answered in five to ten minutes. RN 1 stated that if no one comes to help the resident and the resident needs to go to the bathroom, resident can have an accident. RN 1 also stated, some of the residents would ask to give them a diaper, so they won't feel embarrassed if they have an accident on themselves. RN 1 stated she would feel uncomfortable and uneasy when you must wait for longer period and the residents would too. 2. During a record review of Resident 32's admission record, the admission record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses that included hemiplegia ( paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left dominant side , dysphagia(difficulty of swallowing),diabetes(high blood sugar), and gastrostomy status ( creation of an artificial external opening into the stomach for nutritional support). During a record review of Resident 32's Minimum Data Set (MDS- a standardized and care screening tool) dated 11/2/22, indicated Resident 32 had a moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS also indicated resident was always incontinent of urine and feces. During a record review of Resident 32's History and Physical (H &P) dated 1//24/22, the H &P indicated the resident can make needs known but cannot make medical decisions. During a concurrent observation and interview on 12/6/22 at 10:03 a.m. with Resident 32, in his room, Resident 32 was observed, in an upright position and pressed the call light at 10:08 a.m. He stated his diaper needed to be changed because it was wet. Observed Certified Nursing Assistant (CNA) 2 entered Resident 32's room at 10:21 a.m. to answer the call light. Resident 32 stated sometimes he had to wait a lot longer to get assistance for anything and it made him feel abandoned and upset. During an interview on 12/7/22, at 11:23 a.m. with CNA 2, CNA 2 stated that all staff members are responsible to answer the call lights of residents and should respond to call lights right away. CNA 2 stated, it was important to answer call lights of residents right away to prevent residents getting upset and to keep them satisfied with the facility's service. During an interview on 12/7/22, at 11:47 a.m. with CNA 5, CNA 5 stated call light should be answered as soon as possible within a minute or two because it could be an emergency or resident might have fallen or in pain. During an interview on 12/8/22, at 3:12 p.m. with Director of Nursing (DON), DON stated call light should be answered within three to five minutes. She stated if call light was not answered in a timely manner, accidents can happen, or residents could get upset. During a record review of the facility Policy and Procedure (P&P) titled Answering the Call Light dated revised September 2022, the P&P indicated that the facility is to ensure timely responses to the resident's request and needs. It also indicated that the call system should be answered immediately. During a record review of the facility Policy and Procedure (P&P) titled Dignity dated revised February 2021, the P&P indicated that, residents are treated with dignity and respect at all times, staff are expected to promote dignity and assist residents promptly for a request for toileting assistance and residents are allowed to choose when to conduct activities of daily living. During a record review of the facility Policy and Procedure (P&P) titled Activities of Daily Living (ADL'S), dated revised March 2018, the P&P indicated that, Appropriate care and services will be provided for residents who are unable to carry out ADL's independently including support and assistance with elimination and hygiene, care and services to minimize functional decline will include appropriate pain management, and residents will be provided with care, treatment and services to maintain or improve their ability to carry out activities of daily living.

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

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 six residents (Resident 32) preference t...

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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 six residents (Resident 32) preference to take a shower was honored. This deficient practice resulted in Resident 32 feeling uncomfortable and had the potential to affect Resident 32's quality of life. Findings: During a record review of Resident 32's admission Record, the admission Record indicated Resident 32 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of the one side of the body) and hemiparesis (weakness of the one side of the body) following cerebral infarction (lack of adequate blood supply to the brain ) affecting left dominant side, dysphagia(difficulty of swallowing),diabetes(high blood sugar), and gastrostomy status ( creation of an artificial external opening into the stomach for nutritional support). During a record review of Resident 32's Minimum Data Set (MDS- a standardized and care screening tool) dated 11/2/22, indicated the resident had a moderately impaired cognition (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. The MDS also indicated resident was always incontinent of urine and feces. During a record review of Resident 32's History and Physical (H &P) dated 1//24/22, the H &P indicated Resident 32 can make needs known but cannot make medical decisions. During an observation on 12/6/22, at 10:30 a.m. in Resident 32's room, Resident 32 asked Certified Nursing Assistant (CNA) 2 to have a shower. CNA 2 responded that it was not Resident 32's day of shower and he already had a shower yesterday. Resident 32 stated that he felt wet and uncomfortable that's why he wanted a shower. During an interview on 12/7/22, at 11:23 a.m. with CNA 2, CNA 2 stated Resident 32 did not get a shower on 12/6/22, because the staff members should follow residents' shower schedules. She stated Resident 32's shower days are Mondays and Thursday and 12/6/22 was not Resident 32's scheduled shower day. During an interview on 12/7/22, at 12:03 p.m. with CNA 5, CNA 5 stated residents have the right to request for a shower because they can feel neglected if their request was not granted. CNA 5 stated if she cannot finish her shower schedules for residents, other staff members can still accommodate Resident 32's request because the incoming shift can do the shower of the residents that are not done for that day. During an interview on 12/8/22, at 11:36 a.m. with CNA 6, CNA 6 stated if a resident requested for a shower even it was not his scheduled day, facility staff should accommodate his request because it was the right of every resident to request for a shower if he wants to. During an interview on 12/8/22, at 3:12 pm with Director of Nursing (DON), DON stated facility CNAs were trained to give shower even it was not the residents' scheduled shower time. DON stated accommodating the needs of the resident and respecting their preferences will maintain resident's dignity. During a record review of facility's policy and procedure (P&P) titled Activities of Daily Living, Supporting revised 3/18, the P&P indicated appropriate care and services will be provided for residents who are unable to carry out Activity of Daily Living (ADL- basic tasks of everyday life such as taking a shower, eating , dressing or getting out of bed or chair) independently including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care), mobility, toileting, dining and communication. During a record review of facility's P&P titled Resident Rights Under Federal Law revised 3/1/22, the P&P indicated, each resident should be treated with respect, dignity and care in an environment that promotes maintenance or enhancement of his/her self-esteem and self-worth. The P&P also indicated resident's goals, preferences, and choices should be incorporated into their care.

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 observation, interview, and record review, the facility failed to ensure assessment entries on the Minimum Data Set (MD...

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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 assessment entries on the Minimum Data Set (MDS)-a standardized assessment and screening tool) was coded accurately for two of five sampled residents (Resident 17) who had a bedrail and Resident 271 who was admitted to the facility with bilateral hearing aids. This deficient practice had the potential to negatively affect Resident 1 and Resident 17's plan of care and delivery of necessary care and services. Findings: During a record review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease (a rare inherited disease that causes progressive break down of nerve cells that affect a person's functional abilities), muscle weakness, dysphagia (difficulty of swallowing) and cachexia (a wasting disorder characterized by weight loss and lack of proper nutrition). During a record review of Resident 17's Minimum Data Set (MDS) dated [DATE], the MDS indicated Resident 17 had unclear speech, rarely or never understand others, and required total assistance from staff members with bed mobility, transfer, eating, dressing, toilet use, and personal hygiene. The MDS did not code the bilateral bedrails installed on Resident 17's bed. During a record review of Resident 17's consent for use of bedrails, indicated a signature but undated and person who signed the consent was not identified on the consent. During a record review of Resident 17's active Physician's Order dated 2/21/20 indicated, an order for application of bilateral upper half bed rail for safety due to uncontrolled body movement secondary to Huntington's disease. During a record review of Physician's Order dated 10/10/22 indicated a physician's order for quarter (¼) bedrails, used to assist Resident 17 for turning and repositioning in bed. During an observation on 12/5/22, at 10:53 a.m. in Resident 17's room, Resident 17's bed had ¼ siderails on both sides of her bed. Observed Resident 17 was moving and raising both of her arms involuntarily, frequently, unable to speak coherently and not following commands or directions. During an interview on 12/7/22, at 12:46 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated, the reason why bedrail was not coded in the MDS assessment because it was for safety, and not a restraint. MDSC reviewed the meaning of restraint in MDS and Resident Assessment Instrument (RAI-helps nursing home staff in gathering definitive information on a resident needs and strengths which must be addressed in an individualized care plan), agreed bedrail was a restraint. MDSC stated his assessment did not reflect an accurate assessment on Resident 17's condition and needs. b. During a review of Resident 271's admission Record (AR), the AR indicated, Resident 271 was admitted to the facility on [DATE] with diagnoses of but not limited to spinal stenosis (the space inside the backbone is too small), hypothyroidism (a condition where the thyroid does not create and release enough thyroid hormone into the bloodstream), type two diabetes mellitus (insufficient production of insulin causing high blood sugar) and glaucoma (a group of eye diseases that can cause vision loss and blindness). During a review of Resident 271's Minimum Data Set (MDS- standardized screening tool) dated 11/30/22, the MDS indicated Resident 271 had the ability to understand other and makes self understood. The MDS indicated, Resident 271 needed extensive assistance with bed mobility transferring, walking in the resident's room, locomotion on and off the unit, dressing, and toilet use. The MDS indicated Resident 271 needed limited assistance with personal hygiene and ate independently. During an interview on 12/5/22 at 11:29 a.m. with Resident 271, Resident 271 stated she has hearing aids. During an interview on 12/7/22 at 3:16 p.m. with LVN 6, LVN 6 stated she was not aware of Resident 271 having hearing aids and not aware of Resident 271 having any hearing problem. During an interview on 12/7/22 at 6:10 p.m. with the MDSC, the MDSC stated hearing aids are documented during the interview process with the resident upon admission. The MDSC stated information regarding hearing aids was received from the residents and should be communicated to nursing staff. The MDSC stated he was aware Resident 271 had hearing aids. He stated he did not code the hearing aids on the MDS because Resident 271 informed him, she was unable to use the hearing aids because they needed batteries. The MDSC stated he was supposed to notify nursing staff if a resident has hearing aids. During a review of Resident 271's Inventory List dated 11/29/22, the Inventory List indicated, Resident 271 was admitted to the facility with a right and left hearing aid. During a review of Resident 271's MDS dated [DATE], the MDS indicated, Resident 271 did not use hearing aids and had adequate hearing. During a record review of facility's policy and procedure(P&P) titled Comprehensive Assessments undated, the P&P indicated Comprehensive assessments are conducted to assist in developing person-centered care plans of residents. The P&P indicated comprehensive assessments are conducted in accordance with criteria and timeframes established in RAI User manual and an error in an assessment where the resident's overall clinical status is not accurately represented or miscoded on the erroneous assessment will result in an inappropriate plan of care. During a record review of facility's policy and procedure (P&P) titled Use of Restraints revised 4/17, the P&P indicated Physical restraints are defined as any manual method or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. The P&P indicated that the definition of restraint is based on the functional status of the resident and not the device and if the resident cannot remove a device in the same manner in which the staff applied it given the resident's physical condition and this restricts his/her typical ability to change position or place, that device is considered a restraint.

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 observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and 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 follow through with the Preadmission Screening and Resident Review ([PASRR] a federal requirement to help ensure that individuals are not inappropriately placed in nursing home) recommendation to obtain a PASRR level II evaluation for one of eight (8) sampled residents (Resident 37). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 37. Findings: During a record review of Resident 37's PASRR Level 1 screening (tool that helps identify possible serious mental illness, intellectual disability, or developmental disability) dated 1/6/22 indicated, Resident 37 had a positive Level 1 screening, and a Level 2 evaluation (helps determine placement or specialized services) was required. During a record review of Resident 37's PASRR Level 2 evaluation letter dated 4/4/22 indicated, Resident 37 was discharged from the facility and the evaluation was unable to be completed. During a record review of Resident 37 admission Record, the admission Record indicated, Resident 37 was admitted to the facility on [DATE], with a diagnoses of anxiety disorder (feeling of worry and nervousness), bipolar disorder (psychiatric illness characterized by manic[having or relating to a mental illness that causes someone to become very excited or emotional] and depressive [ loss of interest in activities, causing significant impairment in daily life episodes) and history of falling. Resident 37 was a current resident in the facility During a record review of the Minimum Data Set (a comprehensive assessment and screening tool) indicated, Resident 37 had moderate cognitive impairment (trouble remembering, concentrating, or making decisions that affect their everyday life). During an observation on 12/5/22 at 11:30 a.m., Resident 37 was observed lying in bed, able to respond verbally and hold a conversation. Resident 37 was wearing a diaper and has left side weakness of the arm and leg from a previous stroke. During a concurrent interview and record review on 12/6/22 at 10:18 a.m. with the admission Coordinator (AC), the AC stated, each PASRR referral was reviewed with the Director of Nursing (DON) and if there were any behaviors that need to be followed. The AC stated, if there was a positive Level 1 PASRR, she informed the DON. Reviewed Resident 37 positive Level 1 PASSR with AC, AC stated, the referral should have gone to the DON, and DON responsibility was to make sure the PASRR 2 evaluation was done. During a concurrent interview and record review on 12/6/22 at 10:24 a.m. with the DON, the DON stated that if there was a positive Level 1 PASRR, it was her responsibility to follow up with PASRR Level 2 evaluation. Review of Resident 37 medical record with DON, DON stated there was no PASRR 2 in Resident 37's medical record (records relating to the health history, diagnosis, or condition of a patient, or relating to treatment). During a concurrent interview and record review on 12/6/22 at 11:18 a.m. with the DON, the DON stated, a Level 2 PASSR report was found online. The DON stated, the Level 2 PASSR evaluation report indicated, it was not done because the resident was discharged from the facility. DON stated, she just found the report dated 12/6/22 but the report was completed on 4/4/22. The DON stated, she was not aware the results was online and confirmed that if the report was followed up in April 2022, the facility would have found out the result was in error because Resident 37 remained in the facility. During a record review of the facility policy and procedure (P&P) titled, PASRR Completion Policy, the policy indicated, the facility will make sure that all admissions will have the appropriate PASRR completed, the facility will make sure that the level of care is done on all potential residents and that the Business Office Manager (BOM) must have copies of the Level of Care and/or PASRR in the Business Office resident file.

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** Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-center...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an individualized person-centered, and comprehensive care plan with measurable objectives, time frame, and intervention for three of 18 sampled residents (Resident 17, Resident 63 and Resident 271) by failing to: 1. Develop a plan of care for Resident 17's usage of bedrail. 2. Develop a plan of care for Resident 63 special utensils needed for eating. 3. Develop a plan of care for Resident 271 hearing loss. This deficient practice had the potential to negatively affect the delivery of necessary care delay in interventions and services for Resident 17, 63, and 271. Findings: 1.During a record review of Resident 17's admission Record (AR)indicated Resident 17 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease (a rare inherited disease that causes progressive break down of nerve cells that affect a person's functional abilities), muscle weakness, dysphagia (difficulty of swallowing) and cachexia (a wasting disorder characterized by weight loss and lack of proper nutrition). During a record review of Resident 17's Minimum Data Set (MDS- standardized screening tool) indicated the resident had unclear speech, rarely or never understand others and required total assistance from staff members with bed mobility, transfer, eating, dressing, toilet use, and personal hygiene. During an observation on 12/5/22, at 10:53 a.m. in Resident 17's room, Resident 17's bed had bilateral quarter (¼) siderails. Observed Resident 17 moving and raising both of her arms involuntarily, unable to speak coherently and not following commands or directions. During a concurrent record review and interview on 12/7/22, at 6:37 p.m., with Registered Nurse (RN) 1, RN 1 stated there was no care plan found on Resident 17's the medical records for the use of bedrail. She stated, there should be a care plan addressing the use of bed rail and care plan should be focused on the resident's condition and care. During an interview on 12/8/22, at 3:12 p.m. with director of nursing (DON), DON stated bedrail should be a part of the care plan if a resident was using a bedrail. DON stated care plan should be developed and revised quarterly or annually depending on the MDS to make sure it was current. 2.During a review of Resident 63's admission Record (AR), the AR indicated Resident 63 was admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis (a chronic inflammatory disorder that can affect the joints), weakness, joint contractures (a permanent tightening of the muscles, tendons, skin and tissues that causes the joints to shorten and become very stiff) and dysphagia (difficulty swallowing). During a review of Resident 63's History and Physical (H&P) dated 9/30/22, the H&P indicated Resident 63 had the capacity to understand and make decisions. During a review of Resident 63's MDS dated [DATE], the MDS indicated Resident 63 needed limited assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 12/05/22 at 1:04 p.m. with CNA 8, in Resident 63's room, Resident 63 was observed lying in bed while the lunch trays were being served. CNA 8 stated Resident 63 was a feeder and used a curved spoon for feeding and was on a special diet. During an interview on 12/7/22 at 3:04 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated Resident 63 should have a care plan for using special utensils needed to eat. LVN 6 stated all licensed staff are responsible for initiating the care plan to provide care that the resident needs. During a interview on 12/8/22 at 4:04 p.m. with the DON, the DON stated Resident 63 does not have a care plan for using special utensils for eating. 3.During a review of Resident 271's admission Record (AR), the AR indicated Resident 271 was admitted to the facility on [DATE] with diagnoses of spinal stenosis (the space inside the backbone is too small), hypothyroidism (a condition where the thyroid does not create and release enough thyroid hormone into the bloodstream), type two diabetes mellitus (insufficient production of insulin causing high blood sugar) and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye). During a review of Resident 271's MDS dated [DATE], the MDS indicated, Resident 271 had the ability to understand other and makes self understood. The MDS indicated Resident 271 needed extensive assistance with bed mobility transferring, walking in the resident's room, locomotion on and off the unit, dressing, and toilet use. The MDS indicated Resident 271 needed limited assistance with personal hygiene and independent with eating. During an interview on 12/5/22 at 11:29 a.m. with Resident 271, Resident 271 stated she has a hearing aid. During an interview on 12/7/22 at 3:16 p.m. with LVN 6, LVN 6 stated Resident 271 does not have a care plan for hearing loss and should have a care plan. During an interview on 12/7/22 at 6:58 p.m. with RN 1, RN 1 stated if a resident has hearing aid a care plan should be done so staff will know how to communicate with the resident. During an interview on 12/8/22 at 3:23 p.m. with the DON, the DON stated the RN 1 initiates the care plan. The DON stated individualized care plan should be initiated to every resident in the facility. DON stated resident with hearing loss should have a care plan to meet their needs and provide care. During a record review of facility's policy and procedure (P&P) titled Care Plan Comprehensive dated 8/25/21, the P&P indicated an Individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychological needs shall be developed for each resident. The P&P indicated care plan should be built on resident's individualized needs, strengths and preferences.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

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 one of 18 sampled residents (Resident 271) was provided with ...

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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 one of 18 sampled residents (Resident 271) was provided with batteries for Resident 271's hearing aids (devices designed to help people who have hearing loss). This deficient practice resulted in Resident 271 not able to hear effectively and communicate well with staff. Findings: During a review of Resident 271's admission Record (AR), the AR indicated Resident 271 was admitted to the facility on [DATE] with diagnoses of spinal stenosis (the space inside the backbone is too small), hypothyroidism (a condition where the thyroid does not create and release enough thyroid hormone into the bloodstream), type two diabetes mellitus (insufficient production of insulin causing high blood sugar) and glaucoma (a group of eye diseases that can cause vision loss and blindness) During a review of Resident 271's Minimum Data Set (MDS- standardized screening tool) dated 11/30/22, the MDS indicated Resident 271 had the ability to understand other and makes self understood. The MDS indicated, Resident 271 needed extensive assistance with bed mobility transferring, walking in the resident's room, locomotion on and off the unit, dressing, and toilet use. The MDS indicated Resident 271 needed limited assistance with personal hygiene and independent with eating. During an interview on 12/5/22 at 11:29 a.m. with Resident 271, Resident 271 stated she has hearing aids, but she was not using them because her hearing aids needed batteries. During an interview on 12/7/22 at 10:50 a.m. with the Social Services Assistant, the SSA stated nursing staff should check if Resident 271's hearing aids were working, and in need of repairs or batteries. During an interview on 12/7/22 at 3:16 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated, social services makes appointments for the resident if the hearing aids were not working or needed batteries. During an interview on 12/7/22 at 6:10 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated, hearing aids are documented during the interview process with the resident upon admission. The MDSC stated information regarding hearing aids was received from the residents and relayed to nursing staff. The MDSC stated he was aware Resident 271 had hearing aids but did not code the hearing aids on the MDS because Resident 271 stated she was not using the hearing aids because they needed batteries. The MDSC stated he should have assisted Resident 271 with getting batteries for her hearing aids. During an interview on 12/7/22 at 6:58 p.m. with Registered Nurse (RN) 1, RN 1 stated, any staff should report a resident complaining about not having batteries for hearing aids. The RN 1 stated the MDSC should have informed her if the resident stated they need batteries for their hearing aids. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, (undated), the P&P indicated The appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with communication (speech, language, and any functional communication systems). During a review of the facility's policy and procedure (P&P) (untitled and undated), the P&P indicated Devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired. Staff are required to demonstrate competency on the use of devices and equipment and are available to assist and supervise residents as needed.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

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 staff failed to ensure one of two sampled residents (Resident 47) received pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure one of two sampled residents (Resident 47) received proper assistive devices to maintain visual abilities by not facilitating an optometry (practice or profession of examining the eyes for visual defects and prescribing corrective lenses) appointment. This deficient practice resulted in Resident 47 not having glasses for more than 22 months and feeling depressed because she was not able to watch her favorite television show as part of her preferred activities. Findings: During a review of Resident 47's admission Records(AR) the AR indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses that included glaucoma (a group of eye conditions that can cause vision loss or blindness), cerebral infarction ((lack of adequate blood supply to the brain ), type 2 diabetes (a condition in which the body fails to metabolize (process) glucose (sugar) correctly ), and hypertensive chronic kidney disease (high blood pressure caused by narrowing of blood vessels that carry blood to the kidneys). During a review of Resident 47's MDS Minimum Data Set (MDS-comprehensive screening tool), dated 8/31/22, the MDS indicated, Resident 47 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making and had impaired vision. During a review of Resident 47's Order Summary Report dated, December 2022, the report indicated Resident 47 had an active order for Ophthalmology Consult and treatment as needed for patient health and comfort, order date was 11/18/20. During an interview on 12/05/22 at 11:36 a.m., with Resident 47, Resident 47 stated she lost her glasses in the activity room in February 2021. Resident 47 stated she discussed her lost glasses with Social Service Director (SSD) and nursing staff and had not received new glasses. Resident 47 stated she love to watch the wheel of fortune (television game show) every night and without her glasses she cannot see the letters and she felt depressed because she cannot enjoy her favorite show. During a review of Resident 47's Optometry Exam Consult Note dated, 3/31/22, the note indicated Resident 47 was sleeping, no response, no exam. During a review of the facilities optometry list of residents to be seen on 7/7/22, Resident 47 was not included on the list. During a review of the facilities Optometry List of residents to be seen on 10/12/22, Resident 47 was not included on the list. During a review of Resident 47's Optometry Exam Consult Note, dated, 11/15/22, the note indicated Resident 47 had a history of decreased vision, trouble with fine print, reading, and television and plan for glasses. During a concurrent interview and record review on 12/07/22 at 10:32 a.m., with Social Service Assistant (SSA), Resident 47's Social Service progress note dated 5/2022 was reviewed. The social service note indicated on 5/18/22 at 12:32 p.m., Social Service Director (SSD) met with Resident 47 and Resident 47 verbalized she wanted to be seen by optometrist. SSD informed Resident 47 optometrist would be at the facility on 5/26/22 and Resident 47 would be added to the list to be seen. SSA stated she was unable find Resident 47's consult notes or visit log for 5/26/22. SSA stated optometry appointments were required for each resident every six month and as needed. SSA stated social services was responsible for making optometry appointments and following up on recommendations. SSA stated if a resident report they lost their glasses social service will investigate to try and locate the glasses. If unable to locate glasses, an appointment would be made for resident to see the optometrist for new glasses. SSA stated she does not know why Resident 47 has not received her glasses. SSA stated she will call the optometry office on 12/7/22 to follow up. During a review of the facility's policy and procedure (P&P) titled, Referral, Social Service, (undated), the P&P indicated, social services personnel shall coordinate most resident referrals with outside agencies. Referrals will include podiatry, dental, audiology, and ophthalmology services. Social service will coordinate these services once referral is made and/or communicated to social service department.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

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 Restorative Nursing Assistant (RNA) services 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 Restorative Nursing Assistant (RNA) services per physician's order for a resident with limited range of motion (ROM - movement of the joints) and receive appropriate treatment and services to increase, prevent, and maintain the ROM mobility for one out of eight sampled residents (Resident 28) by failing to get the resident out of bed to the wheelchair twice a week. This deficient practice had the potential for the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to Resident 28's lower extremities, maintain resident highest level of physical, mental, and psychosocial well-being, to promote and maintain Resident 28's, independence and enhance the quality of life. Findings: During an interview on 12/5/22 at 11:40 a.m. with Resident 28, Resident 28 stated, she has not been out of bed since, before Thanksgiving Day. Resident 28 stated, 11/17/22 was the last time she was out of bed. During a record review of Resident 28 admission Record (AR) dated 12/8/22, AR indicated, Resident 28 was admitted to the facility on [DATE] for muscle weakness, osteoarthritis (a type of arthritis that occurs when the cartilage at the ends of the bone wear down) and need for assistance with personal care. During a review of Resident 28 Minimum Data Set (MDS - a standardized assessment and screening tool) dated 11/4/22, the MDS indicated, Resident 28 was alert and oriented and had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS also indicated, Resident 28 was total dependent for transfers and needed two-person assist for transfer from the bed to the wheelchair. During a review of Resident 28 physician order dated 6/28/22, the physician order indicated, Resident 28 had an order for RNA treatment to assist with wheelchair transfers using a hoyer-lift (mechanical lift to assist with transfers) as tolerated twice a week every Tuesdays and Thursdays. During a review of Resident 28 care plan, revised 11/22/22, the care plan indicated, Resident 28 requires assistance with transfers due to limited mobility. The care plan also indicated, Resident 28 demonstrated a loss of range of motion in her lower extremities related to functional deterioration and that restorative nursing was needed to prevent contractures and maintain skin integrity. During a record review of the Restorative Nurse Aide (RNA) documentation log dated:11/17/22, 11/22/22, 11/24/22, 11/29/22, 12/1/22 and 12/6/22 the RNA log indicated that Resident 28 was assisted out of bed by the RNA to a wheelchair as ordered by the physician. During an interview on 12/7/22 at 12:16 p.m. with the RNA, the RNA stated that his role was to improve residents' range of motion and ambulation. The RNA stated, Resident 28 was supposed to get out of bed to the wheelchair twice a week. The RNA stated, Resident 28 did not get out of bed 12/6/22, but he signed the restorative nurse documentation log that she did get out of bed. He stated, he signed that he got Resident 28 out of bed by mistake, but Resident 28 did not get out of bed. Lastly, the RNA stated, it was important for resident to get out of bed, so resident will not develop contractures. RNA stated, if a resident refused to get out of bed, he reports it to the charge nurse. RNA stated he failed to report to the charge nurse Resident 28 refusal to get out of bed on 12/6/2022. During an interview on 12/7/22 at 12:34 p.m. with Resident 28, Resident 28 stated, she had not gotten out of bed in two weeks. Resident 28 stated, she has not refused to get out of bed and was not asked if she would like to get out of bed. She stated she would like to get out of bed on Tuesdays and Thursdays and she has a physician order to get out of bed on those days. During an interview on 12/7/22 at 3:08 p.m. with the RNA, the RNA stated, he should have written refused on the restorative nurse documentation log for 12/6/22, instead of signing that he got Resident 28 out of bed. Lastly, the RNA stated, he knows the documentation was false. During an interview on 12/8/22 at 3:51 p.m. with the director of nursing (DON), the DON stated, the RNA works with the DON and the Director or Rehab (DOR), and they are responsible for the RNA. The DON stated, the RNA documents based on the physician order and if the resident refuses, the RNA should document R for refused on the log. The DON stated, it was important for RNA treatment, to promote resident circulation, prevent depression and pressure injury from being in bed all the time. The DON stated, Resident 28 was alert, and can verbalized needs to facility staff. Lastly, the DON stated the RNA should not have signed that he got her up if he did not and that was falsification of documentation. During a record review of the facility policy and procedure (P&P) titled Physician Orders dated 3/22/22, the P&P indicated that the facility will, ensure that all physician orders are complete and accurate. During a record review of the facility policy and procedure (P&P) Restorative Nursing dated revised 6/1/21, the P&P indicated, Restorative Nursing programs are coordinated by nursing in collaboration with rehabilitation, are patient specific based on the individual patient needs, to help the patient attain and maintain optimal physical, mental an psychosocial functioning, the RNA should implement the restorative nursing program according to the specifics on the care plan and the RNA should document daily on the Restorative Nursing Record.

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 ensure one of three sampled residents (Resident 8) wi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 8) with a gastrostomy tube ([GT] a tube that is passed through the abdominal wall to the stomach used to provide nutrition) feeding was on and infusing to ensure Resident 8 received tube feeding continuously for 20 hours day per physician order. This deficient practice resulted in Resident 8 not receiving the volume of tube feeding formula as ordered by physician, and had the potential to cause dehydration, malnutrition, and weight loss to Resident 8. Findings: During a review of Resident 8's admission Record (AR), the AR indicated, Resident 8 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included cerebrovascular disease (a group of conditions that affect the blood flow to the brain), type 2 diabetes (chronic condition that affects how the body processes sugar), dysphagia (difficulty swallowing food and liquid), and GT. During a review of Resident 8's History and Physical (H&P), dated 11/30/22, the H&P indicated Resident 8 was to receive tube feeding as scheduled. During a review of Resident 8's MDS Minimum Data Set (MDS-comprehensive screening tool), dated 10/12/22, the MDS indicated, Resident 8 had severe cognitive (ability to learn remember, understand and decisions) impairment for daily decision making, had a GT, and received more than 51% of her nutritional intake via GT. During a review of Resident 8's Order Summary Report, dated, 12/2022, indicated, provide Glucerna 1.2 calories via enteral (GT formula) pump continuously at 55 milliliters ([ml] unit of volume) per hour for 20 hours or until nutrient delivered to provide 1100 ml/1320 kilocalorie (kcal) per 20 hours. Continuous water flush at 50 ml per hour for 20 hours equaling 1000 ml per 20 hours. Tube feeding to start at 1;00 p.m. and stop at 9:00 a.m. During a review of Resident 8's care plan initiated on 7/12/15, and revised on 9/25/22, the care plan indicated, Resident 8 was at risk for dehydration and had nutritional risk related to being dependent upon enteral feeding for all nutritional and hydration needs. Interventions included to provide tube feeding as ordered and monitor intake and output. During a review of Resident 8's Medication Administration Record (MAR) for the month of December 2022, the MAR indicated, resident 8 had been receiving the tube feeding at the rate of 55ml per hour for 20 hours as ordered. During an observation on 12/5/22 at 10:40 a.m. Resident 8 was observed lying in bed with Glucerna 1.2 calories, formula bottle (1500 ml) connected to feeding pump. Observed Resident 8 feeding pump was off. The formula bottle was labeled with a start date of 12/4/22 at 9:00 p.m., the rate of 55 ml per hour, and there was 1200 ml of formula remaining in the bottle. A review of the label on Resident 8's Glucerna formula bottle indicated, the feeding pump ran for 12 hours, and Resident 8 should have received 660 ml's of formula. However, during the observation, the formula bottle had 1200 ml's of formula left which indicated Resident 8 received 300 ml of formula over 12 hours. During an observation on 12/6/22 at 9:30 a.m., Resident 8 was lying in bed, GT feeding Glucerna 1.2 calories, formula bottle (1500 ml) connected to pump and was off. The formula bottle was labeled with a start date of 12/6/22 at 12:00 a.m., the rate of 55 ml per hour, and there was 1250 ml of formula remaining in the bottle. Resident 8's Glucerna formula bottle label indicated, the feeding pump ran for 9 hours. Resident 8 should have received 495 ml's of formula. However, during the observation, the formula bottle had 1250 ml's of formula left which indicated Resident 8 received 250 ml of formula over 9 hours. During a concurrent observation and interview on 12/6/22, at 4:40 p.m., with Licensed Vocational Nurse (LVN) 4, in Resident 8's room, Resident 8 was observed lying in bed, GT feeding connected to pump and pump was off. LVN 4 read the label on the formula bottle which indicated a start date of 12/6/22 at 12:00 a.m., the rate of 55 ml per hour, and observed there was 1250 ml of formula remaining in the 1500 ml bottle. LVN 4 stated the pump should be on at this time. LVN 4 stated from 12:00a.m. to 9:00 a.m., Resident 8 should have received a volume of 495 ml's, and from 1:00 p.m. to 4:00 p.m. Resident 8 should have received a volume of 165 ml's. LVN 4 stated the total volume infused after the bottle was hung should have been 660 ml's, and Resident 8 only received 250 ml's. LVN 4 stated she does not know why the feeding pump was off because the formula was Resident 8's only source of nutrients. LVN 4 stated, licensed nurses were responsible for starting, stopping, and changing enteral feeding and it was important for a resident to receive adequate nutrition to prevent dehydration, weight loss, and skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Enteral Feeding - Closed, dated 2021, the P&P indicated, Enteral feeding will be administered via pump and as ordered by the attending physician.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

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 it was free of medication error rate of five pe...

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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 it was free of medication error rate of five percent (%) or greater as evidenced by three medication errors out of 26 opportunities for error to yield a medication error rate of 11.53 percentage (%), for one of five residents (Residents 59) observed during medication administration (MedPass). The observed errors were as follow: 1. Facility failed to ensure Resident 59's was administered the correct insulin (lowers the level of glucose [a type of sugar] in the blood) medication, Basaglar (a long-acting basal insulin used to control high blood sugar) KwikPen (a disposable, single-patient-use prefilled insulin pen) as ordered by the physician instead of administering an incorrect insulin medication, Novolog (rapid-acting insulin) Flexpen (a prefilled disposable device that looks like a pen) on 12/6/2022 during morning medication pass (Refer to F760) 2. Facility failed to stir and dissolve Resident 59's non-prescription medication, GlycoLAX ([Polyethylene glycol 3350] a laxative used to treat constipation) as order by the physician and in accordance with manufacturer's specification prior to administering the GlycoLAX to the resident. This failure had the potential for Resident 59 to experience side effects that included nausea and abdominal pain. This deficient practice of medication administration error rate of 11.53 % exceeded the five (5) percent threshold. Findings: During a review of Resident 59's admission Record (Face Sheet), the Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 59's diagnoses included Type 2 Diabetes Mellitus (DM2, a disease that occurs when the blood glucose [blood sugar] is too high) and dysphagia (difficulty swallowing). A review of Resident 59's Minimum Data Set ([MDS], a standardized assessment and care planning tool that measures health status in nursing home residents) dated 9/15/2022, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) required supervision while eating, limited assistance for personal hygiene, and extensive, one person physical assistance for activities of daily living (getting in and out of bed, dressing, bathing, and toileting). During a medication pass observation on 12/6/2022 from 9:32 AM to 9:39 AM., with Licensed Vocational Nurse (LVN 3) on the North Nursing Station at Medication Cart (MedCart 1), LVN 3 was observed preparing Resident 59's medications with a 9 a.m. administration time. LVN 3 prepared the following medications that included but was not limited to the two following medications: 1) placing 17 gram ([gm] - unit of measure for weight) of GlycoLAX Powder into a medication cup and 2) drawing up into a syringe 26 units of NovoLog insulin. LVN 3 entered Resident 59's room poured some water into a five-ounce ([oz] - a unit of measure for volume) medication cup that contained 17 gm of GlycoLAX Powder and gave the cup to Resident 59 to drink. Undissolved white powder was observed inside the medication cup. LVN 3 added more water to the cup and used a second cup to mix the remaining GlycoLAX Powder and gave the cups one at a time to Resident 59 to drink. During a review of Resident 59's Physician Order Summary Report, dated 12/2022, the Physician orders included orders for: 1. Basaglar KwikPen 100 units per milliliter (ml, units of measure), order date 9/19/2022, instructions indicated, inject 26 units subcutaneously (under the skin) one time a day for DM2. 2. Novolog Flexpen 100 unit/1 ml, order date 8/31/22, instructions indicated, inject as per sliding scale: if blood sugar (BS): 70 - 130 = 0 units; 131 - 150 = 2 units; 151 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units for BS over 401 give 12 units and inform MD, subcutaneously before meals and at bedtime for DM2. 3. GlycoLAX Powder 17 gram (gm, unit of measure) per scoop, order date 6/8/22, instructions indicated, give one scoop by mouth one time a day for bowel management. Hold for loose stool. Mix with 8 (eight) ounces of water. During a concurrent record review and interview on 12/6/2022 at 2:46 PM with LVN 3, LVN 3 reviewed Resident 59's physician orders for insulin, the actual insulin pen used to administer medication to the resident, and the resident's electronic Medication Administration Record (eMAR, a written record of all medications given to a resident) for the scheduled administration time of 9 AM on 12/6/22. LVN 3 opened MedCart 1 and showed the Novolog pen and stated this is the insulin administered to Resident 59 during the 9 AM medication pass (MedPass) on 12/6/22. LVN 3 reviewed Resident 59's eMAR and pointed to Basaglar signed with her initial to indicate that Basaglar was documented as administered to the resident. LVN 3 reviewed the two different insulins (Basaglar and Novolog) both labeled for Resident 59 inside the medication cart and stated she should have administered Basaglar instead of Novolog. During a concurrent record review and interview on 12/6/2022 at 3:16 PM with LVN 3, Resident 59's physician order for GlycoLAX and the manufacturer's package labeling was reviewed. LVN 3 stated she should have administered the GlycoLAX with 8 ounces of water as ordered. LVN 3 read the GlycoLAX manufacturer's package label that indicated, Stir and dissolve in any 4 to 8 ounces of beverage (cold, hot, or room temperature) then drink. Ensure that the powder is fully dissolved before drinking. Do not drink if there are any clumps. LVN 3 stated, she should have made sure the medicine was fully dissolved before giving the medication to the resident to drink. A review of the facility's undated policy and procedures (P&P) titled, Administering Medications, indicated, Medications are administered in accordance with prescriber orders .The individual administering medication check the label Three (3) times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication .Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse verifies that the correct pen is used for that resident. A review of the facility's P&P titled, General Dose Preparation and Medication Administration, dated 1/13, indicated, Follow manufacturer medication administration guidelines .

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

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 five sampled resident's medication regim...

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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 five sampled resident's medication regimen, was free from significant medication errors (Resident 59). This deficient practice jeopardized Resident 59's health and safety by failing to administer the long acting Basaglar insulin (lowers the level of glucose [a type of sugar] in the blood) as ordered on 12/6/22 instead of the rapid acting sliding scale Novolog insulin. The failure had the potential for Resident 59 to experience uncontrolled blood sugar levels, hospitalization, or death. Findings: During a review of Resident 59's admission Record (Face Sheet), the Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 59's diagnoses included Type 2 Diabetes Mellitus (DM2, a disease that occurs when the blood glucose [blood sugar] is too high) and dysphagia (difficulty swallowing). A review of Resident 59's Minimum Data Set ([MDS], a standardized assessment and care planning tool that measures health status in nursing home residents) dated 9/15/2022, indicated the resident had a moderately impaired cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) required supervision while eating, limited assistance for personal hygiene, and extensive, one person physical assistance for activities of daily living (getting in and out of bed, dressing, bathing, and toileting). During a medication pass observation on 12/6/2022 from 9:32 AM to 9:39 AM., with Licensed Vocational Nurse (LVN 3) on the North Nursing Station at Medication Cart (MedCart 1), LVN 3 prepared and administered to Resident 59 's morning medications that included but was not limited to Novolog (rapid-acting insulin) Flexpen (a prefilled disposable device that looks like a pen). LVN 3 was not observed checking Resident 59's BS prior to administering to the resident 26 units of Novolog insulin. During a review of Resident 59's Physician Order Summary Report, dated 12/2022, the Physician orders included orders for: 1. Basaglar (a long-acting basal insulin used to control high blood sugar) KwikPen (a disposable, single-patient-use prefilled insulin pen) 100 units per milliliter (ml, units of measure), order date 9/19/2022, instructions indicated, inject 26 units subcutaneously (under the skin) one time a day for DM2. 2. Novolog Flexpen 100 unit/1 ml, order date 8/31/2022, instructions indicated, inject as per sliding scale: if blood sugar (BS): 70 - 130 = 0 units; 131 - 150 = 2 units; 151 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units for BS over 401 give 12 units and inform MD, subcutaneously before meals and at bedtime for DM2. A review of Resident 59's 12/2022 electronic Medication Administration Record (eMAR, a written record of all medications given to a resident) indicated by licensed nurse initial and a check mark that Resident 59 was documented to have been administered 26 units of Basaglar KwikPen Insulin on 12/6/22 at the 9 AM scheduled administration time. A review of Resident 59's 12/2022 eMAR for Novolog Flexpen indicated the scheduled administration times was 6:30 AM, 11:30 AM, 4:30 PM, and 9 PM. Resident 59's medical record was documented by licensed nurse initial and check mark to have received Novolog on 12/6/2022 at 6:30 AM. There was no check mark on the eMAR to indicate Resident 59 was administered Novolog on 12/6/2022 at 9 AM as observed during medication pass or for the 11:30 AM scheduled administration time on 12/6/2022. During a concurrent record review and interview on 12/6/2022 at 2:46 PM with LVN 3, LVN 3 reviewed Resident 59's insulin orders with a scheduled administration time of 9 AM. LVN 3 stated she should have administered Basaglar at 9 AM instead of Novolog. LVN 3 stated, Resident 59's blood sugar was low at lunch time (on 12/6/2022) and she did not give another dose of Novolog. LVN 3 stated she documented the administration of Basaglar that was scheduled for 9 AM administration on 12/6/2022, yet she had not administered Basaglar and gave Novolog by mistake. LVN 3 stated the medication error could have caused Resident 59 to experience adverse effects that include the blood sugar level going too low that could lead to diabetic shock. During an interview on 12/6/22 at 3:53 PM with the Director of Nursing (DON) and a Registered Nurse (RN 1), RN 1 and DON stated they were informed that Resident 59 received Novolog instead of Basaglar during the morning medication pass. RN 1 stated she reviewed with Resident 59 the sign and symptoms of low blood sugar that included sweaty, weak, unresponsive, shaky, pale and could lead to hospitalization, coma, or death. RN 1 stated they will inform Resident 59's physician of the insulin medication error. A review of the facility's undated policy and procedures (P&P) titled, Administering Medications, indicated, Medications are administered in accordance with prescriber orders .insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse verifies that the correct pen is used for that resident. A review of the facility's P&P titled, General Dose Preparation and Medication Administration, dated 1/13, indicated, Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to: 1. Store five medications at the correct temperature as required by t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to: 1. Store five medications at the correct temperature as required by the manufacturer's specifications for two of two medication carts (MedCart 3 and MedCart 2) observed. 2. Ensure an expired medication was removed from the medication cart to not be available for resident use, observed in one of two medication carts (MedCart 2). These deficient practices had the potential to negatively affect the residents' health and well-being by improperly storing medications that required refrigeration and failure to remove expired medication to ensure they were not available for resident use. Findings: 1a. On [DATE] between 12:31 PM to 1:27 PM during an observation of MedCart 2 on North Nursing Station with Licensed Vocational Nurse (LVN 6) and MedCart 3 on South Nursing Station with Director of Staff Development (DSD), the following issues with medication storage were identified: On [DATE] at 12:31 PM., with LVN 6 of MedCart 3 on South Nursing Station, inside of MedCart 3 was: One unopened vial of Humulin R (an insulin used to treat diabetes [a disease that affects blood glucose (a type of sugar)]) labeled for Resident 5 One Insulin Aspart Flexpen (a prefilled disposable device that looks like a pen) with no open date labeled for Resident 277. During an interview on [DATE] at 12:40 PM with LVN 6, LVN 6 stated the insulin for Resident 5 was delivered to the facility around 10 AM this morning and should have been refrigerated right away if not used. LVN 6 stated Resident 277 was administered a dose of Insulin Aspart today, [DATE]. LVN 6 stated she did not know when the insulin for Resident 277 was first opened or used before today, [DATE] as there should have been an open date on the Insulin Aspart Flexpen that was stored in MedCart 3, but there was not. 1b. On [DATE] at 1:18 PM, with Director of Staff Development/Licensed Vocational Nurse, (DSD) of MedCart 2 on North Nursing Station, inside of MedCart 2 was: Two Basaglar KwikPen (a prefilled disposable device that looks like a pen) with no open dates labeled for two different residents (Resident 11 and Resident 26). One Insulin Lispro KwikPen with no open date labeled for Resident 121. During an interview on [DATE] at 1:18 PM with DSD, DSD reviewed the insulins stored unrefrigerated in MedCart 2 and stated the insulin pens labeled for Resident 11, Resident 26, and Resident 121 looked unused. DSD stated, Unused insulin should be stored in the refrigerator until expiration date or until opened to be used. There should be a date when opened and is should be used within 28 days. DSD stated, If the insulin is not dated or stored properly, the medication may become less effective and may fail to adequately control or maintain the residents BG levels. DSD stated residents with uncontrolled BG levels could cause the residents to experience adverse reactions up to and including a stroke or death. 2. On [DATE] at 1:27 PM, with DSD of MedCart 2 on North Nursing Station, inside of MedCart 2 was: One bottle of expired Proheal Liquid Protein (supplement for wound healing) a floor stock (facility provided non-prescription medication available to be used for more than one resident on the written orders of a physician) with an open date of [DATE]. During an interview on [DATE] at 1:27 PM with DSD, DSD stated the bottle of Proheal Liquid Protein in MedCart 2 was opened on [DATE]. DSD stated the manufacturer's label on the bottle of medication indicated, Discard after 60 days. DSD stated the Proheal Liquid Protein should have been discarded in [DATE]. DSD stated if given after expired, the medication would not be effective when administered to residents to help with wound healing. A review of the facility's Policy and Procedure (P&P) titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated 4/2022, indicated, Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. A review of the facility's P&P, titled, Insulin Storage Recommendations, dated 4/2019, indicated, all unopened insulin stored in the refrigerator at 36 degrees Fahrenheit [°F] - 46°F (2° Celsius [C] - 8°C) can be used until the manufacturer expiration date on the carton. Insulin stored at room temperature unopened or opened has a shortened expiration date with Humulin R vial per manufacturer expire after 31 days and the insulin pens (e.g., Insulin Aspart [Novolog] Flexpen, Basaglar Kwikpen, and Insulin Lispro [Humalog] Kwikpen) per manufacturers each expired after 28 days when stored unrefrigerated.

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 F0773 (Tag F0773)

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 Registered Nurse (RN) 1 reviewed and reported ...

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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 Registered Nurse (RN) 1 reviewed and reported abnormal labs results [high potassium (nutrient helps your nerves and muscles function) to the physician in a timely manner for one of five sampled residents (Resident 12), who had a history of hyperkalemia (high potassium level in the blood). This deficient practice resulted in Resident 12's high potassium level going untreated for two (2) days and had the potential to cause Resident 12 to experience an arrhythmia (abnormal heartbeat), cardiac arrest, and death. Finding: During a review of Resident 12's admission Record (AR), the AR indicated, Resident 12 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included respiratory failure (condition that makes it difficult to breathe on your own), atrial fibrillation (irregular heart beat), encephalopathy (brain damage), type 2 diabetes (chronic condition that affects how the body processes sugar), and hypertension (HTN - high blood pressure). During a review of Resident 12's History and Physical (H&P), dated [DATE], the H&P indicated Resident 12 had the capacity to understand and make decisions, was chronically ill, and had fair rehabilitation potential. During a review of Resident 12's MDS Minimum Data Set (MDS-comprehensive screening tool), dated [DATE], the MDS indicated, Resident 12 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, required extensive assistance with bed mobility, transfers, dressing eating, and required limited assistance with personal hygiene. During a review of Resident 12's care plan dated, [DATE], the care plan indicated Resident 12 had a high potassium level. Interventions included laboratory (lab) tests as ordered, report abnormal laboratory test results to physician promptly, administer medication as ordered, and monitor for signs and symptoms of hyperkalemia such as palpitation. During a review of Resident 12's Laboratory Results Report dated, [DATE], the lab report indicated Resident 12 had blood collected for potassium level on [DATE], the potassium level was 6.0 milliequivalent per liter (mEq/L), the lab results were reported to the facility on [DATE] at 8:24 a.m., and Registered Nurse (RN) 2 reviewed the lab report [DATE] at 10:06 a.m. During a review of Resident 12's Situation, Background, Assessment, Recommendation [(SBAR) a technique used to facilitate prompt and appropriate communication] form, dated, [DATE], indicated Resident 12's was assessed to be alert, oriented to person, place time and event, denied chest pain or discomfort, no shortness of breath, breathing was unlabored, no palpitation. Medical doctor (MD) was informed of high potassium level, new order was received, Sodium Polystyrene Sulfonate Suspension (used to treat high levels of potassium in the blood) 15 grams/60 milliliter - give 30 grams by mouth one time only for hyperkalemia (high potassium level in the blood) and BMP -Basic Metabolic Panel lab on [DATE]) noted, carried out, and daughter was notified. SBAR note was signed by RN 2. During a review of Resident 12's Lab Results Report dated, [DATE], the lab report indicated Resident 12 had blood collected for repeat potassium level on [DATE], the potassium level was 5.3 mEq/L, the results were reported to the facility on [DATE] at 3:52 a.m., and RN 2 reviewed the lab report on [DATE] at 2:02 a.m. During a review of Resident 12's Lab Results Report dated, [DATE], the lab report indicated Resident 12 had blood collected for potassium level on [DATE], the potassium level was 5.9 mEq/L, the results were report to the facility on [DATE] at 10:24 a.m., and RN 1 reviewed the lab report on [DATE] at 9:22 a.m. During a review of Resident 12's SBAR Communication Form, dated, [DATE], indicated Resident 12's had lab results with potassium level of 5.9., MD, and family member notified on [DATE]. SBAR Communication Form indicated, will continue to monitor and MD ordered a onetime administration of Sodium Polystyrene Sulfonate (Kayexalate) 30 grams solution by mouth, repeat lab on [DATE]. SBAR note was signed by Licensed Vocational Nurse (LVN) 7. During an observation on [DATE] at 12:15 p.m., outside Resident 12's room, RN 1 and Infection Preventionist Nurse (IPN) was observed performing cardiopulmonary resuscitation (CPR - an emergency lifesaving procedure performed when someone's breathing, or heartbeat has stopped). CPR was continued by facility staff until the fire department arrived and took over at 12:23 p.m. At 12:27 p.m. fire department stated Resident 12 heart rhythm was ventricular tachycardia (V-tach- an abnormal fast heart rhythm, or arrhythmia). Resident 12 was shocked and was given emergency medication. At 12:37 p.m., pulse check, rhythm asystole (pulseless) CPR was continued. At 12:49 p.m. Resident 12 did not respond to treatment and was pronounced deceased . During an interview on [DATE] at 6:36 p.m., with RN 1, RN 1 stated Resident 12 was prescribed Kayexalate on [DATE] because Resident 12 potassium level was high (5.9 mEq/L). RN 1 stated she called Resident 12's MD and informed him of the abnormal potassium level on [DATE] after reviewing the labs in the Electronic Medical Records (EMR). RN 1 stated she was not aware the labs had been reported by the lab provider on [DATE], 2 days before she reviewed the lab report. RN 1 stated labs are reviewed by RN supervisor every day and abnormal results are reported to MD immediately. RN 1 stated abnormal results given to MD after 2-3 days can cause a delay in care. During a concurrent interview and record review on [DATE] at 4:17p.m., with Director of Nursing (DON), Resident 12's lab report dated, [DATE] was reviewed. DON stated the lab results are uploaded directly into the EMR from the lab provider. DON stated Administrator (ADM), DON, and RN Supervisor have access to log into the lab portal if there was a delay with getting lab results. DON stated labs must be reviewed by RN supervisor immediately after they were reported by lab to the facility DON stated labs must be reported to MD promptly to prevent a delay in care and waiting two (2) days to review Resident 12's abnormal labs caused a delay in care and treatment. DON stated it was not acceptable for a nurse to wait longer than 2 hours to review labs. DON stated a high potassium level was very serious and must be reported to MD and treated promptly because high potassium can cause arrythmia and can lead to cardiac arrest. During a review of the facility's policy and Procedure (P&P), titled Diagnostic Tests, dated 2021, the P&P indicated all diagnostic results are reported to attending physician/advance practice provider promptly.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: a. Ensure a resident (Resident 26) on dialysis (proc...

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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: a. Ensure a resident (Resident 26) on dialysis (process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) was administered Renvela ([sevelamer carbonate] used to control phosphorus levels in adults and children with chronic kidney disease (CKD) on dialysis) to prevent high levels of phosphorus in the body that can cause brittle bones, increased risk for heart attach and stroke) as ordered and failed to notify the physician when resident was not administered the medication to meet the resident's needs. This deficient practice put Resident 26 at risk for adverse reactions that may result from high phosphorus levels in the system. b. Ensure three bottles of refrigerated Lorazepam, a controlled (a medication with a high abuse potential) and one bubble pack (a card holding tablets or capsules that are individually packaged in a clear plastic case sealed to a card) of Lorazepam was appropriately locked and securely stored on North Nursing Station inside the medication room and inside the South Nursing Station Medication Cart (MedCart 3). This deficient practice created the potential for drug (medication) diversion (transfer of a medication from a legal to an illegal use), loss, or misuse. c. Ensure Registered Nurse (RN) 1 who prepared sodium polystyrene sulfonate [(Kayexalate) medication to treat high potassium in the blood] for administration, was the nurse who administered to Kayexalate to Resident 12, a resident with a high potassium level. This deficient practice had the potential to cause medication errors. d. Ensure Licensed Vocational Nurse (LVN) 7 signed the Medication Administration Record for Resident 12 after administering Kayexalate. This deficient practice had the potential to result in Resident 12 receiving an extra dose of sodium polystyrene sulfonate. Findings: a. During a review of Resident 26's admission Record ([Face Sheet] a document containing medical and demographic information), the Face Sheet indicated the resident was originally admitted to the facility 9/3/2021 and readmitted on [DATE]. Resident 26's diagnoses included myocardial infarction (heart attack, blockage of blood flow to the heart muscle), End Stage Renal Disease (when the kidneys have little to no function), Dependence on Renal Dialysis (a mechanical method to rid the body of waste, due to kidney malfunction). A review of Resident 26's Minimum Data Set ([MDS], a standardized assessment tool that measures health status in nursing home residents) dated 9/25/2022, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding through thought and the senses) required supervision while eating, limited assistance for personal hygiene and activities of daily living (getting in and out of bed, dressing, bathing, toileting, and movement on and off the unit). During a concurrent medication pass observation and interview on 12/5/2022 at 2:13 PM with the Minimum Data Set Coordinator/Licensed Vocational Nurse (MDSC) and Resident 26 on North Nursing Station Medication Cart 2, MDSC offered to administer to Resident 26 his Renvela. Resident 26 stated, My doctor told me I have to have the Renvela with food. During an interview on 12/5/2022 at 2:19 PM with Resident 26, Resident 26 stated, I never get my medication, Renvela for high phosphorus at the right time. I did not get the Renvela with breakfast and I just returned from dialysis about 1:30 PM. Resident 26 stated his food tray was at his bedside when he returned from dialysis, and he already finished eating. Resident 26 stated his Renvela should be taken with the meal. A review of Resident 26's physician Order Summary Report for 12/2022 indicated an order for Renvela (Sevelamer Carbonate) Tablets 800 milligrams ([mg] unit of measure), give 1600 mg (two tablets) by mouth with meals for supplement, order date 8/2/2022. During an interview on 12/5/2022 at 4:04 PM with the Director of Nursing (DON), DON stated the facility's mealtimes are breakfast at 7:30 AM, lunch at 12:30 PM, and dinner at 5:30 PM. During a concurrent interview and record review on 12/6/2022 at 4:06 PM with DON, Resident 26 physician order was reviewed with the DON. Resident 26 physician order dated 8/3/2022 for Renvela and electronic Medication Administration Record (MAR, a written record of all medications given to a resident) for 8/2022 through 12/2022 indicated the administration times for Renvela was scheduled for 7:30 AM, 11:30 AM, and 4:30 PM. DON stated the letter AW documented on the eMAR indicated Resident 26 was away from the facility and was not administered his Renvela. On 12/6/2022 at 4:18, DON reviewed Resident 26 eMAR from 8/2022 through 12/2022 and stated the letters AW was documented for Renvela on the e[DATE] times for 11/2022, 27 times for 10/2022, 25 times for 9/2022, 16 times for 8/22 and three times between 12/1/2022 to 12/5/2022. During an interview on 12/6/2022 at 4:43 PM with DON, DON stated Resident 26 not being administered his Renvela as prescribed may result in the resident experiencing abnormal laboratory results. DON stated the resident may not do well during dialysis procedure or dialysis may not be as effective as it should be for the resident. DON stated Resident 26 could have a decline in his condition and the high phosphorus level may contribute to the renal failure. A review of Resident 26's laboratory values on a form titled, 6 Month Cumulative Report showing all values for the month, indicated Resident 26's phosphorus levels were high (normal phosphorus level is 2.5 to 4.5 mg/ deciliter ([dL] is a unit of volume) for 10 out of the 12 times tested from 6/22 to 11/22 as follow: June 22 - 3.8 mg/dL July 22 - 5.8 mg/dL and 6.6 mg/dL August 22 - 6.4 mg/dL and 5.7 mg/dL September 22 - 5.3 mg/dl and 4.4 mg/dL October 22 - 7.8 mg/dl and 7.2 mg/dL November 22 - 6.3 mg/dL, 6.7 mg/dL, and 6.3 mg/dl During a concurrent record review and interview with DON on 12/6/22 at 4:24 PM, Resident 26's nursing progress notes was reviewed from 5/11/2022 through 12/5/2022. DON stated there was no documentation in the nursing notes that Resident 26's physician was notified that the resident was missing Renvela multiple times due to being away for dialysis. DON stated there was no documentation that Resident 26 was administered Renvela when he returned to the facility at a time different from the scheduled time of administration. A review of the facility's undated policy and procedure (P&P) titled, Administering Medication, indicated, Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: 1. Enhancing optimal therapeutic effect of the medication: 2. Preventing potential medication or food interactions: and 3. Honoring resident choices and preferences, consistent with his or her care plan. According to DailyMed, a database of manufacturer labeling submitted to the Food and Drug Administration (FDA), updated 1/2017, indicated for under, Patient Counseling Information. Inform patients to take Renvela with meals and adhere to their prescribed diets. According to the National Kidney Foundation, reviewed by the Council on Renal Nutrition dated 4/19, article titled, Phosphorus and Your Diet, indicated, Extra phosphorus causes body changes that pull calcium out of your bones, making them weak. High phosphorus and calcium levels also lead to dangerous calcium deposits in blood vessels, lungs, eyes, and heart. Over time this can lead to increased risk of heart attack, stroke, or death. b. During a medication area inspection on 12/7/2022 at 10:50 AM with a Licensed Vocational Nurse (LVN 5) the North Nursing Station Medication Room was inspected. Observed inside the unlocked refrigerator located inside the North Nursing Station Medication Room was Lorazepam 2 mg/ ml Oral Concentrate labeled for three different residents (Resident 9, Resident 39, and Resident 45). During an interview on 12/7/2022 at 11:05 AM with LVN 5, LVN 5 stated the refrigerator inside the medication room on the North Nursing Station was unlocked. LVN 5 stated the refrigerator contained controlled medications (Lorazepam) and should have been locked. During an interview on 12/7/2022 at 11:40 AM with Registered Nurse (RN 1) inside the North Nursing Station Medication Room, RN 1 stated, The refrigerator should be locked because it contains narcotics, Lorazepam, a controlled medication. During a concurrent interview and inspection of MedCart 3 on the South Nursing Station on 12/7/2022 at 12:31 PM with LVN 6, observed inside of MedCart 3 was a bag of medication labeled for Resident 272 that included a bubble pack of Lorazepam 0.5 mg with a fill date of 11/19/2022 that contained 28 pills. LVN 6 stated she was unaware the Lorazepam was in MedCart 3. LVN 6 stated the Lorazepam was a home medication (medication brought to the facility by resident or family) for Resident 272 and was not included in the daily controlled medication count or stored in the locked section inside MedCart 3. During an interview on 12/7/2022 at 3:38 PM with DON, DON stated the facility does not accept controlled medication brought into the facility by resident or family. DON stated controlled medications awaiting disposal must be kept in a double locked cabinet in the DON's office. DON stated the refrigerator should be locked because it contains controlled medication. A review of the facility's P&P titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated 4/22, indicated under Controlled Substances Storage, the following: 1. After receiving controlled substances and adding to inventory, Facility should ensure that Scheduled II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room .) and double locked. 2. Controlled Substances stored in the refrigerator must be in a separate container and double locked. c. d. During a review of Resident 12's admission record, the admission record indicate Resident 12 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included respiratory failure (condition that makes it difficult to breathe on your own), atrial fibrillation (irregular beat), encephalopathy (brain damage), type 2 diabetes (chronic condition that affects how the body processes sugar), and hypertension (HTN - high blood pressure). During a review of Resident 12's History and Physical (H&P), dated 10/18/2022, the H&P indicated Resident 12 had the capacity to understand and make decisions, was chronically ill, and had fair rehabilitation potential. During a review of Resident 12's MDS dated [DATE], the MDS indicated, Resident 12 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, required extensive assistance with bed mobility, transfers, dressing, eating, and required limited assistance with personal hygiene. During a review of Resident 12's Care Plan dated, 10/27/2022, the Care Plan indicated resident 12 had an abnormaly high potassium level (which if untreated can cause muscle fatigue, weakness, paralysis, palpitations and nausea). Interventions included labs as ordered, report abnormal results to MD promptly, administer medication as ordered, and monitor for signs of hyperkalemia such as palpitation. c. During a review of resident 12's Omnicell (automated medication dispensing system) transaction report, dated 12/7/2022, indicated on 12/4/2022 8:02 p.m., RN 1 removed, Kayexalate Suspension 15 grams/60 milliliter, quantity of two. During an interview on 12/7/2022 at 6:36 p.m., with RN 1, RN1 stated she removed Kayexalate Suspension 15 grams/60 milliliter, quantity of two (Kayexalate) from the Omnicell and gave it to LVN 7 to administer to Resident 12. RN 1 acknowledged because she removed the medication from the Omnicell she should have given it to Resident 12 herself, and she should not have given the medication to LVN 7 to administer. RN 1 stated she removed the medication from the Omnicell because she wanted to help. RN 1 stated it is the facility's policy the nurse who pulls the medication (out of the omnicell) must administer the medication. During an interview on 12/08/2022 at 06:09 p.m., with LVN 7, LVN 7 confirmed he did not remove the Kayexalate from the Omnicell. LVN 7 stated RN 1 informed him of Resident 12's abnormal potassium level and gave him the medication to administer. LVN 7 stated he did not call the physician or obtain the kayexalate order. LVN 1 stated he verbally verified the medication order with RN 1, and he did not review the written order prior to administering the medication. LVN 1 stated he did not follow the professional standard of practice by not checking the order prior to giving the kayexalate. d. During a review of Resident 12's Medication Administration Record (MAR), dated December 2022, the MAR listed Kayexalate 15 grams/60 milliliter - give 30 grams by mouth one time only for hyperkalemia 5.9 mmol/L (normal range 3.5 mmol/L- 5.0 mmol/L) until 12/4/2022- 11 p.m. took from Omnicell- start date 12/4/22 at 10 p.m. Sunday, 12/4/22 was unsigned on the MAR. The MAR was signed two days later, on 12/6/22 at 3:11 p.m. by RN 1. During an interview on 12/7/2022 at 6:36 p.m. with RN 1, RN1 stated she signed Resident 12's MAR on 12/6/22 because she was reviewing Resident 12's chart and the Kayexalate was unsigned. RN 1 stated licensed nurses must sign the MAR after they administer a medication and if they are signing later, they must indicate late entry in the record and not sign for a different date. During an interview on 12/08/22 at 06:09 p.m. with LVN 7, LVN 7 stated after administering medication to a resident he must sign the MAR. LVN 7 stated he documented in Resident 12's EMRtha , all due medication was given because he could not find the order on the MAR. During a review of the facility's policy and Procedure (P&P), titled, Medication Administration dated 2019, the P&P indicated, medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next ones. During a review of the facility's policy and Procedure (P&P), titled, Physician Orders, dated 2022, the P&P indicated whenever possible, licensed nurse receiving the order will be responsible for documenting and implementing the order.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to: a.Ensure an open frozen pie crusts were dated and labeled in the freezer. b.Ensure chicken salad's temperature was tracked an...

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Based on observation, interview and record review, the facility failed to: a.Ensure an open frozen pie crusts were dated and labeled in the freezer. b.Ensure chicken salad's temperature was tracked and checked after preparing and removing it from the refrigerator. These deficient practices placed residents at risk for foodborne illness (any illness resulting from ingestion of food contaminated with bacteria, viruses or parasites). Findings: a. During a concurrent observation and interview on 12/5/22, at 8:45 a.m. in the facility's kitchen with [NAME] (CK) 1, observed an open frozen pie crusts were open but not labeled with open date. During an interview on 12/5/22, at 8:50 a.m. with CK 1, CK 1 stated the frozen pie crust was already out of the box and it was important to label with the date opened, so facility staff will know when or how long the food was in the freezer. CK 1 stated residents can get sick from eating expired foods. b.During an observation on 12/6/22, at 11:45 a.m. with CK 1, a tray of chicken salad sitting on ice was observed with temperature of 37 degrees Fahrenheit (scale for measuring temperature). During a record review of temperature logs of food on 12/6/22 at 11:48 a.m., indicated chicken salad's temperature was not tracked after preparation and after removing from the refrigerator. During an interview on 12/6/22, at 11:45 a.m. with CK 1, CK 1 stated he checked the temperature after preparing and removal of chicken salad from the refrigerator but did not document on the temperature log. CK 1 stated it was important to track and check the temperature of chicken salad before serving to prevent food borne illness to residents in the facility. During a record review of facility's policy and procedure (P&P) titled Food Storage: Cold Foods revised 4/18, P&P indicated all perishable foods will be maintained at a temperature 41 degrees Fahrenheit or below. During a record review of facility's policy and procedure(P/P) titled Receiving revised 9/17, P&P indicated safe food handling procedures for time and temperature control will be practiced in transportation, delivery, and subsequent storage of all food items. The P&P also indicated all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.

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 implement acceptable infection control practices to pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement acceptable infection control practices to prevent the spread and transmission of coronavirus (COVID-19, a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath), by failing to: a. Ensure Certified Nurse Assistant (CNA) 1 wore gown in Residents 26's room while removing dirty bed linen, who was residing in the yellow zone (zone for residents who are mixed quarantine or symptomatic) to prevent transmission of COVID-19 infection. b. Ensure Physical Therapist Assistant (PTA) wore gown and gloves while in the red zone (zone for residents who are positive for Covid 19). c. Ensure meal trays/cart from the red zone was transported through the yellow zone and left in the hall outside the kitchen uncovered. d. Ensure Multiuse container of Blood Glucose ([BG] a type of sugar) test strips used for multiple residents throughout the facility was not taken inside individual residents' rooms (Resident 26, Resident 59 and Resident 15) in the yellow zone (area in the facility for residents that are under observation for COVID-19, a respiratory disease caused by coronavirus), for two of five residents (Resident 26 and Resident 59). e.Ensure Stethoscope indicated by manufacturer as Single Patient Use was not shared between Resident 15 and Resident 59 who were in the yellow zone. These deficient practices placed residents, staff, visitors, and the community at a high risk for cross contamination and increased spread of COVID-19 infection. Findings: a. During a review of Resident 26's admission Record indicated Resident 26 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included myocardial infarction (blockage of blood flow to the heart muscle), end stage renal disease (permanent kidney function loss) dependent on renal dialysis (filtering waste and excess fluid from the blood), right leg below the knee amputation (removal). During a review of Resident 26 's History and Physical (H&P), the H&P indicated Resident 26 had the capacity to understand and make decisions. During a review of Resident 26's MDS Minimum Data Set (MDS-comprehensive screening tool), dated 9/25/2022, the MDS indicated, Resident 26 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, required limited assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and required supervision with eating. During an observation on 12/07/2022 at 8:10 a.m. in the yellow zone, CNA 2 was observed in Resident 26's room removing dirty linen from Resident 26 bed and was not wearing a gown. CNA 2 was wearing face shield, N95 (respiratory protective device designed to achieve a very close facial fit) mask, and gloves. During an interview on 12/07/2022 at 11:47 a.m., with CNA 2, CNA 2 stated she was removing dirty linen from Resident 26's bed, who was going to dialysis, and she forgot to put on a gown. CNA 2 stated the required Personal Protective Equipment ([PPE] specialized clothing or equipment worn by an employee for protection against infectious materials) in a resident's room in the yellow zone were gown, gloves, N95 mask, and face shield. CNA 2 stated she must wear the proper PPE in the yellow zone to protect herself, residents, staff, and visitors and to prevent the spread of Covid 19. b. During a concurrent observation and interview on 12/5/2022 at 10:50 a.m., with PTA outside resident's room adjacent to the red zone, PTA was observed crossing into the red zone with a computer and did not put on gown or gloves. PTA stated he was asked to drop off the computer in the red zone and he went to the break room in the red zone to drop off a computer and did not put on gown or gloves. PTA stated after dropping off the computer he exited the red zone and entered the yellow zone. PTA stated the red zone was an area with Covid positive resident, and to prevent the spread of Covid 19 he must wear the proper PPE. During an interview on 12/7/2022 at 12:48 p.m. with Infection Preventionist Nurse (IPN), IPN stated the facility is currently in a Covid 19 outbreak there were six residents in the red zone that were Covid 19 positive. IPN stated designated staff was assigned to the red zone and staff who are not assigned in the red zone should not freely cross into the red zone because that action put the entire facility at risk of spreading covid. IPN stated the required PPE for all visitors and staff is N95 mask and face shield or goggles. PPE requirement in the red zone is N95 mask, face shield or goggles, gown, and gloves. c. During an observation on 12/06/2022 at 10:50 A.M., in the hallway outside the facility kitchen, observed an uncovered food cart with a red sign and the words red zone printed on the sign was observed in the hall unattended and uncovered with six (6) breakfast trays. The breakfast trays had opened milk cartons, empty cups, used utensils, and plates with uneaten food items. During an interview on 12/06/2022 at 10:52 a.m., with Dietary Supervisor (DS), DS stated the uncovered cart and trays from the red zone were left outside the kitchen door. DS stated the red zone cart will be left in the hallway outside the kitchen uncovered, until all the dishes from the yellow zone are cleaned and sanitized. DS stated the red zone cart was then taken into the kitchen where the dishes and cart will be cleaned and sanitized. DS stated she was advised by IPN it is ok to leave the cart and trays from the red zone in the hall outside the kitchen. During an interview on 12/06/2022 at 11:06 a.m., with CNA 1, CNA 1 stated she is assigned to yellow zone and today she brought the red zone cart to the kitchen by pushing it down the north hall without wearing gloves. CNA 1 stated she was informed by Director of Staff Development (DSD) the red zone cart must be pushed outside the door in the red zone and picked up by dietary staff. CNA 1 stated DS informed her the red zone cart and meal trays can be pushed out of the red zone into the yellow zone and to the kitchen. During a concurrent observation and interview on 12/06/2022 at 11:10 a.m., with CNA 1 in the hallway outside the kitchen, observed a resident in a wheelchair touched the red zone meal cart. The resident attempted to touch meal tray but was stopped by CNA1. CNA 1 stated she can now see why it is important not to leave the cart from the red zone in the hall outside the kitchen uncovered. During an interview on 12/06/2022 at 11:06 a.m., IPN stated the red zone meal cart and trays should not sit in the hallway outside the kitchen uncovered. IPN stated the cart and meal trays should go directly into the kitchen because a resident might touch the cart or items on the cart. IPN stated touching items from the red zone can lead to cross contamination and if cross contamination occurs, resident in the yellow zone that are negative for COVID-19 were exposed to COVID-19 and can become infected with the virus. During a review of the facility's policy and procedure (P&P) titled, Infection Control, Covid 19 Management, dated 10/2022, the (P&P) indicated gloves and gown were to be donned (put on) before entering a room where the resident was in quarantine or isolation, and doffed (taken off) before exiting the room. d. During an observation on 12/5/2022 at 2:30 PM with the Minimum Data Set Coordinator/ Licensed Vocational Nurse (MDSC), MDSC was observed taking a multiuse container of BG test strips used for multiple residents into Resident 26's room, opened the container and removed one test strip to check Resident 26's blood glucose level. During an interview on 12/5/2022 at 2:35 PM, MDSC stated, he was supposed to take a few test strips out of the container and should not have taken the entire container of BG test strips into Resident 26's room. MDSC stated he will have to toss the container of BG test strips due to infection control. During an observation on 12/6/2022 at 3:47 PM, with a Licensed Vocational Nurse (LVN 3), LVN 3 was observed taking a multiuse container of BG test strips into Resident 59's room opened the container and removed a test strip to check Resident 59's blood glucose level. During an interview with LVN 3, Director of Nursing (DON) and a Registered Nurse (RN 1), DON stated the container of BG test strips should not have been taken into the resident's room because of infection control. DON stated the BG test strips are used for multiple residents and can cause contamination from one resident to another. e. During a medication pass observation on 12/6/2022 at 8:59 AM with LVN 3, LVN 3 was observed using a single patient use yellow stethoscope to check gastrostomy tube ([G-tube] a tube placed through the abdominal wall into the stomach as a way to provide food and / or medication) placement for Resident 15. LVN 3 completed medication pass for Resident 15 and placed the yellow single patient use stethoscope on her medication cart. During a concurrent observation and interview on 12/6/2022 at 10:10 AM with LVN 3, LVN 3 was observed reusing the same yellow single patient use stethoscope with a different resident, Resident 59 and returned the stethoscope to the medication cart. LVN 3 stated she cleaned the single patient use stethoscope after using it with Resident 15 and before reusing the same stethoscope for Resident 59. During an interview on 12/7/22 at 11:46 AM with RN 1, RN 1 stated using the Single Patient Use disposable stethoscope for more than one resident can cause cross contamination between residents even if the disposable stethoscope is cleaned before using for a different resident. RN 1 stated the facility's yellow zone is for residents that are under observation for suspected exposure to infection and residents that came from the hospital, and it is unknown what they may have been exposed to. RN 1 stated, even residents under observation should not share disposable stethoscopes. RN 1 acknowledged that Resident 15 and Resident 59 was currently in the facility's yellow zone. On 12/7/2022 at 11:54 AM RN 1 checked one of the isolation carts located outside of each resident's room and located an unused disposable stethoscope. A review of the manufacturer's package labeling indicated, Single Patient Use Stethoscope .Recommended for single patient use only. During a review of the facility's Mitigation Plan, undated, the Mitigation Plan indicated the facility had implemented a staffing plan to limit transmission, including dedicated, consistent staffing teams who directly interact with residents that are covid positive. There should be no rotation of staff between floors or wings during the period they are working each day. A review of the facility's undated Policy and Procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, indicated, Single resident-use items are cleaned/disinfected between uses by a single resident and disposal of afterwards.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · 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 a signed mortuary (funeral home) receipt was received from th...

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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 signed mortuary (funeral home) receipt was received from the mortuary prior to releasing the deceased body of Resident 12. This deficient practice caused Resident 12's mortician (a person whose job is to deal with the bodies of people who have died and to arrange funerals) receipt to be incomplete and unsigned. Findings: During a review of Resident 12's admission Record (AR), the AR indicated, Resident 12 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included respiratory failure (condition that makes it difficult to breathe on your own), atrial fibrillation (irregular beat), encephalopathy (brain damage), type 2 diabetes (chronic condition that affects how the body processes sugar), and hypertension (HTN - high blood pressure). During a review of Resident 12's History and Physical (H&P), dated [DATE], the H&P indicated Resident 12 had the capacity to understand and make decisions, was chronically ill, and had fair rehabilitation potential. During a review of Resident 12's Physician/Advance Practice Provider Discharge summary dated [DATE], indicated Resident 12 passed away on [DATE]. During a concurrent interview and record review on [DATE] at 4:17 p.m., with director of nursing (DON), reviewed Resident 12's Record of Death/Mortician receipt, dated [DATE]. The Record of Death/Mortician receipt indicated the remains of Resident 12 was released on [DATE] at 4:30 p.m. by Licensed Vocational Nurse (LVN) 3. The Record of Death/Mortician receipt was unsigned and did not have the name and address of the mortician and the mortuary. DON stated it was the facility's policy to obtain a signed mortician receipt prior to releasing the remains of decedent. DON stated staff must obtain a mortician receipt and LVN 3 did not get the documentation signed prior to releasing Resident 12 remains to the mortuary. During a review of a fax confirmation sheet attached to Resident 12's Record of Death/Mortician receipt dated [DATE], it was indicated the fax confirmation sheet was sent to mortuary, on [DATE], the comments indicated please sign the mortician receipt and fax back to us asap. We are on survey. Thank you for your cooperation. During a review of the facility's Policy and Procedure (P&P) titled, Documenting the Death of a Resident, undated, the P&P indicated, The person removing the deceased resident from the facility must sign the release for the body, and the release must be filed in the resident's records.

THE EARLWOOD

The Good

The Bad

The Ugly 90 deficiencies on record

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THE EARLWOOD

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