How many inspection deficiencies does CALIFORNIA HEALTHCARE AND REHABILITATION CENTER have?

CALIFORNIA HEALTHCARE AND REHABILITATION CENTER has 83 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at CALIFORNIA HEALTHCARE AND REHABILITATION CENTER?

CALIFORNIA HEALTHCARE AND REHABILITATION CENTER has a three-star staffing rating from CMS with 0.84 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

CALIFORNIA HEALTHCARE AND REHABILITATION CENTER

Name: CALIFORNIA HEALTHCARE AND REHABILITATION CENTER
Address: 6700 SEPULVEDA BLVD., VAN NUYS, CA, 91411, US
Telephone: (818) 988-2501
Rating: 1.0

6700 SEPULVEDA BLVD., VAN NUYS, CA 91411 · (818) 988-2501

For profit - Corporation 201 Beds LONGWOOD MANAGEMENT CORPORATION Data: November 2025

Trust Grade

38/100

#993 of 1155 in CA

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

California Healthcare and Rehabilitation Center in Van Nuys has received a Trust Grade of F, indicating poor performance with significant concerns. It ranks #993 out of 1,155 facilities in California, placing it in the bottom half, and #283 out of 369 in Los Angeles County, meaning there are many better options nearby. The facility is worsening, with issues increasing from 22 in 2024 to 35 in 2025, which raises red flags for potential residents. Staffing is rated average at 3 out of 5 stars, with a turnover rate of 30%, which is better than the state average, suggesting some stability among staff. However, the facility has faced concerning incidents, such as not ensuring residents were free from physical restraints and failing to properly assess residents' needs, which could lead to serious risks for those living there. While there is good RN coverage, more than 82% of state facilities, families should weigh these strengths against the significant weaknesses before making a decision.

Trust Score: F
In California: #993/1155
Safety Record: Low Risk
Inspections: Getting Worse
Staff Stability: 30% turnover. Near California's 48% average. Typical for the industry.
Penalties: $20,102 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets 50 minutes of Registered Nurse (RN) attention daily — more than average for California. RNs are trained to catch health problems early.
Violations: 83 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 22 issues

2025: 35 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (30%)
18 points below California average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 30%

16pts below California avg (46%)

Typical for the industry

Federal Fines: $20,102

Below median ($33,413)

Minor penalties assessed

Chain: LONGWOOD MANAGEMENT CORPORATION

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 83 deficiencies on record

May 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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure the call light above the resident ' s door is functioning for one out of four sampled residents (Resident 3) to alert staff the call light is on. This deficient practice had the potential to result in a delay in care, and Resident 3`s inability to ask for assistance. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated that Resident 3 was admitted to the facility on [DATE], with diagnoses including Parkinson ' s Disease (brain disorder that causes unintended or uncontrollable movements such as shaking, stiffness, and difficulty with balance and coordination), spinal stenosis (a condition where the spaces in the spine become narrower, putting pressure on the nerves and spinal cord), and elevated white blood cell (responsible for protecting your body from infection). During a review of Resident 3 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/8/2025, the MDS indicated that Resident 3 was cognitively impaired (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent (helper does all the effort) on staff for toileting, showering, bathing, personal hygiene, and putting on/talking off footwear. During a concurrent observation and interview on 5/21/2025, at 10:30 a.m., with CNA 1, observed the call light above Resident 3's door was not turning on when Resident 3 pressed the call button. CNA 1 stated the call light above Resident 3's door should have been repaired to ensure the resident can request assistance without any delay in care. During an interview on 5/21/2025, at 3:45 p.m., with the Director of Nursing (DON), the DON stated the call light above Resident 3's door was not functioning and it should have been repaired to properly alert staff when activated. The DON stated without a functioning call light, there is a risk of delayed response to Resident 3's requests or needs. During a review of the facility ' s policy and procedure, titled Maintenance Interior General Maintenance dated 7/16/2024, the facility policy indicated to check daily a proportionate number of nurses ' call system buttons, buzzers, cords, and lights so that each part of the system is checked at least once a week. Press button. Check to see that signal lights up over the resident ' s door, that signal sounds a nurse ' s station, and nurses ' call enunciator lights up.

May 2025 31 deficiencies

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a comprehensive Minimum Data Set ([MDS] a federally mandated resident assessment tool) for one of 38 sampled residents (Resident 690) after admission on [DATE]. This failure had the potential to prevent Resident 690 from receiving services to achieve Resident 690's goal of walking with a single point cane ([SPC] walking device with a curved or bent handle at the top and long shaft that ends in a single tip used to provide support while walking) to return home. Findings: During a review of Resident 690's admission Record, the admission Record indicated the facility admitted Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges (three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic intracerebral hemorrhage (bleeding in brain tissue), lack of coordination, muscle weakness, foot drop (condition where the individual experiences difficulty or inability to lift their foot or toes) of both feet, and reduced mobility (ability to move). During a review of Resident 690's admission Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 4/29/2025, the admission MDS indicated Resident 690 had clear speech, expressed ideas and wants, clearly understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS did not include the signature of the Registered Nurse (RN) Assessment Coordinator verifying the completion of Resident 690's admission MDS. During a concurrent observation and interview on 5/6/2025 at 11:27 a.m. with Resident 690 in the resident's room, Resident 690 was awake, alert, and spoke with clear, fluent speech while lying in bed with the head-of-bed elevated. Resident 690 stated the facility was aware of Resident 690's complaints regarding not receiving rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) services. Resident 690 stated she underwent brain surgery three times and walked with a SPC due to left leg weakness after the second brain surgery and prior to the third surgery in 2/2025. Resident 690 stated the desire to return home after receiving therapy. During a concurrent interview and record review on 5/8/2025 at 10:19 a.m. with the MDS Coordinator RN (MDSC), Resident 690's admission MDS, dated [DATE], was reviewed. The MDSC stated the MDS (in general) was a thorough assessment to ensure the residents were receiving appropriate care and meeting their goals. The MDSC stated the Admisison MDS should be completed by the 14th day of admission. The MDSC stated the facility admitted Resident 690 on 4/18/2025 and should have completed the admission MDS on 4/29/2025. The MDSC stated Resident 690's admission MDS was not completed since all the departments did not complete their assigned section of the MDS. The MDSC stated the facility could fail to address an area of Resident 690's care since the admission MDS was not completed. During a review of page 2-17 of the Resident Assessment Instrument (RAI) Manual, revised 10/1/2023, the RAI Manual indicated the admission MDS should be completed no later than the 14th calendar day of the resident's admission.

CONCERN (D)

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

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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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 Minimum Data Set (MDS - a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one (1) out of one (1) sampled residents (Resident 35). This deficient practice had the potential to result in delayed services for Resident 35. Findings: During a review of the admission record , the admission record indicated Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including type 2diabetes (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly), urinary tract infection (infection in any part of the urinary system), and essential hypertension (high blood pressure that is not due to another medical condition). During a review of Resident 35's Record of Death dated [DATE], the record of death indicated that the body of Resident 35 was released on [DATE]. During a review of the Transfer/ Discharge Report, dated [DATE], the Transfer/Discharge Report indicated that the resident was DNR. During a review of Resident 35's Discharge Summary Report dated [DATE], the Discharge Summary Report indicated Resident 35 resident expired on [DATE]. During a review of the Minimum Data Set assessment dated [DATE], (MDS, a standardized assessment and care screening tool), the MDS indicated Resident 30 had mildly impaired cognition (a slight decline in mental abilities, memory and completing complex tasks). The MDS indicated Resident 30 required moderate assistance for all activities of daily living (ADL- basic tasks that must be accomplished every day for an individual to thrive). During a concurrent interview and record review on [DATE] at 2:45 p.m., with Minimum Data Set Coordinator 1 (MDSC 1), Resident 35`s MDS assessments were reviewed. MDSC 1 stated that when a resident is being discharged from the facility, they (facility) are required to complete an MDS assessment . MDSC 1 stated, We have 14 days to complete the discharge MDS. MDSC 1 stated Resident 30 was discharged from the facility on [DATE], however, the MDS for discharge was not completed and not submitted to Center for Medicaid Services (CMS). During an interview on [DATE] at 3:15 p.m., with the Director of Nursing (DON) the DON stated the discharge assessment has to be done and submitted to CMS in 14 days following the resident's discharge, by the Minimum Data Set Nurse (MDSC). The DON stated the potential outcome of not completing discharge MDS assessment on time is a delay in care and payment for Resident 30. During a review of the facility's Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, Version 1.19.1 dated [DATE], indicated all Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS completion date.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a complete baseline care plan within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for one of one sampled resident (Resident 99) reviewed under catheter care area. This deficient practice had the potential of Resident 99 to not receive appropriate care and treatment in the facility. Findings: During a review of Resident 99's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 9/15/2020 and readmitted on [DATE], with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), obstructive uropathy (a blockage in the urinary tract that prevents urine from draining normally), and reflux uropathy (when urine flows backward into the kidneys). During a review of Resident 99's Minimum Data Set (MDS - a resident assessment tool) dated 4/6/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 99 was dependent on staff for showering and bathing. The MDS indicated that Resident 99 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, and upper body dressing. The MDS further indicated that Resident 99 had an indwelling catheter. During a review of Resident 99's physician Order Summary Report (physician orders) dated 4/25/2025, the Order Summary Report indicated an order for indwelling catheter due to neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). The order summary report indicated to provide indwelling catheter care during every day shift for 30 days. During a concurrent interview and record review on 5/7/2025 at 8:30 a.m., with the Assistant Director of Nursing (ADON), Resident 99`s baseline care plan was reviewed. The ADON stated that Resident 99 was readmitted to the facility on [DATE] with an indwelling catheter. The ADON stated that Resident 99`s baseline care plan initiated on 1/22/2025, did not indicate that the resident had an indwelling catheter. The ADON stated that residents` baseline care plans must be completed thoroughly reflecting a problem, initial care plan outcome, and nursing interventions. The ADON stated that the potential outcome of not thoroughly completing a resident`s baseline care plan is the inability to meet the resident`s immediate care needs and lack of care. During an interview on 5/8/2025 at 3:00 p.m., with the Director of Nursing (DON), the DON stated a resident`s baseline care plan is required to be completed within 48 hours of the resident`s admission to the facility. The DON stated upon admission, licensed staff are required to develop a complete and thorough baseline care plan for each resident indicating a problem and all nursing interventions to be done for that problem. The DON stated Resident 99`s baseline care plan developed on 1/22/2025 was not completed thoroughly and it did not indicate anything regarding the resident`s indwelling catheter. The DON stated the potential outcome is the inability to meet the resident`s immediate care needs for the indwelling catheter and the delivery of necessary services to the resident. During review of the facility`s Policy and Procedure (P&P) titled Care Plans-Baseline, last reviewed on 7/16/2024, the P&P indicated that a baseline plan of care to meet the resident`s immediate health and safety needs is developed for each resident within 48 hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include minimum healthcare information necessary to properly care for the resident. The resident and/or representative are provided a written summary of the baseline care plan that includes but is not limited to any services and treatment to be administered by the facility and personnel acting on behalf of the facility.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's restraint freedom splint (multipurpose soft splints that help restrict elbow and knee movement) was discontinued, for one of two sampled residents (Resident 63). This deficient practice had the potential to result in confusion in the delivery of care and service. Findings: During a review of Resident 63's admission Record, the admission Record indicated that the facility admitted the resident on 2/14/2018 and readmitted the resident on 6/17/2024 with diagnoses including acute respiratory failure (a condition in which your blood doesn't have enough oxygen causing shortness of breath and difficulty breathing), encephalopathy (brain disease, damage, or malfunction of brain), chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), and quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs). During a review of Resident 63's Minimum Data Set (MDS- a resident assessment tool) dated 3/20/2025, the MDS indicated that the resident had severely impaired cognitive skills (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS indicated that Resident 63 was totally dependent on staff with all activities of daily living (ADLs - activities related to personal care). During a review of the Resident 63's care plan, revised on 3/26/2025, the care plan indicated that Resident 63 had a restraint freedom splint and was at high risk for injury and complications due to pulling life sustaining equipment. During a review of Resident 63's physician order dated 4/17/2025, the physician order indicated to discontinue freedom splint to left upper extremity. During a concurrent interview and record review on 5/7/2025 at 3:51 p.m., with the Subacute Director (SD), reviewed Resident 63's care plans. The SD stated that Resident 63 did not have episodes of pulling their tracheostomy tube (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe) for the last three months and the physician discontinued the order for freedom splint on 4/16/2025. The SD stated licensed staff did not revise or update Resident 63's care plan addressing that resident's freedom splint was discontinued. The SD stated licensed staff are required to revise a resident's care plan after a resident's condition changed to ensure the effectiveness of care plan interventions. The SD stated the potential outcome of not updating/revising a resident's care plan is the inability to provide appropriate care and monitoring to the resident. During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated that residents' care plans are required to be reviewed and revised after residents' change of condition. The DON stated Resident 63's care plan was not revised or updated after Resident 63's restraints were discontinued. The DON stated the potential outcome of not updating/revising a resident's care plan is the inability to provide appropriate care and services to the resident. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 7/16/2025, the P&P indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of resident's are ongoing and care plans are revised as information about the residents and the residents' conditions change.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 156) was provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in her preferred language in order to effectively communicate with staff. This deficient practice prevented Resident 156 from communicating with the staff and receiving care in a timely manner. Findings: During a review of Resident 156's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 3/26/2024, with diagnoses including dysphagia (difficulty swallowing), essential hypertension (HTN-high blood pressure), and need for assistance with personal care. The admission Record further indicated that Resident 156`s primary language was Chinese. During a review of Resident 156's Minimum Data Set (MDS - a resident assessment tool) dated 4/8/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 156 was dependent on staff (helper does all of the effort) for toileting hygiene, showering/bathing, lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 156`s preferred language was Chinese, and the resident needed or wanted an interpreter to communicate with a doctor or health care staff. During a review of Resident 156's care plan (a document that outlines how a patient's health care needs will be met) for cognitive and communication deficit (a problem or difficulty in the brain's functions, such as memory, attention, problem-solving and speaking) initiated on 4/7/2024, the care plan indicated a goal that the resident`s needs will be anticipated and met daily until the next assessment date. The care plan interventions were to speak clearly and slowly to the residents, explain all procedures and reasons prior to initiating care and treatment and to utilize translator or communication devices as indicated. During a concurrent observation and interview on 5/7/2025 at 11:00 a.m. inside the facility`s activity room, Resident 156 was observed sitting on her wheelchair using her cellphone. The Activity Assistant (AA) was present next to Resident 156 and stated that Resident 156 speaks Chinese and does not understand English well. The AA stated staff are using Resident 156`s cellphone to translate from English to Chinese. The AA stated a communication board with pictures and signs is required for residents who do not speak English. The AA started looking for a communication board/device on Resident 156 wheelchair. However, she did not find one. The AA stated there is no communication board and device inside the activity room either. The AA confirmed that Resident 156 spends a lot of time in the activity room and staff have a hard time communicating with her. During a concurrent observation and interview on 5/7/2025 at 11:05 p.m., with the Activity Director (AD), inside Resident 156`s room, the AD stated for the residents who are not able to communicate their needs in English, the facility places a communication board/device at the residents` bed side. The AD stated that Resident 156 speaks Chinese and requires a communication board at her bedside to be able to make her needs known. The AD started looking for a communication board/device at Resident 156`s bedside. However, she (AD) was not able to find one. The AD stated that the potential outcome of not having a communication board available and accessible to a resident who is not able to communicate effectively in English is inability to meet the resident's needs. During a concurrent observation and interview on 5/7/2025 at 12:10 p.m., inside the facility`s small dining room, Resident 156 was observed eating lunch and sitting with Responsible Party 1 (RP 1). RP1 stated that Resident 156 is alert and able to express her needs. RP 1 stated that Resident 156 speaks Mandarin (one of the dialects of Chinese). RP 1 did not find a communication [NAME] or device attached to Resident 156`s wheelchair. Resident 156 stated that she often does not have a communication board/device, and she normally uses gestures to make her needs known. Resident 156 stated she wishes she knew how to speak English so that she can express her needs. During an interview on 5/8/2025 at 3:08 p.m., with the Director of Nursing (DON), the DON stated staff are required to provide a communication board or device to the residents who do not speak English in the language that they speak. The DON stated Resident 156 was not provided a communication device/board in Chinese. The DON stated the potential outcome of not providing a communication board/device to the residents who do not speak English is the inability to communicate with residents accurately and understand their needs. During a review of the facility's Policy and Procedure (P&P) titled, Accommodation of Needs Related to Communication Deficits, last reviewed on 7/16/2024, the P&P indicated that communication needs will be identified and appropriate interventions including care planning will be developed in order to accommodate the needs of the resident. The care plan will be developed, updated quarterly and as indicated to reflect accurate, current assessments related to communication needs. During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, last reviewed on 7/16/2024, the P&P indicated that 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 communication ( speech, language, and any functional communication system).

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 540) was provided a toileting program and/or bowel and bladder training (when facility staff assist a resident to the restroom at specific timed intervals) to restore as much bladder function as possible. This deficient practice had the potential to result in continued urinary incontinence (the involuntary leakage or loss of bladder control, resulting in unintended urination), development of urinary tract infection (UTI- an infection in any part of the urinary system), and potential to not achieve or restore normal bowel and bladder function. Findings: During a review of Resident 540's admission Record, the admission Record indicated the facility originally admitted the resident on 4/6/2025 with diagnoses including acute and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), acute kidney failure (a condition in which the kidneys are damaged and cannot filter blood well), and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]). During a review of Resident 540's Minimum Data Set (MDS - a resident assessment tool) dated 4/18/2025, the MDS indicated the resident had intact cognition (mental abilities, including remembering things, making decisions, concentrating, or learning) and required moderate - to - maximal assistance from staff for most activities of daily living (ADLs - activities related to personal care). During a review of Resident 540's Baseline Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) dated 4/6/2025, the care plan indicated that Resident 540 was admitted with an indwelling catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) and required catheter care. During a review of Resident 540's Bowel and Bladder Screener dated 4/9/2025, the Bowel and Bladder Screener indicated that Resident 540 was a poor candidate for retraining/scheduled toileting. During a review of Resident 540's physician orders, the physician orders indicated an order to discontinue indwelling catheter, dated 4/18/2025. During a review of Resident 540's Care Plan dated 4/21/2025, the Care Plan indicated that the resident had alteration in elimination patterns related to being always incontinent for bowel and bladder and was not retrainable for bladder and bowel. During a review of Resident 540's Elimination Flowsheet dated 5/7/2025, the Elimination Flowsheet indicated that Resident 540 was continent (the ability to control movements of the bowels and bladder) four times in the last seven days on 5/3/2025, 5/5/2025, 5/6/205 and 5/7/2025. During a concurrent observation and interview on 5/5/2025 at 9:51 a.m., with Resident 540 in Resident 540's room, observed Resident 540 walking to the bathroom independently. Resident 540 stated that he was not provided with any bladder retraining program in the facility and he would like to participate in bladder retraining program because he is able to feel the urge to go to bathroom when he is awake but is not be aware of the need to toilet when he is sleeping. During an interview on 5/7/2025 at 8:34 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that she did Resident 540's Bowel and Bladder Screening on 4/9/2025. The ADON stated that Resident 540 was not a candidate for bladder retraining program due to sleepiness and forgetfulness. The ADON stated that the resident should be screened one more time after he becomes more mobile and alert after his indwelling catheter was removed and put on bladder training program to restore as much bladder function as possible. During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated that the licensed nursing staff did not repeat a bowel and bladder program screening when Resident 540 became more alert and independent and did not provide Resident 540 with an individualized bowel and bladder retraining program. During a review of the facility's policy and procedure titled, Bladder and Bowel Assessment, dated 7/16/2024, the policy indicated bladder and bowel assessment will be completed within 14 days from admission/readmission and updated quarterly. And based on the score, the care plan is developed and the care planned.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 15), who was receiving nutrition by gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), received appropriate care and services to prevent complications of enteral feeding (tube feeding, a way of delivering nutrition directly to your stomach or small intestine). This deficient practice had the potential to lead to the inadequate care of Resident 15 and place the resident at an increased risk for complications such as infection. Findings: During a review of Resident 15's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 11/21/2024 and readmitted on [DATE], with diagnoses including tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs), gastrostomy, and dementia (a progressive state of decline in mental abilities). During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool) dated 4/15/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 15 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering and bathing, upper and lower body dressing, and personal hygiene. The MDS further indicated that Resident 15 was receiving nutrition via gastrostomy tube while a resident in the facility. During a review of Resident 15`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for GT feeding initiated on 1/14/2025 and last revised on 4/30/2025, the care plan indicated a goal that the resident will have minimum risk of infection at his GT site until the next assessment date. The care plan interventions were to provide GT care daily, and assess the skin for redness, pain, swelling, discharge and report to the physician if any present. During a review of Resident 15`s physician Order Summary Report dated 5/5/2025, the Order Summary Report indicated an order to clean the GT site with normal saline (NS- a saltwater solution), pat dry, and cover with dry dressing during every day shift. During a concurrent observation and interview on 5/7/2025 at 11:17 a.m., with Certified Nursing Assistant 2 (CNA 2), inside Resident 15's room, CNA 2 stated that there is no dressing present on Resident 15`s GT insertion site. CNA 2 stated the facility`s Treatment Nurse (TN) is in charge of providing skin care and dressing to residents` GT sites. During a record review of Resident 15`s Treatment Administration Record (TAR-a daily documentation record used by a licensed nurse to document treatments given to a resident) on 5/7/2025 at 12:40 p.m., the TAR indicated that Treatment Nurse 1 (TN 1) documented that he provided treatment to the resident`s GT site during day shift on 5/7/2025. During a concurrent observation and interview on 5/7/2025 at 1:10 p.m., with CNA 2, inside Resident 15's room, CNA 2 stated that there is no dressing present on Resident 15`s GT insertion site. During a concurrent observation and interview on 5/7/2025 at 1:20 p.m., with TN 1 inside Resident 15's room, TN 1 confirmed that there was no dressing on Resident 15`s GT insertion site. TN 1 stated that he provided skin care and placed a dressing on Resident 15`s GT insertion site today at around 9.00 a.m. However, TN 1 stated that he documented in the Resident 15`s TAR that he (TN 1) provided care today at 12:32 p.m. TN 1 stated that he (TN 1) is not sure what happened to the dressing and that Resident 15 must have removed it. TN 1 stated that he (TN 1) is required to document in the residents` medical record right after completing his task so that the documentation reflects the correct time wound care had been provided. TN 1 stated that the potential outcome of not performing skin care, and not placing the dressing on the GT site is infection. During an interview on 5/8/2025 at 3:04 p.m., with the Director of Nursing (DON), the DON stated that licensed staff are required to provide skin care to GT insertion site daily and document in the residents` TAR immediately after completion of the task. The DON stated, If the dressing is not there, it is not done. The DON stated the potential outcome of not performing skin care and placing dressing to a resident`s GT site is infection. During a review of the facility`s Policy and Procedure (P&P) titled Enteral Nutrition, last reviewed 7/16/2024, the P&P indicated that staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of feeding tube such as skin breakdown around insertion site.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1. Ensure that a resident received oxygen as ordered by the physician for one of two sampled residents (Resident 107) reviewed under Respiratory Care area. 2. Ensure that Resident 107`s oxygen tubing had a label indicating the date and time of when it was last changed. 3. Ensure that Resident 107`s oxygen humidifier (a medical device used to add moisture to supplemental oxygen, making it easier and more comfortable to breathe, especially for patients using oxygen therapy for extended periods ) was full. These deficient practices had the potential to place Resident 107 at an increased risk of infection and cause complications associated with oxygen therapy. Findings: During a review of Resident 107's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 4/19/2021 and readmitted on [DATE], with diagnoses including acute (appear rapidly) and chronic (a condition that lasts longer than three months) respiratory failure (a serious condition that makes it difficult to breathe on your own) with hypoxia (a medical condition where there is an inadequate supply of oxygen to the body's tissues), type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and history of falling. During a review of Resident 107's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reliable). The MDS indicated that Resident 107 required the staff substantial/maximal assistance (helper does more than half the effort) for oral hygiene, and upper body dressing. The MDS indicated that Resident 107 was dependent on staff (helper does all of the effort) for toileting hygiene, showering and bathing, lower body dressing, putting on/talking off footwear and personal hygiene. The MDS further indicated that Resident 107 was receiving oxygen therapy while a resident in the facility. During a review of Resident 107's physician Order Summary Report (physician orders) dated 11/15/2024, the order summary report indicated to administer oxygen at two liters per minute via nasal cannula (NC-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) for shortness of breath (SOB) and chronic respiratory failure. The order summary report indicated to titrate (to carefully adjust the amount of oxygen a patient receives to achieve a specific, target level of oxygen saturation in the blood) the oxygen level up to three liters per minute to keep the resident`s oxygen saturation (a measurement of how much oxygen your blood is carrying compared to its maximum capacity-for healthy adults, normal oxygen saturation is between 95% and 100%) above 90%. The order summary report further indicated to change the oxygen tubing every Sunday during night shift. During a review of Resident 107`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for oxygen, initiated on 4/30/2021 and last revised on 8/18/2024, the care plan indicated a goal that the resident will be free of adverse effects related to use of oxygen. The care plan interventions were to administer oxygen as per physician order, monitor the resident`s oxygen saturation, change the oxygen tubing weekly or as needed and to check the rate of oxygen flow during every shift. During a concurrent observation and interview on 5/5/2025 at 10:12 a.m. with Certified Nursing Assistant 1 (CNA1) inside Resident 107`s room, Resident 107 was observed sitting on her bed receiving oxygen. CNA 1 stated that Resident 107 was receiving oxygen at six liters per minute via NC. CNA 1 stated that Resident 107`s oxygen tubing did not have a label including the date and time of when it was last changed. CNA 1 stated that the humidifier connected to Resident 107`s oxygen machine was empty. During a concurrent observation and interview on 5/5/2025 at 10:16 a.m. with Licensed Vocational Nurse 2 (LVN 2) inside Resident 107`s room, LVN 2 stated that Resident 107`s physician ordered to administer oxygen at two liters per minute via NC. However, Resident 107 receives oxygen at six liters per minute via NC. LVN 2 stated that Resident 107`s oxygen tubing did not have a label with the date and time of when it was last changed. LVN 2 stated Resident 107`s oxygen humidifier was empty. LVN 2 stated that the facility staff are required to change oxygen tubing once a week on Sundays. LVN 2 stated the potential outcome of not changing a resident`s oxygen tubing once per week as ordered by the physician is placing the resident at risk for infection. LVN 2 further stated that Resident 107 was receiving oxygen at a greater rate than it was ordered by her physician. LVN 2 stated delivering too much oxygen via NC may be harmful to Resident 107. LVN 2 stated licensed nurses are required to ensure that the oxygen humidifier is full to prevent nostril dryness. LVN 2 stated that he (LVN 2) failed to monitor Resident 107 appropriately to ensure that she is receiving the correct rate of oxygen, that the humidifier is full and the oxygen tubing is dated. During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to implement physician orders for administration of oxygen to residents. The DON stated that the facility staff are required to change the oxygen tubing once per week as ordered by the physician and label the tubing with the date and time it was changed. The DON stated licensed staff are required to monitor residents` oxygen humidifier to ensure the container is full. The DON stated the potential outcome of not changing and labeling the oxygen tubing and humidifier is the increased risk of infection for the residents. The DON stated the potential outcome of administering oxygen more than the physician`s ordered flow rate via NC is difficulty breathing and harm to the resident. During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration, last reviewed on 7/16/2024, the P&P indicated that oxygen will be administered to residents as needed per attending physician`s orders by licensed personnel. Review oxygen order(s) for oxygen use. Administer oxygen as per physician`s orders. Oxygen administered at three liters per minutes pr more requires humidifier. The oxygen tubing should be changed weekly and as needed. The date, time, and initials should be noted on oxygen equipment when it is initially used and when changed. Since oxygen is based on a physician`s order, it is considered a licensed staff procedure.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure non-pharmacological interventions (treatments or therapies that do not involve the use of medications) were attempted prior to administering as needed oxycodone (a drug used to treat moderate to severe pain) for one of two sampled residents (Resident 100). This deficient practice placed Resident 100 at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from oxycodone such as drowsiness, increased risk of falling, or loss of appetite. Findings: During a review of Resident 100's admission Record, the admission Record indicated the facility originally admitted the resident on 9/19/2020 and readmitted the resident on 3/29/2025 with diagnoses including but not limited to sarcoma (a group of cancers which start in the bones and connective tissue), pain in the right knee, and aftercare following surgery for a neoplasm (abnormal and excessive growth of tissue). During a review of Resident 100's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 100 had intact cognition (can think, learn, and remember clearly) and required total assistance or substantial assistance from staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 100's physician orders, the physician orders indicated the following: - Oxycodone 5 milligram (mg- unit of measurement) oral tablets: give one tablet by mouth every four hours as needed for severe pain, ordered 4/12/2025. - Non-pharmacological pain interventions: 1- reposition, 2-dim lights, 3-distraction, 4-relaxation techniques, 5-hot/cold applications, 6-music, 7-massage, 8-other. Document result and effectiveness of intervention. If ineffective administer appropriate pain medication as ordered, ordered 2/17/2025. During a concurrent interview and record review on 5/7/2025 at 12:02 p.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 100's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 4/2025. Resident 100's MAR indicated there was no documentation that non-pharmacological pain interventions were attempted prior to administering oxycodone on 4/14/2025 at 9:00 a.m. LVN 5 stated Resident 100 should be offered non-pharmacological pain interventions before giving pain medication because there is an order to try non-pharmacological options first and it is important to follow that protocol. During a concurrent interview and record review on 5/8/2025 at 12:18 p.m., with Registered Nurse 3 (RN 3), reviewed Resident 100's MAR dated 4/2025. Resident 100's MAR indicated there was no documentation that non-pharmacological pain interventions were attempted prior to administering oxycodone on 4/16/2025 at 11:45 a.m. and 4/24/2025 at 12:50 p.m. RN 3 stated she was not sure why there was no documentation of non-pharmacological pain interventions before she administered oxycodone at those times. RN 3 stated it is important to try non-pharmacological pain interventions first because that might relieve the resident's pain, and the pain medication may be unnecessary. During an interview on 5/8/2025 at 2:39 p.m. with the Director of Nursing (DON), the DON stated non-pharmacological pain interventions should be tried first before giving pain medications. The DON stated they need to see if non-pharmacological pain interventions would relieve the pain before considering pain medication. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, last reviewed 7/16/2024, the P&P indicated non-pharmacological interventions including adjusting room temperature, repositioning, ice packs, range of motion exercises, and diversions may be appropriate interventions alone or in conjunction with medications. The P&P further indicated pain medications can manage pain but can also have adverse effects including drowsiness, increased risk of falling, or loss of appetite.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) received treatment in accordance with standards of practice for one of four sampled residents reviewed under the dialysis care area (Resident 160) by: 1. Failing to assess the resident`s right upper chest quinton catheter (non-tunneled central line catheters, which are often used as temporary access for hemodialysis) dialysis access site. 2. Failing to implement the physician's order for fluid restriction (limiting the amount of liquid a person consumes daily, often prescribed to manage kidney disease) limited to no water pitcher at the resident`s bedside. These deficient practices had the potential to place Resident 160 at risk for fluid overload (a condition where you have too much fluid volume in your body) and infection. Findings: During a review of Resident 160's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 6/7/2024 and readmitted on [DATE] with diagnoses including type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dependence on renal (kidney) dialysis, and end stage renal disease (ESRD-irreversible kidney failure). During a review of Resident 160's Minimum Data Set (MDS - a resident assessment tool) dated 4/1/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 160 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, showering/bathing, putting on/taking off footwear, and personal hygiene. The MDS further indicated that Resident 160 was undergoing hemodialysis while a resident in the facility. During a review of Resident 160`s care plan (a document that outlines how a patient's health care needs will be met) for hemodialysis initiated on 6/20/2024, the care plan indicated that the resident had right upper chest quinton catheter. The care plan interventions were to monitor dialysis access site for sign and symptoms of infection, bleeding, pain, clotting, swelling, drainage, and discoloration, and notify the physician if it occurs. During a review of Resident 160`s care plan for potential for unavoidable bleeding on the AV shunt site or right upper chest central line initiated on 6/20/2024, the care plan indicated a goal that the risk of occurrence of emergency bleeding will be reduced through interventions daily. The care plan interventions were to document monitoring of dialysis site during every shift and as needed. During a review of Resident 160`s admission assessment dated [DATE], the admission assessment indicated that the resident had right upper chest quinton catheter for hemodialysis. During a review of Resident 160's physician Order Summary Report (physician orders) dated 3/26/2025, the Order Summary Report indicated to place Resident 160 on fluid restriction and not place any water pitcher at her bedside. During a review of Resident 160`s care plan for fluid restriction initiated on 4/14/2025, the care plan indicated a goal that the resident will not show any signs and symptoms of fluid overload. The care plan interventions were to place no water pitcher at the resident`s bedside. During a review of Resident 160's physician Order Summary Report dated 4/17/2025, the Order Summary report indicated to monitor Resident 160`s right upper arm arteriovenous fistula (AVF- a connection that is made between an artery and a vein for dialysis access) for bleeding, itching, pain, and swelling during every shift. During a review of Resident 160`s Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 4/1/2025-4/31/2025 and 5/1/2025-5/8/2025, the MARs indicated no documentation of monitoring Resident 160`s right upper chest quinton catheter. During an observation on 5/5/2025 at 9:20 a.m., inside Resident 160`s room, a written note on the wall on top of the resident`s bed indicated No water pitcher at bedside. However, a full pitcher of water, a full glass of milk and juice were observed on the resident`s side table. Resident 160 stated that she is undergoing hemodialysis on Mondays, Wednesdays, and Fridays at noon. During an observation, a right upper chest quinton catheter was observed with dressing. During a concurrent observation and interview on 5/5/2025 at 9:21 a.m. with Infection Preventionist (IPN) inside Resident 160 `s room, IPN stated that there was a full pitcher of water, a full glass of milk and juice at the resident`s side table. IPN stated Resident 160 is undergoing hemodialysis, and her physician ordered to place no water pitcher at her bedside. IPN stated the staff failed to follow Resident 160`s physician order regarding fluid restrictions. IPN stated that the potential outcome is that Resident 160 may experience a fluid overload. During a concurrent interview and record review on 5/8/2025 at 11:45 a.m., with Registered Nurse 1 (RN 1), Resident 160`s physician orders, MARs and care plans were reviewed. RN 1 stated Resident 160 is undergoing hemodialysis and her care plan indicated that she has right upper chest quinton catheter and right upper arm AV fistula. However, she (RN 1) cannot find any physician orders for monitoring Resident 160`s right upper chest quinton catheter. RN 1 stated licensed staff did not implement Resident 160`s care plan intervention and did not monitor the resident`s right chest quinton catheter. RN 1 stated licensed staff are required to monitor residents` dialysis access sites. RN 1 stated the potential outcome of not monitoring residents` dialysis access sites is infection and bleeding. During an interview on 5/8/2025 at 3:18 p.m., with the Director of Nursing (DON), the DON stated that staff are required to implement physician orders for the resident`s fluid restriction. The DON stated Resident 160 requires hemodialysis three times a week, and it is necessary to not place a water pitcher at her bedside as ordered by her physician to prevent fluid overload and edema. The DON stated license staff failed to obtain a physician order for monitoring Resident 160`s right chest quinton catheter and failed to monitor the catheter as indicated in her care plan. The DON stated the potential outcome is infection and bleeding. During a review of the facility`s Policy and Procedures (P&P) titled Care of Resident Receiving Renal Dialysis, last reviewed on 7/16/2024, the P&P indicated that if residents have a central line, assess site for signs and symptoms of complications and notify the physician. The physician orders specific fluids allowed in 24 hours. Fluid restriction limited to no water pitcher at bedside promises improved quality of life. During a review of the facility`s Policy and Procedures (P&P) titled Fluid Restricted-Diet, last reviewed on 7/16/2024, the P&P indicated that when a resident requires fluid restriction, a physician`s order shall be obtained and shall note the parameters of the fluid intake desires. Fluid restricted diet shall be monitored by the nursing department. The nursing department shall remove water pitcher from resident`s bedside.

CONCERN (D)

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

Deficiency F0744 (Tag F0744)

Could have caused harm · This affected 1 resident

Deficiency Text Not Available

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Deficiency Text Not Available

CONCERN (D)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Patient Assessment, policy and procedure for one sampled resident (Resident 18) reviewed under dementia care by failing to conduct a quarterly social service assessment . This deficient practice had the potential for Resident 18 to not attain or maintain the highest practicable physical, mental and psychosocial health. Findings: During a review of Resident 18's admission Record, the admission Record indicated that the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including pneumonia (is an infection that inflames the air sacs [thin-walled structures composed of simple squamous epithelium] in one or both lungs), Parkinsonism (a clinical syndrome characterized by a group of motor symptoms, including bradykinesia[ slowed movement], rigidity[stiffness], and tremor, and often associated with impaired posture and gait), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). During a review of Resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated that the resident had severely impaired cognition (severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning).The MDS indicated that Resident 18 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. During a concurrent interview and record review on 5/8/2025 at 10:12 a.m., with the Social Service Director (SSD), Resident 18`s assessments were reviewed. The SSD stated that social service assessment has to be done quarterly and annually. However, she (SSD) did not conduct a quarterly social service assessment in March 2025. The SSD stated that social service assessment includes psychosocial history, physical, cultural and spiritual factors having impact on the resident`s adjustment and wellbeing in the facility, and the determination of anticipated discharge planning. The SSD stated that the last social service assessment was conducted on 1/13/2025. The SSD stated that the reason she did not conduct a social service assessment for Resident 18 was because she was backed up with assignments for other residents. The SSD stated that the potential outcome of not timely reassessing a resident is the delay in addressing their psychosocial issues. During an interview on 5/8/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated the social worker shall conduct a social service assessment every quarter and annually. The DON stated SSD did not conduct quarterly social service assessment for Resident 18 in March 2025 and the potential outcome is the inability to address psychosocial concerns and prevent psychosocial issues. During review of the facility's Policy and Procedure (P&P) titled, Patient Assessments, last reviewed on 7/16/2024, the P&P indicated The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments- conducted for all residents in the facility: 1.admission Assessment 2.Quaterly Assessments 3.Annual Assessments 4. Significant Change in Status Assessment 5.Significant Correction to prior Comprehensive Assessment 6. Significant Correction to prior Quarterly Assessment 7.Discharge Assessment.

CONCERN (D)

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation to one of seven sampled residents (Resident 690) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with the physician's order, dated 5/1/2025. This deficient practice prevented Resident 690 from receiving a PT Evaluation to assess the possibility of receiving additional therapy to achieve Resident 690's goal of walking with a single point cane ([SPC] walking device with a curved or bent handle at the top and long shaft that ends in a single tip used to provide support while walking) to return home. Findings: During a review of Resident 690's admission Record, the admission Record indicated the facility admitted Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges (three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic intracerebral hemorrhage (bleeding in brain tissue), lack of coordination, muscle weakness, foot drop (condition where the individual experiences difficulty or inability to lift their foot or toes) of both feet, and reduced mobility. During a review of Resident 690's Minimum Data Set (MDS- a resident assessment tool), dated 4/29/2025, the MDS indicated Resident 690 had clear speech, expressed ideas and wants, clearly understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 690 required setup or clean up assistance for eating, partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and dependent for toileting, bathing, dressing, and putting on/taking off footwear. During a review of Resident 690's PT Evaluation and Plan of Treatment, dated 4/19/2025, the PT Evaluation indicated Resident 690's prior level of function (ability prior to admission to the facility) was independent with rolling to both sides of the bed, transferring from lying to sitting at the edge of the bed, transferring from sitting to standing, and walking using a SPC. The PT Evaluation indicated Resident 690's goal was to return to walking with the SPC. The PT Evaluation indicated Resident 690's current ability (as of 4/19/2025) was dependent (helper does all the effort, resident does none of the effort to complete the activity) with rolling to both sides of the bed and dependent with two-person assistance for transferring from lying to sitting at the edge of the bed. The PT Evaluation also indicated that sit-to-stand transfers were not attempted due to medical conditions or safety concerns. The PT Plan of Treatment included therapeutic activity (tasks that improve the ability to perform activities of daily living [(ADLs- tasks related to personal care including bathing, dressing, hygiene, eating, and mobility]), therapeutic exercises (movement prescribed to correct impairments and restore muscle function), neuromuscular re-education (technique used to restore movement patterns through repetitive motion to retrain the brain), orthotic management (the process of designing, making, fitting, and training patients in the use of orthoses [material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion]), and wheelchair management training (training on proper positioning and ability to propel the wheelchair), six times per week for four weeks. The PT Plan of Treatment was signed by Physician 1's (MD 1's) nurse practitioner ([NP] nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) on 4/21/2025. During a review of Resident 690's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated Resident 690 was dependent with rolling to both sides and dependent with two-person assistance for transferring from lying to sitting on the side of the bed. Resident 690's PT Discharge Summary indicated the reason for discharge was in accordance with the physician or case manager. The PT Discharge recommendations included restorative nursing assistant (RNA - an ongoing program that focuses on helping individuals, especially those in long-term care, maintain and improve their functional abilities and independence, often following rehabilitation) to provide Resident 690 with active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms and passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both legs, seven times per week as tolerated. The PT Discharge recommendations also included RNA to apply both pressure relief ankle foot orthoses ([PRAFO] device worn on the calf and foot to suspend the heel and hold the ankle in neutral [90 degree] position) to Resident 690's ankles for two to four hours or as tolerated, seven times per week. During a review of Resident 690's physician's order, dated 4/22/2025, the physician's order indicated RNA for AAROM to both arms and PROM to both legs. Another physician's order, dated 4/23/2025, indicated for the RNA to apply both PRAFOs for two to four hours or as tolerated, seven times per week. During a review of Resident 690's care plan titled, Self care deficits, initiated 4/29/2025, the care plan interventions included Rehabilitation (therapy given to restore an individual back to their highest possible level of physical, mental, and psychosocial well-being) as ordered. During a review of Resident 690's physician's order, dated 5/1/2025, the physician's order indicated PT Evaluation and Treatment when authorized under Medicare Part B (federal medical insurance for persons at least [AGE] years old that covers certain services). During a review of Resident 690's Licensed Nursing Progress Note, dated 5/1/2025 by Registered Nurse 4 (RN 4), the Licensed Nursing Progress Note indicated MD 1 approved the PT Evaluation in accordance with Resident 690's request when authorized under Medicare Part B. The Licensed Nursing Progress Note indicated Resident 690's physician's order was given to the case manager for authorization. During a review of Resident 690's Physical Therapy Note, dated 5/6/2025, the Physical Therapy Note indicated the RNA (unspecified) reported improvement with minimally active movement in the right leg. The Physical Therapy Note indicated the RNA program was changed from PROM to AAROM on the right leg. During a review of Resident 690's physician's order, dated 5/6/2025, the physician's order indicated to discontinue PROM to both legs due to the RNA's reports of improvement in the right leg. The physician's order, dated 5/6/2025, indicated for the RNA to provide Resident 690 AAROM to both arms and the right leg and PROM to the left leg. During an interview on 5/6/2025 at 9:12 a.m., with the Director of Rehabilitation (DOR), the DOR stated the purpose of PT included to improve a resident's mobility, including improving strength, the ability to get out of bed, and the ability to walk, to enhance their independence if possible. During a concurrent observation and interview on 5/6/2025 at 11:27 a.m., with Resident 690 in the resident's room, Resident 690 was awake, alert, and spoke with clear, fluent speech while lying in bed with the head-of-bed elevated. Resident 690 stated she underwent brain surgery three times and walked with a SPC due to left leg weakness after the second brain surgery and prior to the third surgery in 2/2025. Resident 690 stated the hospital discharged Resident 690 to another nursing facility after brain surgery due to Resident 690's inability to move both legs, including the right leg. Resident 690 stated PT and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) provided therapy services at the previous nursing facility. Resident 690 stated she was transferred from the previous nursing facility to the current facility due to safety concerns and to receive more therapy services. Resident 690 stated she spoke with the DOR and worked with Physical Therapist 1 (PT 1) on the first Saturday of admission [DATE]) but did not receive any PT treatment afterward. Resident 690 stated both arms moved well and movement was starting to return to the right leg. Resident 690 was observed without any ROM limitations in both arms. Resident 690 could slowly lift the right leg upward at the hip joint, slowly bent the right knee, and slightly bent the right ankle toward the body. Resident 690 stated RN 4 asked MD 1 for a PT Evaluation last week and was waiting for the DOR to approve it. Resident 690 expressed feelings of anger and frustration because the facility staff does a disappearing act around here especially when it comes to my therapy. Resident 690 stated she wanted to return home after receiving therapy. Resident 690 stated the RNAs provided exercises daily. Resident 690 stated the staff used a mechanical lift to transfer Resident 690 into a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) daily since Resident 690 did not have a wheelchair. During an observation on 5/6/2025 at 1:45 p.m., with Restorative Nursing Assistant 1 (RNA 1) in Resident 690's room, observed Resident 690's RNA session. RNA 1 stood on the left side of Resident 690's bed to perform PROM on the left leg at the hip, knee, and ankle joints. RNA 1 walked to the right side of the bed to perform AAROM of the right leg. Resident 690 was observed lifting the right leg at the hip joint (hip flexion), requiring RNA 1's assistance to lift the right leg higher. Resident 690 was observed moving the right hip into abduction (moving the leg at the hip joint away from the body), requiring RNA 1's assistance to move the right legs further away from the body. Resident 690 slid the right leg at the hip joint back toward the body (hip adduction) without physical assistance. Resident 690 slightly bent and extended the right knee, requiring RNA 1's physical assistance to completely bend and extend the knee. Resident 690 also moved the right ankle toward the body (dorsiflexion) and away from the body (plantarflexion), requiring RNA 1's physical assistance to fully move at the ankle joint. During an interview on 5/6/2025 at 2:18 p.m., with RNA 1, RNA 1 stated Resident 690 was seen for PROM of the left leg and AAROM of both arms and the right leg. RNA 1 stated Resident 690 did ROM exercises to both arms without much physical assistance. RNA 1 stated she reported Resident 690's desire for more therapy services to PT 1. RNA 1 stated PT 1 saw Resident 690 today (5/6/2025) and changed the RNA order from PROM to AAROM on the right leg. During a concurrent interview and record review on 5/7/2025 at 2:47 p.m., with the DOR, reviewed Resident 690's PT Evaluation, dated 4/19/2025, and PT Discharge summary, dated [DATE]. The DOR stated the facility admitted Resident 690 on 4/18/2025 from another nursing facility. The DOR stated the facility was aware Resident 690's health insurance had provided a last covered date (last date the person's health insurance policy covered specific services) of 4/21/2025 for therapy services prior to Resident 690's admission to the facility. The DOR stated PT 1 completed Resident 690's PT Evaluation on 4/19/2025 and recommended treatment six times per week for four weeks. The DOR stated Resident 690 was discharged from PT on 4/21/2025 in accordance with the health insurance's last covered date. The DOR stated the PT Discharge recommendations included an RNA program to provide Resident 690 with PROM to both legs and application of both PRAFOs. During an interview on 5/7/2025 at 3:06 p.m., with PT 1, PT 1 stated RNA 1 reported an improvement in movement to Resident 690's right leg yesterday (5/6/2025). PT 1 stated Resident 690's RNA program was modified from PROM to AAROM exercises to the right leg. During an interview on 5/7/2025 at 3:47 p.m., with the DOR, the DOR stated she did not speak with MD 1 about Resident 690's therapy services. The DOR stated the facility was waiting for authorization from Resident 690's health insurance to provide PT services. During an interview on 5/7/2025 at 3:53 p.m., with the Case Manager (CM), the CM stated the Medicare Managed Health Plan (private company contracted with Medicare to provide health care and services) provided a last covered date for Resident 690's therapy services prior to Resident 690's admission to the facility. The CM stated the previous facility issued Resident 690 a Notice of Medicare Non-Coverage ([NOMNC] form used by Medicare providers to notify beneficiaries when Medicare-covered services are ending) and stated the facility did not receive a copy of Resident 690's issued NOMNC. During an interview on 5/7/2025 at 4:07 p.m., with the CM and Resident 690, Resident 690 stated she did not have a Medicare Managed Health Plan. During a concurrent interview and record review on 5/7/2025 at 4:30 p.m., with Licensed Vocational Nurse 3 (LVN 3) and the DOR, reviewed Resident 690's physician order, dated 5/1/2025. LVN 3 stated the physician was contacted and physician's order was submitted based on the conversation with the physician if a resident (in general) was requesting more therapy services. LVN 3 stated Resident 690's physician order, dated 5/1/2025, indicated PT Evaluation and Treatment when authorized under Medicare Part B. LVN 3 stated the PT was supposed to carry out the physician's order. The DOR stated Resident 690's physician's order for PT Evaluation and Treatment was sent to the CM for authorization. During an interview on 5/7/2025 at 4:37 p.m., with the CM, the CM stated Resident 690 did not have Medicare. The CM stated Resident 690's health insurance provided the last covered date for therapy services. The CM stated Resident 690's physician order, dated 5/1/2025, for PT Evaluation and Treatment was sent to the health insurance for review. During an interview on 5/8/2025 at 10:56 a.m., with the Social Services Director (SSD), the SSD stated Resident 690's discharge plan included receiving therapy and returning home. During an interview on 5/8/2025 at 11:57 a.m., with the CM, the CM stated Resident 609's physician order, dated 5/1/2025, for PT Evaluation was submitted to Resident 690's health insurance on 5/7/2025 at 4:01 p.m. The CM stated Resident 690's physician's order was not submitted to the health insurance on 5/1/2025 because the CM did not work from 5/2/2025 to 5/4/2025 and was catching up on other work from 5/5/2025 to 5/6/2025. During a telephone interview on 5/8/2025 at 12:18 p.m., with MD 1, MD 1 stated Resident 690 had left leg weakness and walked with a cane prior to brain surgery. MD 1 stated Resident 690 requested a PT Evaluation on 5/1/2025 and wrote orders for a PT Evaluation to determine if Resident 690 could benefit from more therapy. During a concurrent interview and record review on 5/8/2025 at 1:52 p.m., with the DOR, reviewed Resident 690's physician's order, dated 5/1/2025, and the facility's policy and procedure (P&P) titled, Rehabilitation Services. The DOR stated Resident 60's physician's order indicated PT Evaluation and Treatment when authorized under Medicare Part B. The DOR stated Resident 690 did not have Medicare and did not receive a PT Evaluation since the health insurance has not authorized the service. The DOR reviewed the facility's P&P and stated the P&P did not indicate to perform the PT Evaluation after receiving authorization from the resident's health insurance. The DOR stated Resident 690 did not receive a PT Evaluation within 48 hours in accordance with the facility's P&P. During a concurrent interview and record review on 5/8/2025 at 2:09 p.m with the Administrator (ADM), reviewed Resident 690's physician's order, dated 5/1/2025, and the facility's P&P titled, Rehabilitation Services. The ADM stated the PT would have evaluated Resident 690 if the physician's order did not specifically indicate when authorized under (Medicare) Part B. The ADM reviewed the facility's P&P titled, Rehabilitation Services, and stated the P&P did not indicate to wait for an authorization prior to performing a PT evaluation. During a review of the facility's undated P&P titled, Rehabilitation Services, the P&P indicated Skilled rehabilitation services shall be made available to resident in order to promote recovery, improve and maintain functional independence, and prevent any further decline. The P&P indicted rehabilitation services require specific orders from the attending physician to be written in the resident's health record. The P&P indicated the therapy evaluation orders shall be address within 48 hours.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide appropriate hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) to one of one sampled resident (Resident 61) reviewed under Hospice and End of Life care area by failing to: 1. Designate a member of the facility's interdisciplinary team to coordinate care provided to the residents by the facility and the hospice company in their Hospice Program, policy. 2. Honor Resident 61`s Responsible Party 2`s (RP 2) wish to end the resident`s hospice services. These deficient practices had the potential to negatively affect Resident 61`s physical comfort and psychosocial well-being. Findings: During a review of Resident 61's admission Record (face sheet), the admission Record indicated that the facility admitted the resident on 4/22/2024, with diagnoses including history of falling, muscle weakness, cerebrovascular disease (conditions that affect blood flow to your brain), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) and encounter for palliative care (specialized medical care for individuals with serious illnesses that focuses on relieving symptoms, managing stress, and improving quality of life for both the patient and their family). During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 61 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS further indicated that Resident 61 was receiving hospice care while a resident in the facility. During a review of Resident 61`s physician Order Summary Report (physician order) dated 4/22/2024, the Order Summary Report indicated to admit Resident 61 to Hospice Agency 1 (HA1) with primary diagnosis of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain). The order summary report further indicated to call HA1 for any changes in the resident`s condition. During a review of Resident 61`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) for expected deterioration (becoming worse) due to terminal illness (a medical condition that is considered incurable and will eventually lead to death) initiated on 5/2/2024, the care plan indicated that Resident 61 was under HA1 care for diagnosis of CVA. The care plan interventions were to respect resident`s and or his family`s wishes, provide support and allow the resident to verbalize his feelings. During a record review of HA 1`s Attendance Flow Sheet for Registered Nurse (RN), the flow sheet indicated that HA 1`s RN last visited Resident 61 in the facility on 5/5/2025 at 1:00 p.m. During a record review of HA 1`s Attendance Flow Sheet for Licensed Vocational Nurse (LVN), the flow sheet indicated that HA 1`s LVN last visited Resident 61 in the facility on 5/6/2025 at 5:00 p.m. During a record review of HA 1`s Attendance Flow Sheet for Certified Home Health Aide (CHHA), the flow sheet indicated that HA 1`s CHHA last visited Resident 61 in the facility on 5/6/2025 at 2:00 p.m. During a concurrent interview and record review on 5/8/2025 at 9:48 a.m., with the Social Service Director (SSD), Resident 61`s physician orders and SS notes were reviewed. The SSD stated that Resident 61 was discharged from hospice services on 5/4/2025 per his Responsible Party 2`s (RP 2) request. The SSD stated that she (SSD) is not sure why Resident 61 is still under HA 1 services. The SSD stated that she called HA 1 and informed the owner that Resident 61`s RP 2 did not wish for Resident 61 to receive hospice services anymore. The SSD stated that she (SSD) did not document her conversation with RP 2 to discontinue Resident 61`s hospice services in the resident`s medical record. The SSD stated she did not document her conversation with HA 1 to end the hospice services in Resident 61`s medical record. The SSD stated HA1`s RN last visited Resident 61 on 5/5/2025. The SSD stated HA 1`s LVN and CHHA last visited the resident on 5/6/2025 after RP 2 made the request to end the hospice services on 5/4/2025. The SSD stated that she should have documented in Resident 61`s medical record about the conversationsshe had with RP 2. The SSD also stated that she should have informed the physician and the facility`s administration regarding RP 2`s request to end the hospice services for Resident 61. Thge SSD stated Resident 61 is still under HA 1 care and hospice continues to receive payments for services they are providing despite RP 2`s request to end hospice services. The SSD further stated that she is the designated staff member to coordinate the care provided to residents by the facility staff and the hospice staff. The SSD stated the facility`s policy titled Hospice Program, does not indicate her name as a designated member. The SSD stated she failed to perform her responsibility as the coordinator of care between the facility and HA 1. The SSD stated the potential outcome of not coordinating Resident 61's care with the hospice provider is not honoring residents` wishes and not providing appropriate care. During a telephone interview on 5/8/2025 at 11:56 a.m., with the DON of HA 1 (HDON), HDON stated that they (HA 1) did not receive any calls from the SSD informing them to end Resident 61`s hospice services. During a telephone interview on 5/8/2025 at 12:10 p.m., with Responsible Party 2 (RP 2), RP 2 stated that she does not want Resident 61 to receive hospice care and services in the facility anymore. RP 2 stated that last week on 5/1/2025 and 5/2/2025, she contacted the SSD and requested to discontinue Resident 61`s hospice services. RP 2 stated that she wants to transfer Resident 61 to a facility closer to where she lives. RP 2 stated if Resident 61 continues to receive hospice care, the transfer will not happen. During an interview on 5/8/2025 at 3:22 p.m., with the Director of Nursing (DON), the DON stated that the SSD is the designated staff member to coordinate care provided to residents under hospice services by the facility staff and the hospice staff. The DON stated the facility`s Hospice Program policy did not indicate the SSD`s name as a designated staff member for coordination, and it should have. The DON stated the SSD did not communicate with HA 1 and the facility staff regarding RP 2's wish to discontinue Resident 61`s hospice services. The DON stated the facility respects all residents and their family members' wishes to receive or discontinue the services the facility provides. The DON stated it is important to honor the resident's wishes to ensure appropriate care. During a review of the facility`s Policy and Procedures (P&P) titled Hospice Program, last reviewed on 7/16/2024, the P&P did not indicate who is the designated person to coordinate care provided to the resident by the facility staff and the hospice staff. This individual is responsible for the following: Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions to ensure quality of care for the resident and family, ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents.

CONCERN (D)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when one (1) fly (a type of insect) was observed in the kitchen. This failure had the potential to result in 138 of 199 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During an observation on 5/6/2025 at 11:06 a.m. one (1) fly was flying around the preparation area and landed on the dessert rack. During an observation on 5/6/2025 at 11:13 a.m. one fly was flying around the trayline area (an area where foods were assembled from the steamtable to resident's plate). During an interview on 5/6/2025 at 12:52 p.m. with the Dietary Supervisor (DS), the DS stated the pest control vendor came in the beginning of 4/2025. The DS stated a fly landing on the food rack is not okay as it could transmit diseases through food contact of the residents. During a review of facility's policies and procedures (P&P) titled Pest Control Policy, reviewed 7/16/2024, the P&P indicated, Policy: The facility shall maintain an effective pest control program. Policy Interpretation and Implementation: (1) This facility maintains an on-going pest control program to ensure that the building is kept free from insects and rodents. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 6.501.111 Controlling Pests. The premises shall be maintained free of insects, rodents and other pests shall be controlled to eliminate their presence on the premises by: a. Routinely inspecting incoming shipments of food and supplies. b. Routinely inspecting the premises for evidence of pests. c. Using methods, if pests are found, such as trapping devices or other means of pest control specified under §§ 7-202.12, 7-206.12, and 7-206.13. d. Eliminating harborage conditions.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 27's admission record, the admission record indicated the facility admitted the resident on 9/20/2023, with diagnoses including multiple sclerosis (a chronic disease that damaged the central nervous system), type two(2) diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/4/2024, the MDS indicated the resident was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The resident had severe cognitive impairment (problems with the ability to think, learn, remember, use judgement, and make decisions). During a review of Resident 27's Care Plan (a document that outlines the actions and interventions needed to address a resident's health and care needs) revised 1/14/2024, the care plan indicated that the resident has self-care deficits due to cognitive deficit and poor safety awareness. The care plan indicated an intervention to provide a safe environment. During an observation on 5/5/2024, at 1:51 p.m., inside Resident 27's room, there was a broken wall molding, with a piece missing behind the resident's bed. During a concurrent observation and interview on 5/6/2025 at 3:50 p.m., with the Director of Nursing (DON) inside Resident 27's room, the DON confirmed that the wall molding behind the resident's bed is broken, with a piece missing. The DON stated the staff should have reported the broken molding to the Maintenance Department. The DON stated the Maintenance Department is responsible for making sure that the wall molding in the room is not damaged. The DON stated she will report the issue to the Maintenance Department for repairs. The DON stated not reporting the broken wall molding to the Maintenance Department placed Resident 27 at risk for injuries and accidents. During concurrent observation and interview with the MD and Administrator on 5/6/2025 at 3:55p.m. in Resident 27's room, the Administrator concurred that the wall molding behind the resident's bed was broken, with a piece missing. The MD stated that he was responsible for ensuring that any damaged moldings were repaired. During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, last reviewed 7/16/2024, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike and encouraged to use their personal belongings to the extent possible. Based on observation, interview, and record review, the facility failed to provide a homelike environment for four of five sampled residents reviewed under the environment task by failing to: 1.Repair or replace ripped and gouged bed rail padding for Residents 182, 642, and 643. This deficient practice placed Residents 182, 642, and 643 at risk to experience an unsanitary and uncomfortable environment. 2.Ensure the molding on the wall behind Resident 27's bed was repaired. This deficient practice has the potential to make residents feel uncomfortable, place residents at higher risk for accidents, and negatively affect the residents' quality of life. Findings: 1. During a review of Resident 182's admission Record, the admission Record indicated the facility originally admitted the resident on 3/29/2025 and readmitted the resident on 4/29/2025 with diagnoses including but not limited to cerebral infarction (an obstruction of blood flow in the brain that leads to tissue damage) and acute respiratory failure (a condition where the lungs cannot release enough oxygen into the blood). During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 182 had severely impaired cognitive skills (problems with the ability to think, learn, and remember clearly) for daily decision making and required total assistance from staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 182's Physicians Orders, the Physicians Orders indicated an order for padded siderails to decrease potential injury dated 4/30/2025. During a review of Resident 182's care plan titled Resident is on Padded siderails, dated 3/30/2025, the care plan indicated the resident needs padded bed rails to prevent or reduce incidences of injuries. During a review of Resident 642's admission Record, the admission Record indicated the facility admitted the resident on 5/1/2025 with diagnoses including but not limited to acute respiratory failure and intracerebral hemorrhage (bleeding inside the brain tissue). During a review of Resident 642's History and Physical, dated 5/3/2025, the History and Physical indicated Resident 642 was not alert or oriented (a person's awareness of their surroundings, including who they are, where they are, and what time it is) and was unable to move any extremities. During a review of Resident 642's Physicians Orders, the Physicians Orders indicated an order for padded siderails to decrease potential injury dated 5/5/2025. During a review of Resident 642's care plan titled (Resident 642's name) is on low bed, floor mat and padded siderails ., dated 4/11/2025, the care plan indicated the goal was to prevent or reduce incidences of injuries. During a review of Resident 643's admission Record, the admission Record indicated the facility admitted the resident on 4/10/2025 diagnoses including but not limited to cerebral infarction and acute respiratory failure. During a review of Resident 643's MDS, dated [DATE], the MDS indicated Resident 643 had severely impaired cognitive skills for daily decision making and required total assistance from staff with ADLs. During a review of Resident 643's Physicians Orders, the Physicians Orders indicated an order for padded siderails to decrease potential injury dated 4/12/2025. During a review of Resident 643's care plan titled .Padded side rails when in bed to decrease potential injury, dated 4/11/2025, the care plan indicated the goal was to prevent or reduce incidences of injuries. During a concurrent observation and interview on 5/8/2025 at 10:51 a.m. with the Subacute Director (SD), Resident 643, 642, and 182's bed rails were observed to be covered with black foam padding in poor repair. The SD stated they change the bed rail padding regularly but do not have a set schedule. The black foam padding on Resident 643's right upper and lower bedrails were observed to have several cracks and gouges exposing porous (has many holes, so liquid or air can pass through) foam surfaces. The black foam padding on Resident 642's right upper bed rail was observed to have a large rip exposing porous foam surfaces. The SD stated the padding on Resident 642's right upper bedrail should be replaced due to the rip. The black foam padding covering the left upper bedrail on Resident 182's bed had a large rip which exposed the bed rail and multiple gouges exposing porous foam surfaces. The SD stated the padding should be replaced due to the rip and because it exposes the bed rail. During a concurrent interview and record review on 5/8/2025 at 2:39 p.m. with the Director of Nursing (DON), the DON stated if the bed rail is exposed the resident could potentially be injured. The DON stated Resident 643, 642 and 182's ripped and gouged bed rail paddings were not in good repair and could potentially harbor bacteria. The DON stated all rooms should have equipment in good repair for safety purposes. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, last reviewed 7/16/2024, the P&P indicated residents are to be provided with a safe, clean, comfortable, environment.

CONCERN (E)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two of three sampled residents (Resident 149 and Resident 183) by failing to: 1. Perform a bed rail/side rail (a safety device that can be installed on the side of a bed to help people get in and out of bed, turn in bed, and prevent falls) assessment prior to putting up the residents' lower side rails. 2. Obtain a physician's order on the use of bed rail/side rail. This deficient practicse had the potential to result in the restriction of residents' freedom of movement and physical harm from entrapment. Findings: a. During a review of Resident 149's admission Record, the admission Record indicated that the facility admitted Resident 149 on 1/14/2025 with diagnoses including but not limited to metabolic encephalopathy (a condition that affects brain function due to an imbalance in the body's metabolism [chemical processes that convert food into energy]), acute respiratory failure with hypoxia (a sudden, life-threatening condition where the lungs struggle to exchange enough oxygen and carbon dioxide in the blood), and congestive heart failure (a condition where the heart muscle is weakened and cannot pump enough blood to meet the body's needs), and need for assistance with personal care. During a review of Resident 149's History and Physical (H&P), dated 5/8/2025, the H&P indicated Resident 149 did have the capacity to understand and make decisions. During a review of Resident 149's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/29/2025, the MDS indicated that the resident can understand others and make himself understood. The MDS indicated that Resident 149 was dependent on staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) such as eating, hygiene. dressing, toileting and bathing. The MDS further indicated the resident was dependent on staff to roll left or right and movements such as sit to lying, sit to stand and walking were not attempted. During a review of Resident 149's Informed Consent dated 3/3/2025, the informed consent indicated a treatment of bilateral upper half siderails for mobility, ADL's (activities of daily living - such as bathing, dressing and toileting a person performs daily) and changing positions. During an observation on 5/5/2025 at 9:52 am in Resident 149's room, Resident 149 was lying in bed with both upper and one lower side rails up. During concurrent observation and interview on 5/5/2025 at 9:59 am, in Resident 149's room with the Assistant Director of Nursing (ADON), the ADON pointed to the lower side rails and stated that the lower side rail must not be up without a signed consent, and it could be considered a restraint because the resident can get stuck in or between the upper and lower rails. During a concurrent interview and record review on 5/8/2025 at 2:33 pm with the Director of Nursing (DON), the DON stated that according to the facility's policy, the use of bed rails is prohibited unless the criteria for use had been met including the assessment of the resident and a signed informed consent. The DON further stated Resident 149 had a consent for upper side rails only and his lower side rails should never have been up because the resident could have been trapped. During a review of the Policy and Procedure (P&P) named Bed safety and Bed Rails, last reviewed on 7/16/2024, the P&P indicated the use of bed rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The P&P further indicated the resident assessment determines potential risks such as accidents associated with the resident attempting to climb over, around, between or throughout the rails or their body could be caught between the rails and mattress. During a review of the P&P named Use of Restraints, last reviewed on 7/16/2024, the P&P stated restraints shall only be used for the safety and well-being of residents. The P&P defined restraints as any manual method or a physical or mechanical device, material or equipment attached to 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. b. During a review of Resident 183's admission Record, the Administration Record indicated that the facility admitted Resident 183 on 3/31/2025 with diagnoses including but not limited to adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), dysphagia (difficulty swallowing), need for assistance with personal care, stiffness on left ankle, and major depressive disorder (persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During a review of Resident 183's History and Physical (H&P), dated 4/2/2025, the H&P indicated Resident 183 did have the capacity to understand and make decisions. During a review of Resident 183's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/12/2025, the MDS indicated that the resident can understand others and make herself understood. The MDS further indicated Resident 183 required substantial assistance from staff for activities such as toileting, hygiene, sit to stand, toilet transfer and walking. During a review of Resident 183's Physician's Order dated 3/31/3035, the order indicated an order for bilateral upper half side rails when in bed for safety and protection. During a review of Resident 183's Informed Consent dated 3/31/2025, the informed consent indicated a treatment of bilateral upper half siderails for mobility, ADL's and changing positions. During an observation on 5/5/2025 at 10:11 am in Resident 183's room, Resident 183 was lying in bed with both upper and one lower side rails up. During concurrent observation and interview on 5/5/2025 at 10:15 am, in Resident 183's room with the Assistant Director of Staff Development (ADSD), the ADSD stated the lower side rail should not be up and could be dangerous because the resident could get a body part stuck in it. During an interview and record review on 5/8/2025 at 2:37 pm with the Director of Nursing (DON), the DON stated according to the facility's policy, the use of bed rails is prohibited unless the criteria for use had been met including the assessment of the resident and a signed informed consent. The DON further stated Resident 183 had a consent for upper side rails only and his lower side rails should never have been up because the resident could have been trapped. During a review of the Policy and Procedure (P&P) named Bed safety and Bed Rails, last reviewed on 7/16/2024, the P&P indicated the use of bed rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The P&P further indicated the resident assessment determines potential risks such as accidents associated with the resident attempting to climb over, around, between or throughout the rails or their body could be caught between the rails and mattress. During a review of the P&P named Use of Restraints, last reviewed on 7/16/2024, the P&P stated restraints shall only be used for the safety and well-being of residents. The P&P defined restraints as any manual method or a physical or mechanical device, material or equipment attached to 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.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 163's admission Record, the admission Record indicated that the facility admitted the resident on 7/20/2024 with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 163's MDS, dated [DATE], the MDS indicated that the resident was in a persistent vegetative state with no discernible consciousness and was dependent on staff for all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). On 5/7/2025 at 12:40 p.m., during a concurrent interview and record review, reviewed Resident 163's MDS records with the Minimum Data Set Coordinator (MDSC). A review of the admission MDS, dated [DATE], Section I - Active Diagnoses indicated that the resident did not have an active diagnosis of schizophrenia. A review of the Quarterly MDS, dated [DATE], Section I - Active Diagnoses indicated that the resident did have an active diagnosis of schizophrenia. A review of the Quarterly MDS, dated [DATE], Section I - Active Diagnoses indicated that the resident did have an active diagnosis of schizophrenia. Reviewed the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 - a comprehensive guide used by mental health professionals to diagnose and classify mental disorders) Criteria for Schizophrenia with the MDSC, which indicated that two or more symptoms or behaviors must be present for a significant portion of time during a 1-month period. The MDSC stated that the resident's admission MDS, dated [DATE], was actually coded correctly because, according to their Centers for Medicare & Medicaid Services (CMS - a federal agency within the Department of Health and Human Services [DHHS]) audit, the resident must have been diagnosed with schizophrenia earlier in life, exhibited at least two behaviors as indicated on the DSM-5 Criteria for Schizophrenia, and have psychiatric progress notes explaining the resident's diagnosis. The MDSC stated that the following Quarterly MDSs should not have been coded for an active diagnosis of schizophrenia because the resident was in a vegetative state and, therefore, did not meet the DSM-5 criteria for a diagnosis of schizophrenia. In addition, the MDSC stated that the resident's diagnosis of schizophrenia was carried over from the hospital, and the facility did not have the documentation to show why the resident was diagnosed with schizophrenia. Reviewed the residents General Acute Care Hospital (GACH) History and Physical (H&P - a comprehensive assessment conducted by a healthcare provider to evaluate a patient's overall health) with the MDSC. The MDSC stated that the only indication from the GACH records that the resident had schizophrenia was from a family interview. The MDSC stated that the staff who completed the Quarterly MDSs should have double checked for the accuracy of information. On 5/8/2025 at 11:18 a.m., during an interview, with the Director of Nursing (DON), the DON stated that the purpose of the MDS was to comprehensively assess residents to guide their plan of care. The DON stated it was important for the MDS to be accurate because it directed what interventions residents may or may not need. The DON stated that if residents' MDS were coded incorrectly, then providers may be giving incorrect care, which can negatively affect the resident. During a review of the facility's policy and procedure titled, Resident Assessments, last reviewed on 7/16/2024, the policy and procedure indicated that all persons who have completed any portion of the MDS resident assessment form sign the document attesting to the accuracy of information. Based on observation, interview and record review the facility failed to provide an assessment that accurately reflects the residents' status for two of two residents (Resident 5 and Resident 163) by failing to: a. Accurately assess and document Resident 5's hearing assessment on the Social Services Hearing Assessment Form on 12/12/24, accurately code Resident 5's ability to hear in section B of the MDS and complete a quarterly Social Services Hearing Assessment thereafter for one of one resident (Resident 5) investigated under the communication/sensory area This failure prevented Resident 5 from receiving the services and equipment needed to hear more clearly. b. Accurately code schizophrenia (a mental illness that is characterized by disturbances in thought) in Resident 163's Minimum Data Set (MDS - a resident assessment tool). This deficient practice had the potential to inaccurately depict the resident's needs thus affecting his/her plan of care. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 2/28/2024 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's need), acute kidney failure (a sudden and significant loss of kidney [organ that filters blood] function), and depression (persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/12/2025, the MDS indicated Resident 5 has some memory issues but is understood and able to understand others. The MDS further indicated Resident 5 had adequate (no difficulty in normal conversation, social interaction, listening to TV) hearing. During a review of Resident 5's Order Summary Report, the Order Summary Report indicated an active order dated 2/28/2024, for an audiology (a branch of science dealing with hearing) consult PRN (as needed) for hearing problems. During a review of Resident 5's Social Service Assessment (Hearing) dated 12/12/2024, the assessment indicated Resident 5 has an impaired hearing pattern and hearing appliances and consultation are not indicated. Further review did not indicate a Social Service Assessment (Hearing) was conducted for the first quarter of 2025. During an interview on 5/5/2025 at 10:50 am with Resident 5 in Resident 5's room, Resident 5 stated he has a hard time hearing and has been waiting for approximately six months for hearing aids. Resident 5 stated about four or five months ago, he went to see the ear doctor but was told because they were late, he could not be seen. Resident 5 stated, and he was told he would be seen at the facility instead, but no one has seen him yet. Resident 5 further stated his favorite activity is watching TV, but it was very hard for him to hear it. During a concurrent interview and record review on 5/7/2025 at 1:35 pm with the Social Service Director (SSD), the SSD stated Resident 5 saw the ENT (ear, nose, throat) doctor on 11/26/24 and recommended an audiology exam for hearing aids. The SSD stated Resident 5 had an audiology appointment on 2/3/2025, but they could not accommodate a gurney and the follow-up audiology appointment on 2/10/2025 was cancelled because the audiology office could not accommodate a gurney. The SSD stated the facility did not offer audiology services in-house. The SSD stated the social worker that completed the Social Service Assessment (Hearing) form on 12/12/2024 no longer works at the facility and should have checked off a hearing consultation is needed. The SSD stated she should have completed a Social Service Assessment (Hearing) by March 2025 to ensure Resident 5 received the services he needed. The SSD further stated six months is too long of a wait for hearing aids and she should have prioritized him. During a concurrent interview and record review on 5/8/2025 with the Minimum Data Set Coordinator (MDSC) at 11:15 am, the MDSC reviewed Resident 5's MDS Section B for hearing dated 3/12/2025 and stated he should have coded moderate difficulty instead of adequate. The MDSC stated it is important to have accurate assessment to make sure residents receive the proper care and services. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, last reviewed on 7/16/2024, the policy and procedure indicated that all persons who have completed any portion of the MDS resident assessment form sign the document attesting to the accuracy of information. During a review of the facility's P&P titled, Hearing Impaired Resident, Care Of, the P&P indicated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. The P&P indicated the facility does not provide comprehensive audiological evaluations or devices to assist with hearing and staff will assist the resident (or representative) with locating available resources, scheduling appointments and arranging transportation to obtain needed services.

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

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b. During a review of Resident 59's admission Record, the admission Record indicated that the facility admitted the resident on 2/20/2025 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, and reduced mobility. During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025, the MDS indicated that the resident had moderately impaired cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated that the resident was at risk of developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. During a review of Resident 59's admission Reassessment, dated 2/21/2025, the reassessment indicated that the resident had a stage II pressure ulcer/injury on the sacrococcyx. During a review of Resident 59's physician's order, dated 4/23/2025, the order indicated to cleanse the resident's sacrococcyx (the area at the base of the spine where the sacrum and coccyx meet) pressure injury with normal saline (NS - a saltwater solution), pat dry, apply honey to the bed wound, and cover with a dry dressing (DD) every day shift for 30 days. On 5/7/2025 at 12:54 p.m., during a concurrent interview and record review, reviewed Resident 59's care plans (a document that outlines a patient's current health status, diagnoses, treatment goals, and interventions) with the Minimum Data Set Coordinator (MDSC). The MDSC stated there was no care plan addressing the resident's pressure ulcer/injury and treatments. On 5/8/2025 at 11:18 a.m., during an interview with the Director of Nursing (DON), the DON stated that the purpose of resident care plans was to guide all disciplines in what interventions to provide residents so they can reach their goals. The DON stated that, in Resident 59's case, the facility should have developed a care plan to address the resident's pressure ulcer/injury and the prescribed treatments. The DON stated that, without a care plan, the resident may not receive proper care or treatment, which can cause the wound to worsen. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 7/16/2024, the policy and procedure indicated that the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual, or Significant Change in Status), and no more than 21 days after admission. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines a patient's current health status, diagnoses, treatment goals, and interventions to two of five sampled residents (Resident 185 and 59) when: a. A diet order was changed from twice daily pureed (a medical diet where all foods are ground, pressed, or strained into a soft, pudding-like consistency) meals to three times a day regular mechanical soft textures (foods that are easy to chew and swallow, requiring minimal effort) meals, reviewed under the nutrition care area. This deficient practice had the potential for Resident 185 to not receive the proper and necessary care regarding her new diet order. b. There was no care plan developed and implemented addressing a Resident 59's pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) and treatments, reviewed under the care area of pressure ulcer/injury. This deficient practice had the potential to result in a failure to deliver the necessary care and services necessary to treat Resident 59's pressure ulcer/injury. Findings: a. During a review of Resident 185's admission Record, the admission Record indicated the facility admitted Resident 185 on 4/2/2025 from the sub-acute unit with diagnoses including diffuse traumatic brain injury (TBI-a widespread disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head)) with loss of consciousness (when a person is neither awake or aware of the external environment), gastronomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and tracheostomy (a surgical procedure that creates an opening in the trachea [tube from mouth to lungs] to allow air to enter the lungs. During a review of Resident 185's History and Physical (H&P), dated 4/3/2025, the H&P indicated Resident 185 did not have the capacity to understand and make decisions. During a review of Resident 185's Minimum Data Set (MDS - an assessment and care screening tool) dated 5/2/2025, the MDS indicated Resident 185 was able to understand others and make herself understood, but forgetful with poor orientation and recall and dependent on staff for eating. The MDS further indicated Resident 185 had a tube feeding (gastrostomy), received 51% or more of her nutrition from tube feeding and received speech therapy (treatment that improves your ability to talk and use other language skills, also assessment for a patient's ability to swallow safely) During a review of Resident 185's Physician's Order on 5/5/2025, the Physician's Order indicated the following orders: -discontinue oral gratification diet - puree texture, nectar/mildly thick consistency, 1:1 feeding for two (2) portions during lunch and dinner. -start regular diet, mechanical soft texture, thin consistency for 3 meals, 1:1 feeding. During an interview with Certified Nursing Assistant 6 (CNA 6) on 5/6/2025 at 11:25 am, CNA 6 stated Resident 185 had pureed diet for lunch and dinner only with one-to-one supervision. CNA 6 stated she was unaware of the diet order change from 5/5/2025 nor was she notified of the change. During a concurrent interview and record review on 5/6/2025 at 4:03 am with Registered Nurse 1 (RN 1), RN 1 stated she was unaware of Resident 185's diet order change. RN 1 looked through Resident 185's care plan and was not able to locate a care plan with interventions for the new diet order change and stated without a care plan with interventions, staff may not know how to properly assist Resident 185 with her meals. RN 1 further stated it is very important to follow all the speech therapists orders to make sure the resident does not aspirate or choke. During a concurrent interview and record review with the Director of Nursing (DON), the DON stated according to the care plan policy, assessments of the residents are ongoing, and care plans are revised as information about the residents and their condition changes. The DON further stated her staff should have created a new care plan for Resident 185's significant diet order change for other staff members to know how to properly care for the residents. During a review of the facility provided Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered last reviewed on 7/16/2024, the P&P indicates a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident. The P&P further indicates assessments of the residents are ongoing, and care plans are revised as information about the residents and their condition changes.

CONCERN (E)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review the facility failed to ensure residents receive treatment and assistive devices to maintain hearing abilities for one of one resident (Resident 5) reviewed under the communication/sensory care area when Resident 5 was not provided with an audiology consultation for his impaired hearing. This failure prevented Resident 5 from receiving the services and equipment needed to improve his hearing ability. Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 2/28/2024 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), heart failure (a condition where the heart muscle is weakened and cannot pump blood effectively enough to meet the body's need), acute kidney failure (a sudden and significant loss of kidney [organ that filters blood] function), and depression (persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed). During a review of Resident 5's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/12/2025, the MDS indicated Resident 5 has some memory issues but is understood and able to understand others. The MDS further indicated Resident 5 had adequate (no difficulty in normal conversation, social interaction, listening to TV) hearing. During a review of Resident 5's Order Summary Report, the Order Summary Report indicated an active order dated 2/28/2024, for an audiology (a branch of science dealing with hearing) consult PRN (as needed) for hearing problems. During a review of Resident 5's Social Service Assessment (Hearing) dated 12/12/2024, the assessment indicates Resident 5 has an impaired hearing pattern and hearing appliances and consultation are not indicated. Further review did not indicate a Social Service Assessment (Hearing) was conducted for the first quarter of 2025. During an interview on 5/5/2025 at 10:50 am with Resident 5 in Resident 5's room, Resident 5 stated he has a hard time hearing and has been waiting for approximately six months for hearing aids. Resident 5 stated about four or five months ago, he went to see the ear doctor but was told because they were late, he could not be seen. Resident 5 stated, and he was told he would be seen at the facility instead, but no one has seen him yet. Resident 5 further stated his favorite activity is watching TV, but it was very hard for him to hear it. During a concurrent interview and record review on 5/7/2025 at 1:35pm with the Social Service Director (SSD), the SSD stated Resident 5 saw the ENT (ear, nose, throat doctor) on 11/26/24 and recommended an audiology exam for hearing aids. The SSD then stated Resident 5 had an audiology appointment on 2/3/2025, but they could not accommodate a gurney and the follow-up audiology appointment on 2/10/2025 was cancelled because the audiology office could not accommodate a gurney. The SSD stated the facility did not offer audiology services in-house. The SSD stated the social services staff that completed the Social Service Assessment (Hearing) form on 12/12/2024 no longer works at the facility and should have checked off a hearing consultation is needed. The SSD stated she should have completed a Social Service Assessment (Hearing) this past quarter to ensure Resident 5 received the services he needed. The SSD further stated six months is too long of a wait for hearing aids and she should have prioritized Resident 5. During a review of the facility's policy and procedure (P&P) titled, Resident Assessments, last reviewed on 7/16/2024, the policy and procedure indicated that all persons who have completed any portion of the MDS resident assessment form sign the document attesting to the accuracy of information. During a review of the facility's P&P titled, Hearing Impaired Resident, Care Of, the P&P indicated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. The P&P indicated the facility does not provide comprehensive audiological evaluations or devices to assist with hearing and staff will assist the resident (or representative) with locating available resources, scheduling appointments and arranging transportation to obtain needed services.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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1.b. During a review of Resident 36's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/6/2014 and readmitted the resident on 4/29/2025 with diagnoses including metabolic encephalopathy (a condition where brain dysfunction results from a problem with the body's metabolism, causing a change in brain function), legal blindness, and a history of falling. During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2025, the MDS indicated that the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 36's Fall Risk Assessment, dated 3/4/2025, the Fall Risk Assessment indicated that the resident was at high risk for falls. During a review of Resident 36's physician's order, dated 5/1/2025, the order indicated to provide the resident with a floor mat to decrease potential injury every shift. On 5/7/2025 at 2:41 p.m., during an observation, observed Resident 36 asleep in bed. No floor mats were observed in the room. On 5/7/2025 at 4:04 p.m., during a concurrent observation and interview, observed Resident 36 in bed. Certified Nursing Assistant 4 (CNA 4) stated she was the assigned CNA for Resident 36. CNA 4 verified that the resident was at high risk for falls and did not currently have floor mats. On 5/8/2025 at 11:18 a.m., during an interview with the Director of Nursing (DON), the DON stated if the resident was not provided with the prescribed floor mats, then the resident could potentially have a fall resulting in injury. During a review of the facility's policy and procedure titled, Falls - Clinical Protocol, last reviewed on 7/16/2024, the policy and procedure indicated that, based on the assessment, the staff and physician will identify pertinent interventions to try to prevent falls and to address risks of serious consequences of falling. Based on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for four (Resident 36, 61, 80 and 182) of six sampled residents reviewed under the accidents care area by: 1. Failing to place floor mats (a floor pad designed to help prevent injury should a person fall) on both sides of the Resident 61 and Resident 36's beds as ordered by the physician. 2. Failing to ensure Resident 182's bed rail padding was intact and did not have a large rip that exposed the hard bed rail for a resident with an order for padded bed rails to decrease potential injuries. 3. Failing to ensure Resident 80 had accurate fall risk assessments. These deficient practices had the potential to place Residents 36, 61, 80 and 182 at risk for injuries. Findings: 1.a During a review of Resident 61's admission Record (face sheet), the admission record indicated that the facility admitted the resident on 4/22/2024, with diagnoses including history of falling, muscle weakness, and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 61's Minimum Data Set (MDS- a resident assessment tool) dated 2/2/2025, the MDS indicated the resident's cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 61 was dependent on staff (helper does all the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS further indicated that Resident 61 had one fall since his admission/entry to the facility. During a review of Resident 61's Order Summary Report (physician order) dated 10/30/2024, the order summary report indicated to place floor mat on both sides of the resident`s bed to decrease potential injuries due to fall. During a review of Resident 61's Change of Condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) Interact Assessment form dated 11/30/2024, the COC assessment form indicated that the resident slid off his wheelchair in the dining room. During a review of Resident 61's care plan (a document that outlines how a patient's health care needs will be met) for actual fall initiated on 11/30/2024, and last revised on 12/2/2024, the care plan indicated a goal that the resident will have minimum risk for falls/injury through appropriate interventions until the next assessment. The care plan interventions were to place the resident`s bed in a low position, and to place floor mats at the resident`s bedside. During a concurrent observation and interview on 5/8/2025 at 8:46 a.m., inside Resident 61's room, the resident was observed in his bed. Certified Nursing Assistant 3 (CNA 3) was sitting next to the resident and assisting him with his breakfast. CNA 3 stated there is no floor mat at Resident 61's bedside as a fall precaution. During a concurrent interview and record review on 5/8/2025 at 8:50 a.m., with Registered Nurse 1 (RN 1), Resident 61`s physician orders were reviewed. RN 1 stated Resident 61`s physician ordered to place floor mats at the resident`s bedside to decrease the potential injuries due to a fall. During a concurrent observation and interview on 5/8/2025 at 8:53 a.m., inside Resident 61's room with RN 1, RN 1stated that Resident 61 did not have any floor mats at his bedside as ordered by his physician and the potential outcome is injuries if a fall occurs. During an interview on 5/8/2025 at 3:11 p.m., with the Director of Nursing (DON), the DON stated that Resident 61 is considered a high risk for falling and his physician ordered to place floor mats on both sides of his bed. The DON stated staff did not place floor mats at Resident 61's bedside and the potential outcome is insufficient care and increased risk of injuries after a fall. During a review of the facility's Policy and Procedure (P&P) titled Falls - Clinical Protocol, last reviewed on 7/16/2024, the P&P indicated that based on the proceeding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The staff and physician will monitor and document the individual`s response to interventions intended to reduce falling or the consequences of falling. During a review of the facility's Policy and Procedure (P&P) titled Low Bed - Floor Mat, not a Restraint, last reviewed on 7/16/2024, the P&P indicated that the facility does not consider the use of low bed and floor mat as a restrain. The use of low bed and floor mat is the least restrictive measure when a resident is in bed. 3. During a review of Resident 80's admission Record, the admission Record indicated the facility originally admitted the resident on 9/3/2021 and readmitted the resident on 10/29/2023 with diagnoses including metabolic syncope (fainting, or a sudden temporary loss of consciousness), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), and seizures (a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements) and history of fall. During a review of Resident 80's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning) was able to make herself understood and usually understands others. The MDS further indicated Resident 80 required supervision of staff to complete most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 80's Care plan initiated on 06/03/2023, the Care plan indicated that Resident 80 was on Falling Star Program and was at risk for fall. During a review of Resident 80's Change of Condition (COC) Assessment Form, dated 10/14/2024, the COC Assessment Form indicated Resident 80 was found on the floor in his room. The COC Assessment Form further indicated Resident 80 stated he tried getting up from the bed to go to the bathroom and fell. During a concurrent interview and record review on 5/8/2025 at 1:39 p.m. with Director of Nursing (DON), Resident 80's Fall Risk Evaluations, dated 10/14/2024 and 4/15/2025 were reviewed. The D section of the Fall Risk Evaluation dated 10/14/2024 titled Predisposing factors, did not reflect seizures as a predisposing factor. The DON stated that the Fall Risk Evaluation should reflect all predisposing conditions including seizures. The second section of Resident 80's Fall Risk Assessment, dated 4/15/2025 titled History of Falls for past three months was blank. The DON stated it is important to accurately complete the Fall Risk Assessment so staff are aware of Resident 80's risk of falling and staff can effectively care for the resident. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, last revised 7/16/2025, the P&P indicated: The staff will document risk factors for falling in the resident's record and discuss resident's fall risk. 2. During a review of Resident 182's admission Record, the admission Record indicated the facility originally admitted the resident on 3/29/2025 and readmitted the resident on 4/29/2025 with diagnoses including but not limited to cerebral infarction (an obstruction of blood flow in the brain that leads to tissue damage) and acute respiratory failure (a condition where the lungs cannot release enough oxygen into the blood). During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 182 had severely impaired cognitive skills (problems with the ability to think, learn, and remember clearly) for daily decision making and required total assistance from staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 182's Physicians Orders, the Physicians Orders indicated an order for padded bed rails to decrease potential injury dated 4/30/2025. During a review of Resident 182's care plan titled Resident is on Padded siderails, dated 3/30/2025, the care plan indicated the resident needs padded bed rails to prevent or reduce incidences of injuries. During a concurrent observation and interview on 5/8/2025 at 10:51 a.m. with the Subacute Director (SD), Resident 182's upper left bed rail padding had a large rip which exposed the hard bed rail. The SD stated the padding should be replaced due to the rip. The SD stated that because the bed rail is exposed due to the rip the padding would not protect the resident from injuries. During an interview on 5/8/2025 at 2:39 p.m. with the Director of Nursing (DON), the DON stated the ripped bed rail padding on Resident 182's upper left bed rail could potentially result in injuries to Resident 182. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, last reviewed 7/16/2024, the P&P indicated residents are to be provided with a safe, clean, comfortable, environment. During a review of the facility's P&P titled Bed Safety and Bed Rails, last reviewed 7/16/2024, the P&P indicated potential risks with the use of bed rails are assessed including accident hazards and skin integrity issues.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit (eKIT-contains certain medications that could be taken if needed immediately) containing controlled medications (CM- medications which have a potential for abuse and may also lead to physical or psychological dependence) for 5/2025, in one (1) of two (2) inspected medication rooms (Medication Room Station 1). 2. Reconcile one (1) medication eKIT containing CMs for 5/2025, in one (1) of five (5) inspected medication carts (Medication Cart Station 2B.) These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use). Findings: During a concurrent observation and interview on 5/5/2025 at 12:50 p.m., with Registered Nurse 1 (RN 1) and in the presence of the Director of Nursing (DON) in Medication Room Station 1, observed one (1) medication eKIT in the refrigerator labeled 109 containing CMs without an accountability log for the reconciliation of CM inventory at every shift for 5/2025. RN 1 stated that all CMs, including medication eKITs containing CMs, should be reconciled at every shift. RN 1 stated that the eKIT labeled 109 containing CMs in Medication Room Station 1 was not reconciled at every shift in 5/2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion, and accidental exposure of harmful substances to residents. The DON stated the eKIT labeled 109 contained CMs and was not reconciled at each shift for 5/2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKITs containing CMs at each shift in Medication Room Station 1. During a concurrent observation and interview on 5/5/2025 at 2:15 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed in Medication Cart Station 2B, one (1) medication eKIT labeled 318 containing CMs without an accountability log for the reconciliation of CM inventory at every shift for 5/2025. LVN 1 stated that the eKIT labeled 318 containing CMs in Medication Cart Station 2B was not reconciled at every shift in 5/2025, and it was important to account for all CMs to ensure accountability, prevent CM diversion, and accidental exposure of harmful substances to residents. During an interview on 5/6/2025 at 12:28 p.m., with the DON, the DON stated that medication eKITs containing CMs need to be counted and reconciled at every shift change to ensure accountability and prevent CM diversion. The DON stated one (1) eKIT containing CMs in Medication Cart Station 2B was not reconciled at each shift for 5/2025. The DON stated that the facility will immediately implement an accountability log for reconciliation of eKITs with CMs at each shift change in Medication Cart Station 2B. During a review of the facility's policy and procedure (P&P) titled, Controlled Medication Storage, last reviewed 7/16/2024, the P&P indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. The DON and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of CMs. At each shift change, a physical inventory of all CMs including the emergency supply is conducted by two (2) licensed nurses and is documented on the CM accountability record.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 34 total opportunities contributed to an overall medication error rate of 8.82% affecting two (2) of six (6) residents observed for medication administration (Resident 151 and 183.) The medication errors were as follows: 1. Resident 151 received carvedilol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) at a different time than ordered by Resident 151 ' s physician. 2. Resident 183: a. did not receive docusate (a medication used to soften stool) as ordered by Resident 183 ' s physician b. received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) that was different than the one ordered by Resident 183 ' s physician These failures had the potential to result in Resident 151 and 183 receiving suboptimal (less than standard) care, experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and resulting in Residents 151's and 183's health and well-being negatively impacted. Findings: During an observation on 5/5/2025 at 9:10 a.m., in Medication Cart 1A, Registered Nurse 3(RN 3) was observed administering multivitamin with minerals tablet orally and not administering docusate tablet to Resident 183. Resident 183 was observed swallowing the multivitamin with mineral tablet with a glass of juice. During an interview on 5/5/2025 at 11:55 a.m., with RN 3, RN 3 stated the physician order for Resident 183 indicated to hold the docusate dose for loose stool. RN 3 stated RN 3 did not administer docusate to Resident 183, during the morning medication administration at 9:10 a.m. since Resident 183 had a soft stool that morning. RN 3 stated Resident 183 did not have loose stool, and the dose should not have been held. RN 3 stated that not administering docusate could potentially harm Resident 183 by increasing the risk of having hard stools and constipation. During the same interview, RN 3 stated RN 3 stated the physician order for Resident 183 indicated to give multivitamin not containing minerals. RN 3 stated RN 3 failed to administer the correct multivitamin as prescribed by Resident 183's physician. RN 3 stated administering multivitamin with minerals to Resident 183 may not be beneficial to their health and may cause adverse effects. RN 3 stated these were considered medication errors. During an observation on 5/6/2025 at 10:05 a.m., in Medication Cart 2B, Licensed Vocational Nurse 1 (LVN 1) was observed administering carvedilol 6.25 milligram ([mg]-a unit of measure of mass) tablet orally to Resident 151. Resident 151 was observed swallowing the carvedilol tablet with a glass of water. During an interview on 5/6/2025 at 11:40 a.m., with LVN 1, LVN 1 the physician order for Resident 151 indicated to administer carvedilol at 8 a.m. with food to prevent stomach discomfort. LVN 1 stated per facility policy there was a 60-minute window for medication administration and LVN 1 administered carvedilol later than that timeframe. LVN 1 stated LVN 1 failed to administer carvedilol as prescribed by Resident 151's physician placing Resident 151 at risk of receiving the next dose closer in time and experiencing stomach irritation. LVN 1 stated this was considered a medication error. During an interview 5/6/2025 at 12:28 p.m., with the Director of Nursing (DON), the DON stated LVN 1 failed to administer carvedilol 6.25 mg tablet to Resident 151 according to physician orders at 8 a.m. that (5/6/2025) morning. The DON stated RN 3 failed to administer multivitamin without minerals and docusate to Resident 183, according to physician orders on 5/5/2025. The DON stated these were considered medication errors. The DON stated Resident 151 may be at risk for having the next dose given in a shorter timeframe since it was ordered to be given twice a day, and possible stomach irritation. The DON stated Resident 183 may possibly experience constipation or hard stools by not receiving docusate and be at risk of not being able to tolerate the additional minerals from the multivitamin. The DON stated licensed nurses should follow facility medication administration guidelines to ensure physician orders are followed and the right medications are administered at the right time to residents. During a review of Resident 183's admission Record (a document containing demographic and diagnostic information,) dated 5/5/2025, indicated Resident 183 was originally admitted to the facility on [DATE] with a diagnosis including malnutrition (a condition when the body does not receive enough nutrients,) and failure to thrive (to do well.) During a review of Resident 183's Order Summary Report, dated 5/5/2025, the report indicated Resident 183 was prescribed: 1. docusate 100 mg to give one (1) tablet by mouth twice a day for stool softener [hold for loose bowel movement], starting 4/1/2025 2. multivitamin to give one (1) tablet by mouth once a day for wound regimen, starting 4/9/2025 During a review of Resident 183's Medication Administration Record ([MAR] - a record of mediations administered to residents), for May 2025, the MAR indicated Resident 183 was prescribed: 1. docusate 100 mg one (1) tablet by mouth twice a day for stool softener [hold for loose bowel movement], to give at 9 a.m. and 6 p.m. 2. multivitamin one (1) tablet by mouth once a day for wound regimen, to give at 9 a.m. During a review of Resident 151 ' s admission Record dated 5/6/2025, indicated Resident 151 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including HTN. During a review of Resident 151's Order Summary Report, dated 5/6/2025, indicated Resident 151 was prescribed carvedilol 6.25 mg to give (1) tablet by mouth twice a day for HTN give with food, starting 4/9/2024. During a review of Resident 151's MAR for May 2025, the MAR indicated Resident 151 was prescribed carvedilol 6.125 mg one (1) tablet by mouth twice a day for HTN give with food, to give at 8 a.m. and p.m. During a review of the facility's policy and procedures (P&P) titled Medication Administration-General Guidelines, last reviewed 7/16/2024, the P&P indicated that Medications are administered as prescribed in accordance with good nursing principles and practices . Preparation 3. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. Administration 2. Medications are administered in accordance with written orders of the attending physician. 10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meals, which are administered based on mealtimes. During a review of the facility's P&P, titled Adverse consequences and Medication Errors, last reviewed 7/16/2024, the P&P indicated: 1. An 'adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may have . An adverse consequence may include: a. Adverse drug/medication reaction b. Side effect 2. The staff and practitioner shall strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer ' s specifications for use, dose, administration, duration, and monitoring of the medication; 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician ' s orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medication error include: a. Omission - a drug is ordered but not administered; f. Wrong drug g. Wrong time. During a review of the facility ' s document, titled Meals Serving Times, [undated], the document indicated: Breakfast - 7:30 to 8:30 Lunch - 12:30 to 1:30 Dinner - 5:30 to 6:30

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) Aspart (short-acting insulin) Flexpen (an injection device containing insulin) for Resident 6, in accordance with manufacturer ' s requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Station 1.) 2. Label one (1) insulin Humulin R (long-acting insulin) vial for Resident 12, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Subacute.) 3. Remove and discard from use one (1) Procrit (brand name medication for epogen used to treat anemia [having low red blood cells) vial for Resident 14, in accordance with manufacturer 's requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Subacute.) These deficient practices increased the risk that Residents 6, 12, and 14 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death. Findings: During an observation on [DATE] at 12:26 p.m., in Medication Room Subacute, in the presence of Registered Nurse 2 (RN 2), the following medications were found either stored in a manner contrary to their respective manufacturer ' s requirements, not labeled with an open date as required by their respective manufacturer ' s specifications, or stored and labeled contrary to facility policies: 1. One (1) opened insulin Humulin R multi-dose (containing more than one dose) vial for Resident 12 was found stored in the refrigerator and without a label indicating when use first began, and an additional label indicating to discard 31 days after opening According to the manufacturer's product labeling, opened Humulin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded after 31 days of opening. 2. One (1) opened single dose vial of Procrit for Resident 14 was found stored in the refrigerator containing unused volume of medication, with a label indicating Single-dose Discard unused potion. According to manufacturer's product storage and labeling, Procrit single-dose vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and once opened to be discarded. During a concurrent interview with RN 2, RN 2 stated the Humulin R vial for Resident 12 opened, not labeled with a date indicating when use began and stored in the refrigerator. RN 2 stated the opened Humulin R vial should be stored at room temperature and once opened good for 31 days, after which the insulin loses potency (effectiveness.) RN 2 stated the Humulin R vial for Resident 12 was considered expired since it was not stored correctly and unaware of the date the vial was opened. RN 2 stated administering expired insulin error to Resident 12 will not be effective in keeping the blood sugar stable and can harm Resident 12 by causing high blood sugar levels leading to coma (a state of deep unconsciousness caused by severe injury or illness), Diabetic Ketoacidosis ([DKA] - a condition that develops when the body doesn ' t have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening], hospitalization or death. RN 2 stated the Humulin R vial for Resident 12 needed to be removed from the refrigerator, disposed of and replaced with a new one from pharmacy. During the same interview, RN 2 stated the Procrit vial for Resident 14 was used with some volume of medication remining in the vial and continued to be stored in the refrigerator. RN 2 stated the Procrit vial for Resident 14 was considered expired since it was opened and used, and continued storage in the refrigerator created the potential for accidental use. RN 2 stated expired Procrit vial has decreased medication potency and when used in error could be ineffective by not treating or controlling Resident 14's anemia, requiring additional treatments. RN 2 stated the Procrit vial for Resident 14 needed to be removed from the refrigerator and disposed of to prevent accidental use. During an observation on [DATE] at 12:50 p.m., in Medication Room Station 1, in the presence of RN 1, the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One (1) open insulin Aspart Flexpen for Resident 6 was found stored in the refrigerator with a label indicating that use began on [DATE], and an additional label indicating to discard 28 days after opening. According to the manufacturer's product labeling, opened Aspart Flexpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening. During a concurrent interview with RN 1, RN 1 stated the insulin Aspart Flexpen for Resident 6 was opened on [DATE] and stored in the refrigerator. RN 1 stated expired insulin has lost its potency and administering expired insulin Aspart to Resident 6 will not be effective in keeping the blood sugar stable and can harm Resident 6 by causing high blood sugar levels leading to DKA and hospitalization. RN 1 stated according to the label the pen expired after 28 days on [DATE] and needed to be removed from the refrigerator and medication room to not be used in error and replaced with a new pen from pharmacy. During an interview on [DATE] at 12:28 p.m., with the Director of Nursing (DON), the DON stated that multi-dose medications like insulin vials and pens should be labeled with a date open label and discarded after 28 days from that date. The DON stated insulin vials with no date open label are considered expired and should not be used, and insulin pens that have expired needed to be removed from use. The DON stated expired insulin has lost its effectiveness and should be discarded to prevent accidental use. The DON stated that administering expired insulin in error will not be effective in controlling blood sugar levels and can harm Residents 6 and 12 by causing high or low blood sugar levels, leading to emergency crisis and requiring hospitalizations. The DON stated that unlabeled and expired insulins needed to be removed from the refrigerator and replaced immediately with new ones from pharmacy. During the same interview, the DON stated single-use vials that have been used immediately expire and should be disposed to prevent accidental use. The DON stated that administering expired Procrit in error will not be effective and can harm Resident 14 by not treating the anemia. The DON stated the Procrit vial needed to be removed from refrigerator and disposed of to prevent accidental use. The DON stated several licensed nurses failed to dispose of single dose Procrit vial from the refrigerator. During a review of facility's policy and procedures (P&P,) titled Storage of Medications, last reviewed on [DATE], the P&P indicated that Medications and biologicals ae stored safely, and properly, following manufacturer ' s recommendations or those of the supplier. J. Medications requiring storage at room temperature are kept at temperatures ranging from 59 degrees Fahrenheit to 86 degrees Fahrenheit. M. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from pharmacy if a current order exist. During a review of facility's P&P titled Procedures for All Medications, last reviewed on [DATE], the P&P indicated: To administer medications in a safe and effective manner. E. Check expiration date on package/container. When opening a multi-dose container, place the date on the container. N. Once removed from the package or container, unused doses should be disposed of in accordance with the medication destruction policy. During a review of facility's P&P titled, Vials and Ampules of Injectable Medications, last reviewed [DATE], the P&P indicated: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. B. The date opened and the initials of the first person to use the vial are recorded on multi-dose vials. C. Ampules and single-dose vials are discarded immediately after use. E. Medication in multi-dose vials may be used until manufacturer ' s expiration date or 6 months after opening unless otherwise specified. Refer to Guide for Special Handling of Medications. During a review of facility's P&P, titled Guide for Special Handling of Medications, last reviewed [DATE], the P&P listed the following: Multiple Dose Vials for injection - Discard 28 days after opening Single Dose vial - Discard after initial use.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance when the temperature of the food were as follows: -Zest spinach 121 degrees Fahrenheit (°F, a scale of temperature) -Chocolate cake 60°F, -Milk 47°F and 49°F -Puree chocolate cake 57°F. This deficient practice placed 138 of 199 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of the facility'' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Spring Cycle Menus, dated 5/6/2025, the spreadsheet indicated residents on Regular and therapeutic diet t would include the following foods on the tray: -Meat balls with gravy 2 pieces 1-2 ounces (oz, a unit of measurement) -Gravy 1 oz -Penne with garlic and herbs ½ cup (c., household measurement -Zesty spinach ½ c. -Fresh green salad with dressing ½ c -Chocolate cake 2x2 ½ inches -Milk 4 oz During a review of the facility's menu spreadsheet titled Spring Cycle Menus, dated 5/6/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: -Puree meatballs 2- number 16 scoops (1/2 c total) -Gravy 1 oz -Puree penne with garlic and herbs ½ c. -Puree zesty spinach 1/3 c. -Puree fresh green salad with dressing 1/3 c. -Puree chocolate cake 1/3 c. -Milk 4 fluid oz. During a concurrent observation on 5/6/2025 at 11:45 a.m. in the trayline (an area where foods were assembled from the steamtable to resident's plate) area with [NAME] 1, observed [NAME] 1 taking temperatures of the hot and cold food. [NAME] 1 stated the green salad was 54.8°F. [NAME] 1 stated he had to put it back in the freezer before serving. During a concurrent observation on 5/6/2025 at 12:11 p.m. in the trayline area with [NAME] 1, observed [NAME] 1 took the temperature the green salad from the freezer. [NAME] 1 stated the green salad temperature was at 50°F and the chocolate cake with icing was at 54.9°F. During an observation on 5/6/2025 at 12:42 p.m. in the trayline area, observed a rack of chocolate cake and milk were out in room temperature. During an observation on 5/6/2025 at 12:48 p.m. of [NAME] 3, [NAME] 3 cooked extra zesty spinach and directly poured it in the steamtable pans without taking the temperature of the spinach. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 5/6/2025 at 1:29 p.m. of the regular test tray with the Dietary Supervisor (DS), observed and the DS stated zesty spinach was at 121°F, chocolate cake with icing at 60 °F and milk was at 49°F when the DS took the temperature of the food using the facility thermometer. During a concurrent test tray observation and interview on 5/6/2025 at 1:35 with the DS, observed the following temperature when the DS took the food temperatures using the facility thermometer: -Milk 49°F -Puree chocolate cake 57°F During an interview on 5/6/2025 at 1:56 p.m. with the DS, the DS stated cold food temperatures could be better as they follow a standard of below 41°F and hot food should be above 135°F. The DS stated hot food should be hot and cold food should be cold. The DS stated zesty spinach at 121°F, chocolate cake of 60°F and milk at 49°F was not okay as the residents expected cold food to be cold and hot food to be hot. The DS stated residents could potentially get food borne illnesses, they might not eat and result in weight loss. During an interview on 5/7/2025 at 12:02 p.m. with [NAME] 3, [NAME] 3 stated she prepared the spinach for yesterday's lunch, and she forgot to take the temperature. [NAME] 3 stated it was important to take the temperature of the food to ensure safety and if it was still cold, it would not be good as bacteria could grow making the residents sick. During a review of the facility's policies and procedures (P&P) titled Food Preparation dated 7/16/2024, the P&P indicated Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. Procedure: (1) All foods will be prepared by methods that preserve nutritive value, flavor and appearance and will be attractively served at the proper temperature and in a form to meet the individual needs of the residents. (9) Food temperatures will be taken to ensure all hot foods are at a proper serving temperature. Food temperature will be recorded daily. (10) Hold foods prior to service for as short time as possible. Food should not be held more than two hours during service. Hot food should be held prior to service at 140°F for above and cold foods at 40°F or below. Keep food covered during holding. During a review of the facility's P&P titled Meal Service reviewed 7/16/2024, the P&P indicated, (2) Food temperatures will be taken to ensure all hot foods are at a proper serving temperature. Food temperature will be recorded daily. Food items: -Vegetables, fruits, grains at least 135°F -Cold beverages, desserts no more than 40°F.

CONCERN (E)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) when puree pasta was sticky pasta and not smooth pudding like consistency. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 18 of 18 residents on puree diet, resulting in unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring Cycle Menus, dated 5/6/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray: -Puree meatballs 2- number 16 scoops (1/2 c total) -Gravy 1 oz -Puree penne with garlic and herbs ½ c. -Puree zesty spinach 1/3 c. -Puree fresh green salad with dressing 1/3 c. -Puree chocolate cake 1/3 c. -Milk 4 fluid oz. During a concurrent observation and interview on 5/6/2025 at 11:15 a.m. of puree pasta preparation with [NAME] 1, observed [NAME] 1 pouring potato flakes to the puree pasta without measuring it. [NAME] 1 stated he used potato flakes as a thickener, and he would know it was in the right consistency by following the recipe and using a spoon tilt test. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 5/6/2025 at 1:35 p.m. with the Dietary Supervisor (DS) and the Registered Dietitian (RD), observed little pasta particles on the puree pasta. The RD stated puree diet should be smooth, no lumps, not sticky but not too watery. The DS stated the puree pasta was sticky and would involve more chewing. The DS stated residents on puree diet could aspirate and had trouble chewing and swallowing as a potential outcome of not achieving correct puree texture and consistency. The DS stated the proper way to prepare puree food was to follow the recipes by measuring the correct ingredients to achieve texture and consistency. During a review of the facility's policies and procedures (P&P) titled Diet Orders reviewed 7/16/2024, the P&P indicated POLICY: The physician will prescribe diets in accordance with the approved Diet Manual. During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed and avoided and sample menus the facility have) titled Regular Pureed Diet reviewed 7/16/2024, the diet manual indicated The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft, and smooth state such as pudding, ice cream, applesauce, mashed potato, etc. During a review of the facility's P&P titled Menu reviewed 7/16/2024, the P&P indicated, Procedure: Menus are planned to meet the Recommended Dietary Allowances of the Food and Nutrition Board, National Research Council, adjusted to the age, activity and environment of the group involved. (5) The menus will be prepared as written using standardized recipes. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes, etc.), the recipe indicated ingredients: (48 servings) starch per recipe: 48 servings, warm milk 48 to 96 oz, instant potato 1 ½ - 3 cups). The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass the IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure and spoon tilt tests). During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Opened plastic bags of frozen pancakes and frozen pie crust in the freezer were not labeled and dated. 2. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. The reach-in refrigerator's ceiling had dust and dirt debris. b. The two drawers by the preparation area were dirty to touch and had dust buildup. c. Plate warmer's internal part where the clean plates were stored had food and white dirt debris. d. The two push carts where clean resident's trays, bases and domes were stored had dirt, food and hair debris. e. Condiment containers contain loose sugar, pepper, sweetener particles and dirt residues. 3. Kitchen equipment and utensils were not maintained in their proper condition, smooth and easy to clean. a. Seven (7) of 7 green shelves in the Walk-in Refrigerators 1 and 2 had cracks, chips, and rust with amber discoloration. b. The green chopping board had black and brown stains and scratches. c. The juice rack had rust. 4. Three (3) staff (two cooks and one dietary aide) were wearing wristwatches, a bracelet and a diamond ring while preparing food. 5. Five (5) of 5 dented were stored with non-dented cans. 6. Gray, clear food containers, plates and resident's trays were stacked wet with water particles. 7. There was no separation between the dirty area (trash can in the handwashing area) and the clean bowl storage area. 8. Staff was wearing nail polish while cooking food. 9. The residents' freezer in Station 1 had no thermometer. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 138 of 199 medically compromised residents who received food and ice from the kitchen. Findings: 1. During an initial kitchen tour on 5/5/2025 at 8:20 a.m., with the Dietary Supervisor (DS), in the walk-in freezer a bag of opened frozen pancakes containing six individual pancakes and a bag of opened frozen pie crusts containing three pie crusts were observed without a label and date of when they were opened. The DS stated that frozen food taken from original packaging in the freezer should be labeled and dated to ensure they will be used first. The DS stated the potential outcome of not dating the opened packages of food is the inability to determine how long the items were stored in the freezer. During review of the facility`s Policy and Procedure (P&P) titled Refrigerator/Frezer Storage, last reviewed on 7/16/2024, the P&P indicated that leftover food or unused portions of packaged foods should be covered, dated and labeled to ensure they will be used first. All items should be properly covered, dated, and labeled. Food items should have the following appropriate dates: Delivery date (upon receipt), Open date (opened container of PHF) and Thaw date (any frozen item). Frozen food taken from the original packaging should be labeled and dated. Food that has freezer burns should be discarded. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. 2. a. During an observation on 5/6/2025 at 8:30 a.m., of the reach-in refrigerator by the handwashing station, observed dust on the ceiling. During an interview on 5/6/2025 at 8:35 a.m. with the DS, the DS stated the refrigerator ceiling was dusty, and staff missed cleaning the ceiling. The DS stated it was not okay that the walk-in refrigerator was dusty due to cross-contamination of dust to food that could potentially get the residents sick of diarrhea, vomiting and stomachache. During a review of the facility's P&P titled Refrigerator and Freezer, reviewed 7/16/2024, the P&P indicated, (17) The refrigerator and freezer area will be clean and dry, well-ventilated at all times. b. During an observation on 5/7/2025 at 11:18 a.m. of the preparation area, observed two drawers where food containers and sandwich bags were stored had dust buildup. During an interview on 5/7/2025 at 11:31 a.m. with the DS, the DS stated the drawer was deep cleaned once a week however, staff cleaned it every day. The DS stated the drawers had dust build up and staff did not clean last night. The DS stated it was important to keep the drawers clean to avoid food borne illnesses for the residents. c. During an observation on 5/7/2025 at 11:24 a.m. of the plate warmer, observed the internal parts of the plate warmer had dust and dirt debris. During a concurrent observation and interview on 5/72/2025 at 11:53 a.m. of the plate warmer with the DS, the DS stated the plate warmer internal parts had white spill dirt and it was noticeable. The DS stated it was not okay due to cross-contamination of food. The DS stated the plates had also water particles and were not air dried. d. During an observation on 5/7/2025 at 11:29 a.m. of the pushcart used to store resident's tray, observed the pushcart had dust and dirt debris. During an observation on 5/7/2025 at 11:30 a.m. of the pushcart used to store dome and lids, observed the pushcart had dust and dirt debris. During a concurrent observation and interview on 5/7/2025 at 11:45 a.m. of the two pushcarts by the trayline (an area where foods were assembled from the steamtable to resident's plate) with the DS, the DS stated the two pushcarts used to store resident's tray, domes and base were a clean area, however it had dirt, food and hair debris. The DS stated the pushcarts were not cleaned yesterday and it was not okay as it could potentially contaminate food items in trayline. e. During a concurrent observation and interview on 5/7/2025 at 11:49 a.m. of the condiment container with the DS, observed the condiment containers had loose sugar, pepper, sweetener particles and dirt. The DS stated the condiment containers were not clean yesterday and it needed to be cleaned to prevent cross-contamination of food potentially causing food borne illness to the residents. During a review of the facility's P&P titled Sanitizing Equipment and Surfaces, reviewed 7/16/2024, the P&P indicated, Sanitizing solution will be used to sanitize equipment and surfaces after each use or as often as needed. During a review of the facility's P&P titled Cleaning Schedule, reviewed 7/16/2024, the P&P indicated, All areas and equipment in the kitchen should be cleaned daily. The assigned dietary personnel will deep clean the area equipment assigned for them that day using the dietary cleaning schedule. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 3. a. During an observation on 5/6/2025 at 8:42 a.m. of the green racks in walk-in refrigerator 1, observed three (3) of 3 green racks had cracks and chips. During an observation on 5/6/2025 at 8:49 a.m. of the green racks in the walk-in refrigerator 2, observed four (4) of 4 green racks had cracks, chips with amber discoloration. During an interview on 5/6/2025 at 8:59 a.m. with the DS, the DS stated the green racks in the walk-in refrigerators were rusted and they needed to be in good condition with no hips and rust as it could potentially make the residents sick of food borne illnesses. b. During an observation on 5/7/2025 at 11:14 a.m. of the white chopping board, observed the white chopping board had black dirt stains and scratches. During an interview on 5/7/2025 at 11:37 a.m. with the DS, the DS stated the chopping board should be free from noticeable scratch because it would not be properly washed or sanitized, and food particles could get stuck in it. The DS stated the white chopping boards were considered as green chopping boards and it had black and brown stains and scratches. The DS stated the fruit could potentially be contaminated if the chopping boards had scratches and stains. During a review of the facility's P&P titled Cutting Board Cleaning reviewed 7/16/2024, the P&P indicated, All cutting boards should be clean and in good condition. c. During an observation on 5/7/2025 at 11:26 a.m. of the juice dispenser rack by the trayline, observed rack was rusted. During a concurrent observation and interview on 5/7/2025 at 11:43 a.m. of the juice rack with the DS, the DS stated the juice rack looked rusty and he needed to contact the company to replace it as it was not acceptable in the kitchen due to cross-contamination of the food. During a review of the facility's P&P titled Sanitizing Equipment and Surfaces reviewed 7/16/2024, the P&P indicated (6) Dietary staff should ensure that all equipment, shelves, serving utensils, and surface areas are clean and in good condition. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 4. During an observation on 5/6/2025 at 8:56 a.m., of the trayline, observed [NAME] 1 was wearing a black wristwatch and Dietary Aide 3 (DA 3) was wearing a silver bracelet while dishing out food from the steamtable to the resident's plate. During an observation on 5/6/2025 at 11:00 a.m. of the cold food preparation, observed [NAME] 2 wearing a wristwatch and diamond ring while preparing cold food. During an observation on 5/6/2025 at 11:08 a.m. of the cold food preparation, observed DA 3 was wearing a silver bracelet while preparing dessert. During an interview on 5/6/2025 at 12:43 p.m. with the DS, the DS stated jewelry was not allowed in the kitchen due to infection control purposes for the residents. During a review of the facility's P&P titled Sanitation and Infection Control, reviewed 7/16/2024, the P&P indicated (9) No dangling jewelry or earrings should be worn. Only wedding rings are acceptable. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 5. During an observation on 5/6/2025 at 9:15 a.m. in the dry storeroom, observed two (2) dented cans stored with non-dented cans. During a concurrent observation and interview on 5/6/2025 at 9:23 a.m. of the dry storeroom with the DS, observed three (3) dented cans stored with non-dented cans from the emergency food supply. The DS stated a separate area of dented cans was designated so the staff would not accidentally use them. The DS stated there were four (4) dented cans stored with non-dented cans and it was not okay as it could cause physical contamination of food resulting in potential food borne illnesses to the residents who would consume it. During a review of the facility's P&P titled Storage of Canned and Dry Goods, reviewed 7/16/2024, the P&P indicated (10) Canned items should be inspected for damage such as dented, leaking or bulging cans. These items will be stored separately in the designated area- Dented Cans for return to the vendor or disposed of properly. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victims to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 6. During an observation on 5/6/2025 at 11:11 a.m. of the food container storage area, gray bins and clear Cambro containers were stacked wet. During an interview on 5/6/2025 at 12:50 p.m. with the DS, the DS stated the process of dishwashing was to wash, rinse, sanitize, then air dry. The DS stated the food containers were staked wet and it was not okay as there were still water particles. The DS stated it was important to airdry dishes to avoid moist that could grow bacteria resulting in food borne illnesses. During a review of the facility's P&P titled Manual Dishwashing-2-3 Compartment Sink, reviewed 7/16/2025, the P&P indicated, (6) Dishes should be allowed to air dry before storage. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 7. During an observation on 5/6/2025 at 11:36 a.m. of the garbage can by the bowl storage area, water splashes observed from handwashing area to the bowl storage area. During an interview on 5/6/2025 at 12:46 p.m. with the DS, the DS stated the bowl storage was a clean area, but it was near the handwashing sink trash can and it was not okay. The DS stated there was no separation of clean and dirty areas that could cause food contamination. During a review of the facility's P&P titled Sanitizing Equipment and Surfaces, reviewed 7/16/2024, the P&P indicated, To prevent cross-contamination and ensure food safety by maintaining strict separation between clean a dirty area within the dietary department. (8) Dietary staff to ensure clean and dirty areas shall be separated by physical barriers where possible workflows must be designated to ensure that the clean and dirty processes do not overlap in time or space. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 8. During an observation on 5/6/2025 at 11:42 a.m. of lunch food preparation, observed [NAME] 3 wearing a turquoise nail polish while cooking food for lunch. During an interview on 5/6/2025 at 1:04 p.m. with the DS, the DS stated staff were not allowed to wear nail polish due to physical contamination as the nail polish could fall in the food. The DS stated [NAME] 3 was wearing nail polish and it was not allowed. During a review of the facility's P&P titled Sanitation and Infection Control, reviewed 7/16/2024, the P&P indicated (3) Fingernails should be clean, clipped and free of nail polish. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, (A) Food employees shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable and not rough. (B) Unless wearing intact gloves in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. 9. During a concurrent observation and interview on 5/7/2025 at 3:51 p.m. of the resident's freezer in Station 1 with Licensed Vocational Nurse 4 (LVN 4), the resident's freezer had no thermometer to monitor the temperature. LVN 4 stated the freezer was not monitored and the temperature log also did not indicate that they were monitoring the freezer temperatures. LVN 4 stated it was important to monitor the freezer to prevent food spoilage and expiration. During an interview on 5/7/2025 at 4:03 p.m. with the Registered Nurse Supervisor (RNS), the RNS stated it was important to monitor the freezer temperature as they did not want the food items to get bad. The RNS stated residents could potentially get sick of food poisoning when consuming food that was not in acceptable temperatures. During a review of the facility's P&P titled Refrigerator/Freezer Storage, reviewed on 7/16/2024, the P&P indicated Dietary staff will check the inside temperature of refrigerators and freezers to ensure the equipment is within appropriate temperature for food storage and handling. (1) Dietary staff will check and record temperatures of all refrigerators and freezers to ensure the equipment is within appropriate temperature for food storage and handling. (2) Dietary staff will record the initial temperature log at the beginning of the shift. (3) If the temperatures are not within appropriate range, dietary staff will notify the dietary supervisor and or Maintenance Supervisor and Administrator. Freezer temperature: 0-degree Fahrenheit (°F, a scale of temperature) or lower. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a Temperature Measuring Device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit. (B) Except as specified in (C) of this section, cold or hot holding equipment used for time/temperature control for safety food shall be designed to include and shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display.

CONCERN (E)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when there were soiled gloves, empty plastic bottles, plastic and other trash on the floor and surrounding areas of the dumpster bin (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts). This failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 138 of 199 facility residents. Findings: During a concurrent observation and interview on 5/7/2025 at 3:10 p.m. of the dumpster with the Dietary Supervisor (DS), observed soiled gloves, empty bottles, plastic and other trash on the ground. The DS stated it was not okay to have trash around the dumpster surroundings because it could attract pests, and could spread sickness to the residents. The DS stated he did not know who maintains the trash area. During an interview on 5/7/2025 at 4:11 p.m. with the Maintenance Director (MD), the MD stated he maintains the dumpster and trash area and it needed to be cleaned to prevent flies, rats and animals around. The MD stated it was not okay that there was trash around the dumpster surroundings. The MD stated this could spread diseases to residents as a potential outcome. During a review of the facility's policies and procedures (P&P) titled Waste Control and Disposal dated 7/16/2024, the P&P indicated All waste will be disposed of daily and as needed throughout the day. (6) Outside garbage bin should be kept closed at all times and surrounding area must be kept clean, During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) records for one of seven sampled residents (Resident 690) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) indicated the provision of passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both legs from 4/22/2025 to 5/5/2025 in accordance with the physician's order, dated 4/22/2025. This failure resulted in the inaccurate provision of care recorded in Resident 690's medical records. Findings: During a review of Resident 690's admission Record, the admission Record indicated the facility admitted Resident 690 on 4/18/2025 with diagnoses including neoplasm (abnormal tissue growth) of meninges (three protective layers of connective tissue that surround the brain and spinal cord), nontraumatic intracerebral hemorrhage (bleeding in brain tissue), lack of coordination, muscle weakness, foot drop (condition where the individual experiences difficulty or inability to lift their foot or toes) of both feet, and reduced mobility. During a review of Resident 690's physician's order, dated 4/22/2025, the physician's order indicated RNA for active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to both arms and PROM to both legs. During a review of Resident 690's Documentation Survey Report (record of nursing tasks) for 4/2025, the Documentation Survey Report indicated the RNA provided AAROM to both arms and the right leg and PROM to the left leg from 4/22/2025 to 4/30/2025. During a review of the Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 4/29/2025, the MDS indicated Resident 690 had clear speech, expressed ideas and wants, clearly understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 690 required setup or clean up assistance for eating, partial/moderate assistance (helper does less than half the effort) for rolling to either side in bed, and dependent for toileting, bathing, dressing, and putting on/taking off footwear. During a review of Resident 690's physician's order, dated 5/6/2025, the physician's order indicated to discontinue PROM to both legs due to the RNA's reports of improvement in the right leg. The physician's order, dated 5/6/2025, indicated for the RNA to provide Resident 690 AAROM to both arms and the right leg and PROM to the left leg. During a review of Resident 690's Documentation Survey Report for 5/2025, the Documentation Survey Report indicated the RNA provided AAROM to both arms and the right leg and PROM to the left leg from 5/1/2025 to 5/7/2025. During an observation on 5/6/2025 at 1:45 p.m. in Resident 690's room, Resident 690's RNA session was observed. Restorative Nursing Assistant 1 (RNA 1) stood on the left side of Resident 690's bed to perform PROM on the left leg at the hip, knee, and ankle joints. RNA 1 walked to the right side of the bed to perform AAROM of the right leg. Resident 690 was observed lifting the right leg at the hip joint (hip flexion), requiring RNA 1's assistance to lift the right leg higher. Resident 690 was observed moving the right hip into abduction (moving the leg at the hip joint away from the body), requiring RNA 1's assistance to move the right legs further away from the body. Resident 690 slid the right leg at the hip joint back toward the body (hip adduction) without physical assistance. Resident 690 slightly bent the right knee, requiring RNA 1's physical assistance to completely bend the knee. Resident 690 also moved the right ankle toward the body (dorsiflexion) and away from the body (plantarflexion), requiring RNA 1's physical assistance to fully move at the ankle joint. During an interview on 5/6/2025 at 2:18 p.m. with RNA 1, RNA 1 stated Resident 690 was seen for PROM of the left leg and AAROM of both arms and the right leg. RNA 1 stated Resident 690 did ROM exercises to both arms without much physical assistance. RNA 1 stated she reported Resident 690's desire for more therapy services to Physical Therapist 1 ([PT 1] professional aimed in the restoration, maintenance, and promotion of optimal physical function). RNA 1 stated PT 1 saw Resident 690 today (5/6/2025) and changed the RNA order from PROM to AAROM on the right leg. During an interview on 5/7/2025 at 3:06 p.m. with PT 1, PT 1 stated RNA 1 reported an improvement in movement to Resident 690's right leg yesterday (5/6/2025). PT 1 stated Resident 690's RNA program was modified from PROM to AAROM exercises to the right leg. During a concurrent interview and record review on 5/8/2025 at 1:02 p.m. with the Director of Medical Records (DMR), Resident 690's physician's orders for RNA, dated 4/22/2025 and 5/6/2025, and the Documentation Survey Report, dated 4/2025 and 5/2025, were reviewed. The DMR stated Resident 690's physician's order, dated 4/22/2025, indicated RNA to provide AAROM on both arms and PROM on both legs, seven days per week, and was discontinued on 5/6/2025. The DMR stated Resident 690's physician's order, dated 5/6/2025, indicated RNA to provide AAROM to both arms and the right leg and PROM to the left leg, seven days per week. The DMR stated the Documentation Survey Report for RNA indicated whether Resident 690 received RNA services. The DMR reviewed Resident 690's Documentation Survey Report, dated 4/2025 and 5/2025, and stated the RNA services provided in the Documentation Survey Reports from 4/22/2025 to 5/5/2025 did not reflect Resident 690's physician's order, dated 4/22/2025. The DMR stated the Documentation Survey Report was inaccurate and indicated the RNA did not provide the treatment in accordance with the physician's orders. During an interview on 5/8/2025 at 3:18 p.m. and 5/8/2025 at 3:35 p.m. with the DMR, the DMR stated the facility did not have a policy and procedure for medical record accuracy.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to: 1. Implement Enhanced Barrier Precautions ([EBP] an infection control intervention in nursing homes designed to reduce transmission of bacteria and other microorganisms that have developed resistance to antibiotics making infections hard to treat) with Resident 130 and 151 in the therapy gym during high contact activities. This deficient practice had the potential to increase the risk of spreading infection to other residents. 2. Clean two of two cloth gait belts (assistive device placed around a person's waist to assist with safe transferring between surfaces or while walking) used with Resident 151 in accordance with the manufacturer's recommendations for disinfecting wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces). This deficient practice had the potential for cross contamination and placed the residents at risk of acquiring an infection. 3. To ensure a resident's oxygen tubing (a flexible tube that delivers supplemental oxygen from an oxygen concentrator or other oxygen supply to a device like a nasal cannula or mask) was not touching the floor for one (Resident 174) out of six sampled residents investigated under the care area of infection control. This deficient practice had the potential to place the resident at increased risk of developing an infection. 4. Maintain infection control practices by failing to ensure a urine bottle (a container for receiving urine) was not hung and stored on a trash can full of trash for one of one sampled resident (Resident 113) during a random observation. This deficient practice had the potential for cross contamination and placed the residents at risk of acquiring an infection. 5. Ensure foam bed rail padding was free from rips and gouges and could be properly cleaned and disinfected for three of five sampled residents (Residents 182, 642, and 643). This deficient practice had the potential for cross contamination and placed the residents at risk of acquiring an infection. 6. Keep the floor of a storage room clean, ensure employees' personal items were not placed on top of boxes containing medical supplies, and ensure boxes of medical supplies were stored off of the floor. These deficient practices had the potential to transmit infectious microorganisms to residents in the facility. Findings: 1. During a review of Resident 130's admission Record, the admission Record indicated the facility originally admitted Resident 130 on 11/16/2023 and re-admitted on [DATE] with diagnoses including hemiparesis (weakness of the arm, leg, and trunk on the same side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, attention to tracheostomy (hole fitted with a device through the front of the neck and into the windpipe [trachea] to allow air into the lungs), and attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 130's care plan titled, Enhanced Barrier Precaution, initiated 6/6/2024, the care plan interventions included to provide EBP with gloves, gowns, and masks. During an observation on 5/6/2025 at 10:09 a.m. in the therapy gym, Resident 130 was seated in a wheelchair with a portable oxygen tank attached to the back of the wheelchair seat. Resident 130 had oxygen flowing into the tracheostomy tube. During an observation on 5/7/2025 at 11:25 a.m. in the therapy gym, Resident 130 walked using a height-adjustable four-wheeled walker (an assistive device with four wheels used for stability when walking) with a padded platform underneath the forearms. The Director of Rehabilitation (DOR) and Certified Occupational Therapy Assistant 1 (COTA 1) were on each side of Resident 130 while walking. The DOR and COTA 1 were not wearing any gowns. During an observation on 5/8/2025 at 9:23 a.m. outside of Resident 130's room, there was a sticker labeled E next to Resident 130's name. During an interview on 5/8/2025 at 9:24 a.m. with Registered Nurse 5 (RN 5) outside of Resident 130's room, RN 5 stated the sticker labeled E next to the resident's name indicated the resident was on Enhanced Barrier Precautions (EBP) because the resident has a tracheostomy tube and prone to infection. RN 5 stated anyone coming into high contact with the residents on EBP needed to wear a gown and gloves to protect the residents from infection and to prevent the spread of infection to the healthcare workers. During an interview on 5/8/2025 at 10:05 a.m. with COTA 1, COTA 1 stated Resident 130's treatment session in the therapy gym yesterday (5/7/2025) included range of motion ([ROM] full movement potential of a joint) exercises. COTA 1 stated Resident 130 required physical assistance of two-persons to perform sit-to-stand transfers during the treatment and walked with assistance while using the height-adjustable four-wheeled walker. 2. During a review of Resident 151's admission Record, the admission Record indicated the facility admitted Resident 151 on 3/21/2024 with diagnoses including cerebral infarction due to occlusion (blockage) or stenosis (narrowing) of the right anterior cerebral artery (blood vessels delivering oxygen rich blood to the front and middle parts of the brain), attention to tracheostomy, attention to gastrostomy, and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of the right elbow, right hand, and both ankles. During a review of Resident 151's care plan titled, Enhanced Barrier Precaution, initiated 4/9/2025, the care plan interventions included to provide EBP with gloves, gowns, and masks. During a concurrent observation and interview on 5/6/2025 at 1:05 p.m. in Resident 151's room, Resident 151 was awake and lying in bed with a bandage over the resident's throat in the front of the neck. During an interview on 5/6/2025 at 3:18 p.m. in the bedroom, Resident 151 stated the tracheostomy tube was removed three weeks ago. During an observation on 5/7/2025 at 10:33 a.m. in the therapy gym, Resident 151's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) session was observed. Resident 151's bandage over the throat did not fully cover the hole in the front of Resident 151's neck. Resident 151 was sitting up in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported). Physical Therapist 1 (PT 1) placed a cloth gait belt around Resident 151's waist and placed a height-adjustable four-wheeled walker in front of Resident 151. PT 1 stood directly next to Resident 151 on the left side while the DOR stood directly on the right side to physically assist Resident 151 with transferring from sitting to standing with the four-wheeled walker. Resident 151 attempted to walk with PT 1 and the DOR while both forearms were supported on a padded platform attached to the four-wheeled walker. PT 1 and the DOR were not wearing any gowns. Resident 151 sat up in a wheelchair at the end of the session. During an observation on 5/7/2025 at 11:13 a.m., PT 1 and Rehabilitation Aide 1 (RA 1) wheeled Resident 151 back to the bedroom. PT 1 and RA 1 put on gowns and gloves prior to entering Resident 151's bedroom. PT 1 placed the cloth gait belt around Resident 151's waist. PT 1 and RA 1 physically assisted Resident 151 to transfer from the wheelchair to the edge of the bed. PT 1 removed the cloth gait belt from around Resident 151's waist and assisted the resident back into the bed. During an observation on 5/8/2025 at 9:28 a.m. outside of Resident 151's room, there was a sticker labeled E next to Resident 151's name. During an interview on 5/8/2025 at 9:29 a.m. with Registered Nurse 1 (RN 1) outside of Resident 151's room, RN 6 stated the sticker labeled E next to the resident's name indicated the resident was on Enhanced Barrier Precautions and stated a gown and gloves needed to be worn while handling Resident 151. RN 1 stated Resident 151 was on EBP because there was an open hole in the throat from Resident 151's recent removal of the tracheostomy tube. During an interview on 5/8/2025 at 9:43 a.m. with PT 1, PT 1 stated Resident 151 was on EBP only inside the resident's room. PT 1 stated EBP were extra precautions for residents with G-tubes and oxygen to prevent infection. PT 1 stated it would be better to wear a gown while providing therapy to Resident 151 in the therapy gym. During a concurrent interview and record review on 5/8/2025 at 9:48 a.m. with the Infection Prevention Nurse (IPN), the facility's P&P titled, Enhanced Barrier Precautions, dated 6/5/2024, was reviewed. The IPN stated residents with EBP were at high-risk of infection and included residents with tracheostomy tubes, G-tubes, and open wounds. The IPN stated personal protective equipment ([PPE] clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) including gowns and gloves were worn during high contact care, including transfers. The IPN stated therapists working with residents while transferring was a high contact activity and should be wearing gowns and gloves. During a review of the Center for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html), dated 6/28/2024, the CDC FAQs indicated EBP should be followed outside resident's rooms when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility. 2. During a review of Resident 151's admission Record, the admission Record indicated the facility admitted Resident 151 on 3/21/2024 with diagnoses including cerebral infarction due to occlusion (blockage) or stenosis (narrowing) of the right anterior cerebral artery (blood vessels delivering oxygen rich blood to the front and middle parts of the brain), attention to tracheostomy (hole fitted with a device through the front of the neck and into the windpipe [trachea] to allow air into the lungs), attention to gastrostomy ([G-tube] surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and contractures (a stiffening/shortening at any joint that reduces the joint's range of motion) of the right elbow, right hand, and both ankles. During an observation on 5/6/2025 at 1:12 p.m., RNA 1 wore a cloth gait belt around the waist with RNA 1's name written in black lettering. During an observation on 5/6/2025 at 2:38 p.m. in Resident 151's room, RNA 1 and RNA 2 physically assisted Resident 151 to transfer from lying in the bed to sitting at the edge of the bed. RNA 1 removed the cloth gait belt from around RNA 1's waist and fastened it around Resident 151's waist. RNA 1 stood directly next to Resident 151's right side while RNA 2 stood on the left side to physically assist Resident 151 from sitting at the edge of the bed to standing using a height-adjustable four-wheeled walker (an assistive device with four wheels used for stability when walking). RNA 2 removed the cloth gait belt from around Resident 151's waist after finishing with sit-to-stand exercises. RNA 1 and RNA 2 assisted Resident 151 back to lying in bed. RNA 2 placed the cloth gait belt on top of Resident 151's dresser drawers. During a concurrent observation and interview on 5/6/2025 at 3:11 p.m., RNA 1 removed the cloth gait from the top of Resident 151's dresser drawers. RNA 1 stated disinfecting wipes were used to clean the cloth gait belt and four-wheeled walker. RNA 1 was observed cleaning the cloth gait belt with disinfecting wipes. During an observation on 5/7/2025 at 10:33 a.m. in the therapy gym, Resident 151's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) session was observed. Resident 151 was sitting up in a Geri chair (reclining chair that allows someone to get out of bed and sit comfortably in different positions while fully supported). Physical Therapist 1 (PT 1) placed a cloth gait belt with PT 1's name in black lettering around Resident 151's waist. PT 1 also placed a height-adjustable four-wheeled walker in front of Resident 151. PT 1 stood directly on Resident 151's left side while the Director of Rehabilitation (DOR) stood on the right side to assist Resident 151 with transferring from sitting to standing with the four-wheeled walker. Resident 151 attempted to walk with PT 1 and the DOR while both forearms were supported on a padded platform attached to the four-wheeled walker. Resident 151 sat up in a wheelchair at the end of the session. PT 1 removed the cloth gait belt from around Resident 151's waist, rolled it up, and placed it in PT 1's left coat pocket. During an observation on 5/7/2025 at 11:13 a.m., PT 1 and Rehabilitation Aide 1 (RA 1) wheeled Resident 151 back to the bedroom. PT 1 placed the cloth gait belt around Resident 151's waist. PT 1 and RA 1 physically assisted Resident 151 to transfer from the wheelchair to the edge of the bed. PT 1 removed the cloth gait belt from around Resident 151's waist and assisted the resident back into the bed. During a concurrent observation and interview on 5/7/2025 at 11:18 a.m., PT 1 placed the cloth gait belt inside PT 1's left coat pocket. PT 1 stated disinfecting wipes were used to clean the cloth gait belt. During a review of the undated manufacturer's recommendations of the disinfecting wipes, the manufacturer's recommendations indicated it was a violation of Federal law to use the product inconsistent with its labeling. The manufacturer's recommendations indicated the disinfecting wipes were for use on hard, non-porous surfaces of non-critical medical devices. During a concurrent observation, interview, and review of the disinfectant wipes' manufacturer recommendations on 5/7/2025 at 4:17 p.m. with the Infection Prevention Nurse (IPN), the IPN stated the disinfectant wipes' manufacture recommendations indicated for use on hard, non-porous surfaces. IPN stated cloth was an example of a porous surface. The IPN observed PT 1's gait belt and stated it was made of thick cloth. The IPN stated the disinfecting wipes were not effective in cleaning cloth gait belts. The IPN stated there was a possibility of bacteria and germs spreading without proper cleaning of cloth gait belts. During a review of the facility Policy and Procedure (P&P) titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised 4/2023, the P&P indicated the manufacturer's instructions will be followed for proper use of disinfecting products, including material compatibility (ability of two or more materials to perform effectively together). During a review the facility's Policy and Procedure (P&P) titled, Enhanced Barrier Precautions, dated 6/5/2024, the P&P indicated EBP was utilized to prevent the spread of multi-drug-resistant organisms ([MDROs] bacteria and other microorganisms that have developed resistance to antibiotics making infections hard to treat) to residents. The P&P indicated EBP employed targeted gown and glove use during high contact resident care activities, including during transfers. 3. During a review of Resident 174's admission Record, the admission Record indicated the facility admitted the resident on 1/11/2025 with diagnoses including acute respiratory failure (occurs when the lungs are unable to efficiently transfer oxygen into the blood, or remove carbon dioxide from the blood, leading to a deficiency in oxygen and/or a buildup of carbon dioxide) and encounter for attention to tracheostomy (a surgical procedure that creates an opening in the front of the neck [trachea] and inserts a tube to provide a direct airway for breathing). During a review of Resident 174's Minimum Data Set (MDS - a resident assessment tool), dated 4/25/2025, the MDS indicated the resident had severely impaired cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). On 5/6/2025 at 9:30 a.m., during an observation, observed Resident 174 asleep in bed. The resident's oxygen tubing was touching the floor. On 5/6/2025 at 9:38 a.m., during a concurrent observation and interview with the Subacute Director (SD), the SD verified that Resident 174's oxygen tubing was touching the floor. The SD stated that residents' oxygen tubing should be kept off the floor. On 5/8/2025 at 11:18 a.m., during an interview with the Director of Nursing (DON), the DON stated if a resident's oxygen tubing was touching the floor, then the resident can potentially develop an infection. During a review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 7/16/2024, the policy and procedure indicated that oxygen tubing should be used in a manner that prevents it from touching the floor. 4. During a review of Resident 113's admission Record, the admission Record indicated that the facility initially admitted Resident 113 on 12/7/2023 and readmitted on [DATE] with diagnoses including but not limited to encephalopathy (a group of conditions that cause brain dysfunction), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), history of falling and weakness. During a review of Resident 113's History and Physical (H&P), dated 6/9/2024, the H&P indicated Resident 113 did have the capacity to understand and make decisions. During a review of Resident 113's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/21/2025, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 113 was dependent on staff with oral hygiene and required set-up assistance for other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During concurrent observation and interview on 5/5/2025 at 10:43 am, in Resident 113's room, Resident 113 was lying in bed and had his urinal hanging inside his trash can and the trash can had food and paper trash in it. Resident 113 stated he hangs it there because he does not have another place to hang it. During concurrent observation and interview on 5/5/2025 at 10:45 am, in Resident 113's room with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated Resident 113 should not have his urinal in the trash because the trash is dirty and the resident can get an infection. CNA 5 then asked Resident 113 if he had a urinal holder and that she will get him one if he did not. During an interview on 5/8/2025 at 1:48 pm with the Director of Nursing (DON), the DON stated staff must empty the urinals as soon as they can and hang it in the urinal holders. The DON stated urinals must never be stored on or in the trash can because it is an infection control issue and the urinal can transmit diseases from the trash to the resident. During a review of the Policy and Procedure (P&P) named Policy: Infection Control, last reviewed on 7/16/2024, the P&P indicated the facility will maintain an infection control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of disease and infection. During a review of the P&P named Bedpan/Urinal, Offering/Removing, last reviewed on 7/16/2024, the P&P stated to store the urinal clean, dry and per facility policy. 5. During a review of Resident 182's admission Record, the admission Record indicated the facility originally admitted the resident on 3/29/2025 and readmitted the resident on 4/29/2025 with diagnoses including but not limited to cerebral infarction (an obstruction of blood flow in the brain that leads to tissue damage) and acute respiratory failure (a condition where the lungs cannot release enough oxygen into the blood). During a review of Resident 182's Minimum Data Set (MDS - a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 182 had severely impaired cognitive skills (problems with the ability to think, learn, and remember clearly) for daily decision making and required total assistance from staff with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 182's Physicians Orders, the Physicians Orders indicated an order for padded siderails to decrease potential injury dated 4/30/2025. During a review of Resident 642's admission Record, the admission Record indicated the facility admitted the resident on 5/1/2025 with diagnoses including but not limited to acute respiratory failure and intracerebral hemorrhage (bleeding inside the brain tissue). During a review of Resident 642's History and Physical, dated 5/3/2025, the History and Physical indicated Resident 642 was not alert or oriented (a person's awareness of their surroundings, including who they are, where they are, and what time it is) and was unable to move any extremities. During a review of Resident 642's Physicians Orders, the Physicians Orders indicated an order for padded siderails to decrease potential injury dated 5/5/2025. During a review of Resident 643's admission Record, the admission Record indicated the facility admitted the resident on 4/10/2025 diagnoses including but not limited to cerebral infarction and acute respiratory failure. During a review of Resident 643's MDS, dated [DATE], the MDS indicated Resident 643 had severely impaired cognitive skills for daily decision making and required total assistance from staff with ADLs. During a review of Resident 643's Physicians Orders, the Physicians Orders indicated an order for padded siderails to decrease potential injury dated 4/12/2025. During a concurrent observation and interview on 5/7/2025 at 9:24 a.m. with Environmental Services Worker 1 (ESW 1) and the Infection Preventionist (IPN) in room [ROOM NUMBER], ESW 1 wiped down the hard plastic bed rails but not the black foam bed rail padding covering the bed rail. ESW 1 stated she does not wipe them down because of the type of soft surface they are made of they get too wet when using cleaning products. The IPN stated it is possible for the foam padding to harbor bacteria. The IPN stated they replace the foam padding but she was not sure how often they replace it. The IPN was unable to provide a policy and procedure on cleaning or replacing the foam bed rail padding when requested. During a concurrent interview and record review on 5/7/2025 at 10:13 a.m. with the Maintenance Director (MD), the MD stated the foam should be cleaned with the hydrogen peroxide wipes in the green packaging. During a concurrent interview and record review on 5/8/2025 at 2:39 p.m. with the Director of Nursing (DON), photographs of Resident 182, 642, and 643's padded bed rails were reviewed. The DON stated the ripped and gouged bed rail padding was not in good repair and could potentially harbor bacteria. During a review of the manufacturers instructions for Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes, dated 2024, the manufacturers instructions indicated the product cleans, disinfects, and deodorizes hard, nonporous medical surfaces. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, last reviewed 7/16/2024, the P&P indicated residents are to be provided with a safe, clean, comfortable, environment. During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, last reviewed 7/16/2024, the P&P indicated surfaces will be disinfected with a disinfectant registered with the Environmental Protection Agency according to the label's safety precautions and use directions. The P&P further indicates manufacturers instructions will be followed including material compatibility. 6. During a concurrent observation and interview on 5/8/2025 at 8:05 a.m. with Respiratory Therapist 1 (RT 1) in the storage room next to room [ROOM NUMBER], boxes containing medical supplies were on the floor, the floor had visible dirt, and two personal backpacks and one personal sweatshirt were on top of boxes containing medical supplies. RT 1 stated respiratory therapy supplies used for residents were stored in this storage room. RT 1 stated personal belongings were stored in the storage room as there was not a lot of space to store personal items elsewhere. During a concurrent observation and interview on 5/8/2025 at 10:20 a.m. with Environmental Services Worker 2 (ESW 2), ESW 2 cleaned debris off the storage room floor and scrubbed a stain off with a mop. ESW 2 stated he was unsure when the floor of the storage room was last cleaned, and he does not usually clean storage room floors. During an interview on 5/8/2025 at 1:50 p.m. with IPN, IPN stated she would not say it was okay that the boxes were stored directly on the floor, but that they have been stored that way for a long time and there has never been an issue. The IPN stated the floor of the storage room should be clean to maintain the equipment. During an interview on 5/8/2025 at 2:39 p.m. with DON, the DON stated the floor of the storage room should be clean to prevent contamination. The DON stated storing boxes with medical supplies on the floor and keeping employee personal items on top of the boxes could lead to contamination or possibly spread an infection to a resident. During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, last reviewed 7/16/2024, the P&P indicated floors will be cleaned on a regular basis, when spills occur, and when visibly soiled. During a review of the facility's P&P titled, Storage Areas, Maintenance, last reviewed 7/16/2024, the P&P indicated storage areas shall be maintained in a clean and safe manner. During a review of the facility's P&P titled, Receipt and Storage of Supplies and Equipment last reviewed 7/16/2024, the P&P indicated all supplies and equipment must be stored in accordance with the manufacturer's recommendations.

CONCERN (E)

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

Deficiency F0907 (Tag F0907)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the therapy gym had adequate space and equipment to provide therapy services by failing to ensure: 1. One of two therapy mats functioned properly and was accessible for resident care. 2. One of eight hand weights was well-maintained for residents' use. 3. One of one oxygen concentrators (medical device used for delivering oxygen) was serviced. 4. One of one containers of ultrasound (imaging test that uses high-energy sound waves to look at tissues and organs inside the body) gel was not expired. These failures had the potential to place residents receiving therapy services from safe and optimal use of the therapy equipment. Findings: During an observation on [DATE] at 9:43 a.m., in the therapy gym, one combination ultrasound and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) machine was in the therapy gym. During a concurrent observation and interview on [DATE] at 9:48 a.m., with the Director of Rehabilitation (DOR), the DOR provided the ultrasound gel container which indicated an expiration date of [DATE]. The DOR stated the ultrasound gel was used with the ultrasound machine to address chronic pain and soften soft tissue (non-bony tissues in the body including muscles, tendons, ligaments). The DOR stated the ultrasound gel had been expired for one-and-a-half years and would limit the effectiveness of the ultrasound to address a resident's pain and soft tissue concerns. During an observation on [DATE] at 9:52 a.m., observed one therapy mat was located toward the entrance of the therapy gym. During a concurrent observation and interview on [DATE] at 10:00 a.m., with the DOR, observed a second therapy mat (therapy mat #2) was located toward the back of the therapy gym. The therapy mat was unplugged and had therapy equipment scattered over the surface of the therapy mat, including a bean bag toss game, eight hand weights, two arm bicycles, a therapy rainbow arch (plastic tubing in a rainbow shaped used to work on arm range of motion [(ROM)] full movement potential of a joint]). One of the eight hand weights was an eight (8) pound (lbs.- unit of measurement) hand weight with its smooth, protective coating chipped off, exposing the metal. The DOR stated therapy mat #2 was broken and was used as equipment storage for the therapists' convenience. The DOR stated the arm bicycles were broken and were supposed to be thrown out. The DOR stated the 8 lbs. hand weight was used as a paperweight and not for resident care. The DOR stated therapy mats (in general) were used to practice bed mobility (ability to move within the confines of a bed, including activities like rolling, scooting, and transitioning between lying, sitting, and standing positions), perform exercises, and work on balance activities with residents. The DOR stated therapy mat #2 was used as storage and not usable for resident care. During a concurrent observation and interview on [DATE] at 10:09 a.m., with the DOR, observed one oxygen concentrator under a wooden table next to the second therapy mat. The DOR stated the oxygen concentrator did not indicate the date it was last serviced. The DOR stated some residents residing in the facility's subacute area (medical care setting where residents require more complex, round-the-clock care) received therapy in the therapy gym. The DOR stated the oxygen concentrator could ineffectively deliver oxygen since the last service date was unknown. During a review of the facility's undated Policy and Procedure (P&P) titled, Rehabilitation Services, the P&P indicated the therapy gym shall be equipped with necessary equipment, including a treatment table and weights. The P&P also indicated Equipment shall be safe and adequate for resident needs and level of services to be provided.

Mar 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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents at risk for developing pressure ulcers localized damage to the skin and/or underlying tissue usually over a bony prominence) had their skin assessed and documented on a weekly basis per the facility policy and procedure (P&P) for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to delay necessary treatments and services and to increase the residents' risk of skin breakdown. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted Resident 1 to the facility on 7/13/2018 and readmitted the resident on 12/05/2018 with diagnoses including diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/21/2024, the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was severely impaired, and the resident was dependent on staff with oral/personal/toileting hygiene, upper/lower body dressing, bed mobility (movement) and transfer. The MDS further indicated that Resident 1 had a risk of developing pressure ulcers/injuries (PU/I). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician orders: - Treatment, renewal, site; sacrococcyx (the area at the base of the spine near the tailbone) skin integrity maintenance, cleanse with normal saline (NS - a saltwater solution), pat dry, apply skin barrier ointment, leave open to air every day shift for 30 days; Order Date: 2/19/2025, Start Date: 2/19/2025, and Stop Date: 3/21/2025. - Treatment, site; open blister on sacrococcyx; cleanse with NS, pat dry, apply thera-honey (used as a wound dressing), followed by collagen granules (used to promote wound healing process), cover dry dressing every day shift for 30 days; Order Date: 3/2/2025, Start Date: 3/2/2025, and Stop Date: 4/1/2025. During a review of Resident 1's Care Plan Report, initiated on 12/16/2018 and last revised on 1/13/2025, the care plan indicated that Resident 1 was at risk for developing pressure sore and other types of skin breakdown related to fragile skin due to aging process, reduced mobility, and dementia. The care plan indicated an intervention for weekly body checks. During a review of Resident 1's weekly Licensed Nurses Note dated 2/23/2025, the weekly Licensed Nurses Note indicated Skin Management Protocols was not marked for skin clear/intact or skin alteration present. During a review of Resident 1's Change of Condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) Licensed Nurses Note, dated 3/5/2025, the COC Licensed Nurses Note indicated Skin Management Protocols was not marked for skin clear/intact or skin alteration present. During a concurrent interview and record review on 3/12/2025 at 4:45 p.m., with the Director of Nursing (DON), reviewed Resident 1's weekly Licensed Nurses Notes dated 2/23/2025 and Resident 1's COC Licensed Nurses Note dated 3/5/2025. The DON stated that the licensed nurses did not document for the section of skin management protocol and was left blank, so the facility was unable to provide information of Resident 1's skin condition and/or skin progress. The DON stated the skin condition and/or skin progress should be assessed and documented at least weekly by the licensed nurses. 2. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 to the facility on 1/15/2023 and readmitted the resident on 2/18/2023 with diagnoses including right hip broken bone and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident's cognitive skills for daily decision making was severely impaired, and the resident was dependent on staff with toileting hygiene and transfer and needed moderate assistance with upper/lower body dressing and bed mobility. The MDS further indicated that Resident 2 had a risk of developing PU/I. During a review of Resident 2's Care Plan Report, initiated on 11/19/2023 and last revised on 2/22/2025, the care plan indicated that Resident 2 was at risk for developing pressure sore and other types of skin breakdown related to aging process, incontinence of bowel and bladder, reduced mobility, and dementia. The care plan indicated an intervention for weekly body checks. During a review of Resident 2's weekly Licensed Nurses Note dated 2/23/2025 and 3/2/2025, the weekly Licensed Nurses Notes indicated Skin Management Protocols were not marked for skin clear/intact or skin alteration present. During a concurrent interview and record review on 3/12/2025 at 4:35 p.m., with the DON, reviewed Resident 2's weekly Licensed Nurses Notes dated 2/23/2025 and 3/2/2025. The DON stated that the licensed nurses should mark for skin clear/intact if no issues with the resident's skin, but the licensed nurses did not mark for Resident 2's skin conditions. The DON stated if not marked, the facility was unable to prove that Resident 2's skin was assessed weekly. During a review of the facility's P&P titled, Pressure Sore Management, last reviewed on 7/16/2024, the P&P indicated, All available measures shall be taken to reduce skin breakdown and pressure sores Individual care plan for management of skin condition will be developed as indicated. During a review of the facility's P&P titled, Licensed Nurses Notes, last reviewed on 7/16/2024, the P&P indicated, Weekly progress notes are to be written on each resident regardless of the amount of daily entries recorded. These progress notes shall include the following Any pertinent information to reflect an overall profile of the resident. When a licensed nurse is writing a weekly summary, the following records are to be reviewed to ensure that the information entered coordinates with the other discipline's documentation.

Jan 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to review and update a care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a resident`s Change of Condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) for one of two sampled residents (Resident 1 ). This deficient practice had the potential to result in Resident 1 receiving inadequate care and supervision to prevent falls. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 4/9/2014, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), need for assistance with personal care, history of falling, and fracture of left femur (thigh bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/12/2024, the MDS indicated that the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 1 was dependent on staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 1`s Quarterly Fall Risk assessment dated [DATE], the assessment indicated that Resident 1 was alert and oriented, had a history of fall in the last six months, required assistance for toileting, and was unable to stand without assistance. The fall risk assessment indicated that Resident 1 had a total score of 28 and a score of 18 or greater indicated that the resident should be considered at high risk for potential falls. During a review of Resident 1`s Change of Condition (COC) Assessment form dated 12/25/2024, the COC assessment form indicated that the resident had an abnormal lab result for [NAME] Blood Cell count of 14000 per microliter (WBC- type of blood cell that protects your body from infection. Generally, normal ranges are 4500-11000 cells per microliter of blood). The COC assessment indicated that Resident 1 had an episode of restlessness, was biting her hair, and moving a lot in her bed. The COC further indicated that Resident 1 slid down from her bed on the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) landing on her knees. The COC assessment indicated that Resident 1 denied having pain or hitting her head and her physician ordered to transfer the resident to hospital for further evaluation of elevated WBC. During a review of the Resident 1`s admission assessment dated [DATE], the admission assessment indicated that the resident was readmitted back to facility with diagnoses of urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 1`s Fall Risk assessment dated [DATE], the assessment indicated that Resident 1 had intermittent (on and off) confusion or poor safety awareness, had history of fall in the last 12 months, required assistance for toileting, and was unable to stand without assistance. The fall risk assessment indicated that Resident 1 had a total score of 26 and score of 18 or greater indicated that the resident should be considered at high risk for potential falls. During a review of Resident 1's risk for fall care plan initiated on 3/30/2023, and last revised on 5/20/2024, the care plan indicated a goal that the resident will have reduced risk for falls and injury through appropriate interventions. The care plan interventions were to develop a fall risk assessment upon admission, quarterly, annually, and with change of condition, to place resident`s call light and frequently used items within her reach, to provide a safe and clutter free environment and frequent observation of the resident. During a review of Resident 1's falling star program care plan initiated on 6/6/2023, and last revised on 8/12/2023, the care plan indicated a goal that the resident will have reduced risk for falls and injury through appropriate interventions. The care plan interventions were to develop a fall risk assessment upon admission, quarterly, annually, and with change of condition, provide frequent visual monitoring, attach call light to resident`s bed, provide night light, apply side rails, and to respect resident`s wishes for independence and dignity. During a concurrent interview and record review on 1/23/2025 at 12:16 p.m., with Registered Nurse 1 (RN 1), Resident 1`s care plans were reviewed. RN 1 stated Resident 1 had a fall on 12/25/2024. RN 1 stated Resident 1`s risk for fall care plan was last reviewed/revised on 5/20/2024. RN 1 stated Resident 1`s falling star program care plan was last reviewed/revised on 8/20/2024. RN1 stated that Resident 1`s care plan for risk for fall and falling star program were not reviewed/revised after the resident's fall on 12/25/2024. RN 1 stated that he (RN 1) does not know how long after a change of condition like a resident`s fall, a care plan should be revised or updated. During a concurrent interview and record review on 1/23/2025 at 12:45 p.m., with the Director of Nursing (DON), Resident 1`s care plans and COC forms were reviewed. The DON stated Resident 1 had a COC for elevated WBC and fall on 12/25/2024, and she was transferred to hospital on [DATE]. The DON stated Resident 1`s risk for fall care plan was initiated on 3/30/2024 and last reviewed/revised on 5/20/2024. The DON stated Resident 1`s falling star program care plan was initiated 6/6/2023 and last reviewed/revised on 8/20/2024. The DON stated when a resident has a fall, licensed staff are required to review/revised both short term and long-term care plans. The DON stated Resident 1`s fall risk and falling star program care plans were not reviewed and revised after the resident's fall on 12/25/2024. The DON stated the purpose of reviewing and re-evaluating the care plans is to check the effectiveness of the care plan interventions and make sure all the pertinent information and intervention regarding residents` care are included in the care plan. The DON stated the potential outcome of not reviewing/revising a resident`s care plan after a fall is inadequate care and supervision and recurrent falls for the resident. During a review of the facility`s Policy and Procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the resident`s conditions changed. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident`s condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, at least quarterly, in conjunction with the quarterly MDS assessments. During a review of the facility`s Policy and Procedure (P&P) titled Assessing Falls and Their Causes, revised 3/2018, the P&P indicated that the purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Review the resident` care plan to assess for any special needs of the resident. When a resident falls, the following information should be recorded in the resident`s medical record: completion of a fall risk assessment

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow the facility's policy and procedure titled Assessing Falls and Their Causes, for one of two sampled residents (Resident 1) by failing to complete a fall risk assessment after the resident`s fall on 12/25/2024. This deficient practice placed Resident 1 at increased risk for recurrent falls and injuries. Findings: During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 4/9/2014, and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), need for assistance with personal care, history of falling and fracture of left femur (thigh bone). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/12/2024, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated that Resident 1 was dependent to staff (helper does all of the effort) for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. During a review of Resident 1`s Quarterly Fall Risk assessment dated [DATE], the assessment indicated that Resident 1 was alert and oriented, had history of fall in the last six months, required assistance for toileting, and was unable to stand without assistance. The fall risk assessment indicated that Resident 1 had a total score of 28 and score of 18 or greater indicated that the resident should be considered at high risk for potential falls. During a review of Resident 1`s Change of Condition (COC) Assessment form dated 12/25/2024, the COC assessment form indicated that the resident had an abnormal lab result for [NAME] Blood Cell count of 14000 per microliter (WBC- type of blood cell that protects your body from infection. Generally, normal ranges are 4500-11000 cells per microliter of blood). The COC assessment indicated that Resident 1 had an episode of restlessness, was biting her hair, and moving a lot in her bed. The COC further indicated that Resident 1 slid down from her bed on the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) landing on her knees. The COC assessment indicated that Resident 1 denied having pain or hitting her head and her physician ordered to transfer the resident to hospital for further evaluation of elevated WBC. During a review of the Resident 1`s admission assessment dated [DATE], the admission assessment indicated that the resident was readmitted back to facility with diagnoses of urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 1`s Fall Risk assessment dated [DATE], the assessment indicated that Resident 1 had intermittent (on and off) confusion or poor safety awareness, had history of fall in the last 12 months, required assistance for toileting, and was unable to stand without assistance. The fall risk assessment indicated that Resident 1 had a total score of 26 and score of 18 or greater indicated that the resident should be considered at high risk for potential falls. During a concurrent interview and record review on 1/23/2025 at 12:00 p.m., with the facility`s Assistant Director of Nursing (ADON), Resident 1`s fall risk assessments were reviewed. The ADON stated Resident 1`s fall risk assessment dated [DATE] is for the resident`s readmission to the facility. The ADON stated Resident 1 was discharged to hospital on [DATE] and returned on 12/29/2024. The ADON stated a fall risk assessment is completed after each admission and readmission. During a concurrent interview and record review on 1/23/2025 at 2:04 p.m., with the Director of Nursing (DON), Resident 1`s fall risk assessments were reviewed. The DON stated licensed staff are required to complete a fall risk assessment after resident`s admission, readmission and after resident`s fall. The DON stated Resident 1 had a fall on 12/25/2025, however, licensed staff did not complete a fall risk assessment after Resident 1`s fall on 12/25/2024. The DON stated the potential outcome of not conducting a fall risk assessment after the resident's fall is insufficient care and placing the resident at risk for recurring falls. During a review of the facility`s Policy and Procedure (P&P) titled Assessing Falls and Their Causes, revised 3/2018, the P&P indicated that the purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Review the resident` care plan to assess for any special needs of the resident. When a resident falls, the following information should be recorded in the resident`s medical record: completion of a fall risk assessment.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was treated with dignity by not communicating with Resident 1 his (Resident 1's) preferred time to receive activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. This deficient practiced had the potential to decrease the resident's sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Findings: During a review of Resident 1's admission Record dated 10/25/2024, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included sepsis (a serious condition in which the body responds improperly to an infection), heart failure (a heart condition in which the heart is unable to pump blood efficiently), pneumonia (an infection of one or both of the lungs caused by bacteria or viruses), anemia (a condition where the body does not have enough healthy red blood cells [a type of blood cell responsible for transporting fresh oxygen all over the body), and need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/6/2024, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the sense) was moderately impaired. Resident 1 required supervision with eating, and was dependent on staff with oral hygiene, toileting, shower/bathing, and dressing. During an interview with Resident 1's responsible party (RP) 1 on 12/20/2024 at 11:10 a.m., RP 1 stated that on 12/7/2024 around 7:00 p.m. RP 1 was informed by Resident 1 that he (Resident 1) had not had a shower that day nor was offered a shower, and it was his (Resident 1) scheduled shower day. RP 1 stated that she met with Registered Nurse (RN) 1, and informed RN 1 that Resident 1 had not had a shower or been offered a shower on 12/7/2024. During an interview with the Director of Staff Development (DSD) on 12/20/2024 at 2:50 p.m., the DSD stated that when Certified Nursing Attendants (CNA) begin their shift, they (CNAs) are instructed to go and introduce themselves to the residents that they are assigned to and discuss with the residents regarding ADL care, including preferred shower times. The DSD stated that she (DSD) was informed that on 12/7/2024 CNA 1 was assigned to Resident 1 and CNA 1 did not discuss with Resident 1 at the beginning of the shift when Resident 1 would like to have a shower. During an interview with RN 1 on 12/20/2024 at 3:10 p.m., RN 1 stated that he was the registered nurse for Resident 1 on 12/7/2024 and RP 1 did inform him that Resident 1 had not had a shower that day or been offered a shower that day. RN 1 stated that he spoke to Resident 1's CNA (referring to CNA 1), and CNA 1 stated that she (CNA 1) was very busy that day and had not had time to provide a shower or discuss Resident 1's shower time with Resident 1. RN 1 stated that he informed CNA 1 that it was important to inform him if CNA 1 was not able to complete her job duties so he could assist. During an interview with the Director of Nursing (DON) on 12/20/2024 at 4:00 p.m., the DON stated that CNA 1 should have spoken with Resident 1 at the beginning of the shift to discuss Resident 1's preferred shower times. A review of the facility policy and procedure titled Dignity with a revision date of 12/20/2024 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem .Residents are treated with dignity and respect at all times .When assisting with care, residents are supported in exercising their rights. For example, residents are groomed as they wish to be groom, encouraged to attend activities of their choice .allowed to choose when to sleep, eat and conduct activities of daily living.

Nov 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit one of four sampled residents (Resident 1) to return to the facility after hospitalization. This deficient practice subjected Resident 1 to an unnecessary prolonged hospitalization. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 5/29/2024 with diagnoses that included intracranial (within the skull) injury with loss of consciousness (when a person is neither awake nor aware of the external environment) of unspecified duration, traumatic subdural (space between the skull and the brain) hemorrhage (excessive bleeding) with loss of consciousness of 30 minutes or less, and acute (sudden) respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool), dated 6/5/2024, the MDS indicated that Resident 1 was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) impaired and was dependent from staff for transfer, dressing, toilet use, personal hygiene, and bathing. During a review of Resident 1's Change of Condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains)/Interact Assessment Form dated 9/10/2024, the COC indicated an order to transfer Resident 1 to General Acute Care Hospital 1 (GACH 1) due to abnormal Computed Tomography (CT- imaging test that produces images of the inside of the body) scan results. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order to transfer to GACH 1 for further evaluation and treatment secondary to abnormal CT scan results, dated 9/10/2024. During a review of the facility's census (daily list indicating resident names with corresponding room numbers) dated 11/16/2024 (census for 11/17/2024), 11/17/2024 (census for 11/18/2024), and 11/18/2024 (census for 11/19/2024), the facility's census indicated that there was one available male bed (room [ROOM NUMBER]B) in the facility. During a review of Resident 1's GACH 1 physician's progress note dated 11/17/2024, the progress note indicated that Resident 1's repeat CT of the head on 10/27/2024 has improved and stable overall. The progress note indicated Resident 1 is now stable for discharge. During a review of Resident 1's GACH 1 Discharge Orders dated 11/19/2024, the Discharge Orders indicated a list of discharge medications to be continued upon Resident 1's return to the facility. During an interview on 11/14/2024 at 3:15 p.m., with the Administrator (ADM), the ADM stated Resident 1 was admitted to the facility on [DATE] to the facility's subacute unit (medical care setting where residents require more complex, round-the-clock care). The ADM stated Resident 1's health had improved and was transferred from the facility's subacute unit to the facility's skilled nursing unit (setting where residents need medical care or treatment that only a licensed nurse or other healthcare professional can provide) until Resident 1 was transferred to GACH 1 on 9/10/2024. The ADM stated Resident 1 had been discharged from the facility for more than 60 days from the facility's skilled nursing unit and now returning to the facility's subacute unit is considered a new resident in the facility's subacute unit. The ADM stated he (ADM) understands that a resident whose hospitalization or therapeutic leave exceeds the bed hold period will return to the facility to the resident's previous room if available or immediately upon the first available bed. The ADM stated since it has been more than 30 days since Resident 1 was transferred to the hospital and Resident 1 is returning to the facility's subacute unit and not the facility's skilled nursing unit, it is the facility's discretion to prioritize the facility's long-term subacute residents who have been discharged no more than 30 days to be fair. During an interview on 11/15/2024 at 3:45 p.m., with the ADM, the ADM stated it is only fair to prioritize to readmit the facility's long-term subacute residents since Resident 1 was discharged from the facility's skilled nursing unit and will be a new admit to the facility's subacute unit. During an interview on 11/19/2024 at 9:40 a.m., with General Acute Care Hospital Case Manager 1 (GACH CM 1), GACH CM 1 stated Resident 1 had a discharge order for 11/17/2024 and the GACH physician consultants cleared Resident 1 to be transferred back to the facility's subacute unit. GACH CM1 stated a bed request referral was sent to the facility on [DATE] and was declined because there was no bed available. During an interview on 11/19/2024 at 10:10 a.m., with GACH CM 2, GACH CM 2 stated Resident 1 had a discharge order dated 11/17/2024. GACH CM 2 stated the facility's admission Director (AD), and the Director of Nursing (DON) stated the facility does not have an available subacute bed. During a concurrent interview and record review on 11/19/2024 at 3:35 p.m., with the AD, reviewed the facility's bed request inquiries titled, Care Services Requests, the facility's census dated 11/16/2024 (census for 11/17/2024), 11/17/2024 (census for 11/18/2024), and 11/18/2024 (census for 11/19/2024), and the facility's policy and procedure titled, readmission to the Facility, last reviewed on 7/16/2024. The AD confirmed by stating that an inquiry for Resident 1's bed request was sent on 11/18/2024 at 8:55 a.m. by GACH CM 1 and on 11/19/2024 at 1:00 p.m. by GACH CM 3. The AD confirmed by stating that the facility's census dated 11/16/2024, 11/17/2024, and 11/18/2024 indicated there was an available male bed (room [ROOM NUMBER]B) in the facility on 11/18/2024 and 11/19/2024. The AD stated the facility should have readmitted Resident 1 based on the facility's readmission to the Facility policy which indicated that residents who have been discharged to the hospital will be given priority in readmission to the facility upon the first availability of a bed. During a concurrent interview and record review on 11/19/2024 at 3:35 p.m., with the DON, reviewed the facility's bed request inquiries titled, Care Services Requests, the facility's census dated 11/16/2024 (census for 11/17/2024), 11/17/2024 (census for 11/18/2024), and 11/18/2024 (census for 11/19/2024), and the facility's policy and procedure titled, readmission to the Facility, last reviewed on 7/16/2024. The DON confirmed by stating that an inquiry for Resident 1's bed request was sent on 11/18/2024 at 8:55 a.m. by GACH CM 1 and on 11/19/2024 at 1:00 p.m. by GACH CM 3. The DON confirmed by stating that the facility's census dated 11/16/2024, 11/17/2024, and 11/18/2024 indicated there was an available male bed (room [ROOM NUMBER]B) in the facility on 11/18/2024 and 11/19/2024. The DON stated the facility should have readmitted Resident 1 based on the facility's readmission to the Facility policy which indicated that residents who have been discharged to the hospital will be given priority in readmission to the facility upon the first availability of a bed. During a review of the facility's policy and procedure titled, readmission to the Facility, last reviewed on 7/16/2024, indicated residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. A Medicaid resident (someone who receives health care coverage through the Medicaid program which is a public health care insurance program for people with limited incomes and resources) whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room.

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure that facility staff (Certified Nurse Assistant 2 [CNA2]) documented blisters (small bubble-like raised bumps [raised area of the skin] on the skin) on the left posterior hand for one of three sampled residents (Resident 2) on the resident's Daily Body Check Report form. This deficient practice had the potential for Resident 2 to not to receive the care and services needed to treat Resident 2's worsening bump on the left posterior hand. Findings: During a review of Resident 2's admission Record, the document indicated the facility readmitted the resident on 9/5/2024 with diagnosis of hemiplegia (paralysis of one side of the body), head injury, and brain damage. During a review of Resident 2's History and Physical dated 3/15/2024, the document indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a care screening tool) dated 9/20/2024, the document indicated Resident 2 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) on staff for activities of daily living (ADL- tasks residents perform every day to care for themselves and maintain their independence). During record review of the facility's Daily Body Check Report dated 9/17/2024, the log indicated CNA2 marked OK, skin good for R2 on 9/17/2024 after providing Resident 2 with a shower. During a concurrent observation and interview on 9/18/2024 at 11:14 a.m., with Registered Nurse (RN) in Resident 2's room, observed Resident 2 in bed. RN examined Resident 2's hand and stated there were multiple fluid filled bumps that looked like blisters on Resident 2's left posterior hand. RN stated he (RN) was not sure how long R2 has had these blister. During an interview on 9/18/2024 at 11:59 a.m., with CNA 2, CNA2 stated that the bump on R2 posterior left hand has gotten progressively worse over the last month. When CNA2 was asked when the last time CNA 2 gave R2 a shower, CNA2 stated that CNA 2 last gave R2 a shower on 9/17/2024. When asked if the CNA2 documented R2's progressively worsening bump on the left posterior hand on R2's Daily Body Check Report dated 9/17/24, CNA2 stated no. During an interview on 9/18/2024 at 1:24 PM with the Assistant Director of Nursing (ADON), the ADON stated that when a facility Certified Nurse Assistants (CNA) notes any skin integrity issues on a resident during ADL care, the CNA is to report the findings on the resident's Daily Body Check Report. During a review of the facility's policy and procedure titled, Change of Condition, dated 9/18/2024, the policy indicated a change of condition is a sudden or marked difference in resident's complaints, open or red areas (new), bruises, blisters, rashes, or skin tears, and new or marked skin conditions. All changes of condition in a resident shall be handled promptly. Documentation of change in condition shall be performed by the licensed nurse for at least 72 hours, reassess resident condition as needed . During a review of the facility's policy and procedure titled, Quality of Care, dated 9/18/2024, the policy indicated the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, to promote healing and prevent infection.

Aug 2024 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident`s fingernails of two of five sampled residents (Resident 2 and 3) were not dirty as evidence by black substances under the tip of the nails. This deficient practice resulted in Resident 2 and 3 having dirty fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth. Findings: 1. During a review of Resident 2 ' s admission Record, the admission Record indicated that the facility admitted Resident 2 on 5/20/2024 and readmitted Resident 2 on 7/29/2024 with diagnoses that included dementia (a decline in mental function that affects a person's ability to think, remember, and reason), tracheostomy(a surgical procedure to create an opening through the neck into the trachea [windpipe]), and gastrostomy tube (g-tube: a tube inserted through the belly that brings nutrition directly to the stomach). During a review of Resident 2 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/5/2024, the MDS indicated Resident 2 ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS further indicated that Resident 2 was dependent on staff with oral hygiene (keeping a resident clean), toileting hygiene, shower/bathing, upper/lower body dressing, and bed mobility (movement). During a review of Resident 2 ' s untitled care plan initiated on 6/4/2024 and revised on 7/18/2024, the care plan indicated that Resident 2 had self-care deficits (when someone is unable to perform daily tasks that are related to their health and well-being) related to Resident 2 ' s medical conditions that included cognitive deficits impairments in mental processes that affect a person's ability to acquire knowledge, understand the world, and act in it and joint (the place where two or more bones meet and connect) limitation (when a joint can't move as freely as it normally would). The care plan indicated a goal for Resident 2 to be clean, dry, and well-groomed daily, and one of interventions was indicated to assist Resident 2 with grooming and trimming of fingernails. During a concurrent observation and interview with the Subacute (providing intensive services for medically fragile and technically dependent residents) Director (SD) on 8/19/2024 at 2:56 p.m., the SD observed Resident 2 ' s fingernails inside Resident 2 ' s room. The SD stated that Resident 2 ' s fingernails had yellowish to blackish substances under the tip of the nail. SD further stated that Resident 2 ' s middle fingernail on the left hand was long and curved. SD stated that the facility will cut, trim, and clean Resident 2 ' s fingernails. 2. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 originally on 11/9/2022 and readmitted Resident 3 on 7/16/2024 with diagnoses that included cerebral (relating to the brain) infarction (death of tissue resulting from a failure of blood supply), right hand contracture (a permanent tightening of the muscles, skin, and nearby tissues that caused the joints to shorten and become very stiff), left hand contracture, tracheostomy, and gastrostomy tube. During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 ' s cognition was severely impaired. The MDS further indicated that Resident 3 was dependent on staff with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, personal hygiene, and rolling left and right on the bed. During a review of Resident 3 ' s untitled care plan initiated on 12/15/2022 and revised on 2/29/2024, the care plan indicated, Resident 3 had self-care deficits related to Resident 3 ' s medical conditions that included joint limitation and muscular weakness. The care plan indicated a goal for Resident 3 to be clean, dry, and well-groomed daily. One of interventions was indicated to assist Resident 3 with grooming and trimming of fingernails. During a concurrent observation and interview with the SD on 8/19/2024 at 3 p.m., the SD observed Resident 3 ' s fingernails inside Resident 3 ' s room. The SD stated that Resident 3 ' s fingernails on both hands were long and dirty with a black color substance under the tip of fingernails. SD stated that Resident 3 ' s fingernails needed to be cleaned and trimmed. During a review of the facility ' s policy and procedure titled Activities of Daily Living (ADL), Supporting, revised 03/2018 and last reviewed 7/16/2024, the policy indicated that Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good . grooming and personal and oral hygiene 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: a. hygiene (bathing, dressing, grooming, and oral care).

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure two of 11 sampled staff (Certified Occupational Therapy Assistant 1 [COTA 1] and Physical Therapy Assistant 1 (PTA 1) wore isolation gowns (protective apparel, used to protect the wearer from the spread of infection or illness if the wearer comes in contact with potentially infectious liquid and solid material) while providing therapy services to Resident 4, in Resident 4 ' s room which was placed on enhanced standard precautions (ESP - a set of infection control measures that involve wearing gowns and gloves during high-contact resident care activities for residents at increased risk of Multidrug- Resistant Organisms [MDROs - bacteria that have become resistant to certain antibiotics [a medicine that fights bacterial infections] such as residents with wounds or indwelling medical devices [a medical device that is left inside the body for variety of reasons including to administer food or medications]). These deficient practices had the potential to result in the spread of infection placing residents, staff, and visitors at risk for infection. Findings: During a review of Resident 4 ' s admission Record, indicated the facility admitted Resident 4 on 3/21/2024 with diagnoses with that included cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked, causing brain tissue to die), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe]), and gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach, allowing for a tube to be inserted for food and medication administration). During a review of Resident 4 ' s Minimum Data Set (MDS - a standardized resident assessment and care screening tool) dated 7/3/2024, indicated Resident 4 was dependent on staff with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, personal hygiene, bed mobility (movement), and transfer. During a record review of Resident 4 ' s History and Physical dated 4/24/2024, indicated that Resident 4 did not have the capacity to understand and make decisions. During a record review of Resident 4 ' s Physician ' s Order Summary Report dated 5/1/2024, indicated that, the physician ordered for ESP to indwell medical devices and any open wounds. During a concurrent observation and interview on 8/19/2024, at 1:45 p.m., observed COTA 1 and PTA 1 providing rehabilitation services (health care services that help residents regain or improve their physical abilities that have been lost or impaired) to Resident 4, in Resident 4 ' s bed. COTA 1 and PTA 1 were observed not wearing isolation gowns. COTA 1 stated that it was her first day at the facility and did not see the ESP signage before entering the room. PTA 1 confirmed the finding and stated that she was aware of the ESP signage and should have worn an isolation gown before entering Resident 4 ' s room and while providing rehabilitation services to Resident 4. PTA 1 stated that Resident 4 had tracheostomy, on tube feeding (a way to provide nutrition when a person cannot eat or drink safely by mouth) and had a wound. During an interview on 8/19/2024 at 1:53 p.m. with the Infection Prevention Nurse (IPN), the IPN stated that on the residents ' name plaque (a flat piece of metal, stone, wood, or plastic with writing on it that is attached to a wall or door), attached to a wall by the resident ' s door prior to entering the resident ' s room, a letter E mark was made to communicate to the facility staff that the resident was under ESP. The IPN further stated that the ESP signage was posted on the wall of each resident ' s head of the bed for awareness. During a review of the facility policy and procedure (P&P) titled Infection Control last reviewed on 7/16/2024, indicated This facility has established and will maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. During a review of the facility provided ESP signage indicated to Wear gloves and a gown for the high-contact resident care activities below. Six (6) moments for ESP 1. Activities of daily living (dressing, grooming, bathing, changing bed linens, feeding). 2. Caring for devices & giving medical treatments .

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 F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 3) was provided with a left-hand splint (a device that supports and protects the hand and wrist, and keeps them positioned correctly) to reduce further contractures (a permanent tightening of the muscles, skin, and nearby tissues that causes the joints to shorten and become very stiff) of Resident 3 ' s left hand. This deficient practice placed Resident 3 at increased risk for worsening and further development of contractures. Findings: During a review of Resident 3 ' s admission Record indicated the facility admitted the resident originally on 11/9/2022 and readmitted on [DATE] with diagnoses that included cerebral infarction (a type of stroke that occurs when blood flow to the brain is blocked, causing brain tissue to die), right hand contracture, left hand contracture, tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe]), and gastrostomy (a surgical procedure that creates an opening in the abdomen and into the stomach, allowing for a tube to be inserted for food and medication administration). During a review of Resident 3 ' s Minimum Data Set (MDS- a standardized assessment and screening tool) dated 6/5/2024, indicated Resident 3 ' s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS further indicated that Resident 3 was dependent on staff with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing and personal hygiene. During a review of Resident 3 ' s Physician ' s Order Summary Report dated 7/17/2024, indicated that Restorative Nursing Assistant (a healthcare professional who helps residents maintain or regain their physical function and quality of life) to apply bilateral (having or involving two sides) elbow splints, right hand splint, and left knee splint for four to six hours or as tolerated daily for seven days with daily skin checks. During a review of Resident 3 ' s untitled care plan initiated on 12/15/2022 and revised on 2/29/2024, indicated Resident 3 had alteration in joint mobility as evidenced by limitations noted in the right hand and left hand. The care plan indicated a goal to minimize the risk for further loss of range of motion daily. The interventions included were for RNA to apply both (left and right) hand splints for four to six hours or as tolerated daily for seven days with daily skin checks and to position Resident 3 to prevent further contractures with pillow or splints as needed. During a concurrent observation and interview with the Subacute Director (SD) on 8/19/2024 at 3:00 p.m., the SD observed Resident 3 ' s both hands and stated that Resident 3 ' s both hands were contracted. During a concurrent interview and record review on 8/20/2024 at 9:45 a.m., with the Director of Rehabilitation (DOR), the DOR reviewed Resident 3 ' s physician ' s order dated 7/17/2024 to apply bilateral elbow splints, right hand splint, and left knee splint for four to six hours or as tolerated daily for seven days with daily skin checks for Resident 3. The DOR stated that Resident 3 should have been provided with a left-hand splint for his left-hand contracture. The DOR further stated that the SD should have completed a reassessment the next day (on 8/20/2024) and should have clarified the physician ' s orders for the use of left-hand splint. The DOR further stated that the purpose of applying splints four to six hours daily as tolerated was to prevent further contractures. During a review of the facility ' s policy and procedure titled, Joint Mobility Contracture Management Program last reviewed on 7/16/2024, indicated, To reduce contractures in upper or lower extremities, and to promote function and skin integrity The therapist shall make recommendations regarding special positioning, range of motion or stretching program, handrolls or splints and any special adaptive positioning equipment Nursing shall assure that if the resident is readmitted after an acute hospital stay, the physician and therapist shall be consulted regarding continuing the splints/positioning devices.

Jul 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of five sampled residents (Resident 1). This deficient practice had the potential to result in a delay with resident care, possible injury to residents when unable to obtain the needed care and services and residents not receiving assistance with activities of daily living (ADL- tasks of everyday life such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses that included cerebrovascular disease (conditions that affect blood flow to the brain), skull (the bony framework of the head) fracture (broken bone), and seizure (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings and levels of consciousness [the state of being aware of and responsive to one's surroundings]). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and that Resident 1's vision (ability to see in adequate light) was highly impaired (object identification is in question, but eyes appear to follow objects). The MDS further indicated that Resident 1 was dependent on staff with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, personal hygiene, bed mobility (movement), and transfer. During a review of Resident 1's untitled care plan initiated on 5/2/2024 and revised on 5/21/2024, indicated, Resident 1 had self-care deficits (an inability to perform certain daily functions related to health and well-being) related to Resident 1's medical conditions, cognitive deficits, visual deficits, and muscular weakness. The care plan indicated a goal for Resident 1 to be clean, dry, and well-groomed daily. The interventions included to assist Resident 1 with ADLs, to ensure Resident 1's call light is within reach and to attend to Resident 1's needs promptly. During an observation and concurrent interview with the Director of Staff Development (DSD) and the Infection Preventionist Nurse (IPN), in Resident 1's room, on 7/29/2024 at 9:20 a.m., observed Resident 1's call light placed on the seat of Resident 1's wheelchair, under Resident 1's clothing tangled with Resident 1's belongings and was out of Resident 1's reach. The IPN confirmed the finding and stated that the Resident 1's call light was not within Resident 1's reach. The IPN stated residents' call light should be always within reach. During a review of the facility's policy and procedure titled Answering the Call Light, last revised on 09/2022, last reviewed 7/16/2024, indicated it is the facility's policy to ensure timely responses to the resident's request and needs. The policy and procedure indicated to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide care and services to maintain good grooming and personal hygiene for one of five sampled residents (Resident 1). This deficient practice resulted in Resident 1 having dirty fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses that included cerebrovascular disease (conditions that affect blood flow to the brain), skull (the bony framework of the head) fracture (broken bone), and seizure (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings and levels of consciousness [the state of being aware of and responsive to one's surroundings]). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and that Resident 1's vision (ability to see in adequate light) was highly impaired (object identification is in question, but eyes appear to follow objects). The MDS further indicated that Resident 1 was dependent on staff with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, personal hygiene, bed mobility (movement), and transfer. During a review of Resident 1's untitled care plan initiated on 5/2/2024 and revised on 5/21/2024, indicated, Resident 1 had self-care deficits (an inability to perform certain daily functions related to health and well-being) related to Resident 1's medical conditions, cognitive deficits, visual deficits, and muscular weakness. The care plan indicated a goal for Resident 1 to be clean, dry and well-groomed daily. The interventions included to assist Resident 1 with Activities of Daily Living (ADL - tasks of everyday life) and to assist Resident 1 with grooming and trimming of fingernails. During an observation and concurrent interview with the Director of Staff Development (DSD) and the Infection Preventionist Nurse (IPN) on 7/29/2024 at 9:16 a.m., observed Resident 1's fingernails in Resident 1's room. The DSD stated that Resident 1's fingernails had black substance and needed to be cleaned and trimmed right away. The DSD further stated that resident's fingernails should always be kept clean. During an interview with the Director of Nursing (DON) on 7/29/2024 at 2:10 p.m., the DON stated that is the responsibility of all nursing staff to ensure resident's fingernails were clean and trimmed at all times. During a review of the facility's policy and procedure titled Activities of Daily Living (ADL), Supporting, last revised 03/2018, last reviewed 7/16/2024, indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene 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: a. hygiene (bathing, dressing, grooming, and oral care).

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 F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure that the Physician Progress Notes (record that documents the physician's role in the assessment, evaluation, and care of residents) were completed as required for one of five sampled residents (Resident 1). This deficient practice had the potential for inconsistent care coordination due to incomplete records and placed Resident 1 at risk for poor continuity of care and care needs. Findings: During a review of Resident 1's admission Record indicated the facility admitted the resident on 4/22/2024 with diagnoses that included cerebrovascular disease (conditions that affect blood flow to the brain), skull (the bony framework of the head) fracture (broken bone), and seizure (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings and levels of consciousness [the state of being aware of and responsive to one's surroundings]). During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 5/2/2024, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired and that Resident 1's vision (ability to see in adequate light) was highly impaired (object identification is in question, but eyes appear to follow objects). The MDS further indicated that Resident 1 was dependent on staff with oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, personal hygiene, bed mobility (movement), and transfer. During a review of Resident 1's Physician Order dated 5/1/2024, timed at 3:23 p.m., indicated an order for an Ear Nose and Throat (ENT - medical conditions or diseases affecting the ear, nose, and throat) appointment on 5/7/2024 at 2:30 p.m. During a review of Resident 1's Physician Progress Notes, there were no Physician Progress Notes found related to Resident 1's ENT appointment visit on 5/7/2024. During a review of Resident 1's Physician's Order dated 7/8/2024, timed at 1:18 p.m. indicated an order for a hearing aid (a small electronic device worn in or behind the ear) appointment for Resident 1 on 7/18/2024 at 1:30 p.m. During a review of Resident 1's Nursing Progress Notes dated 7/18/2024, timed at 3:13 p.m., indicated Resident 1 returned from the hearing aid appointment. During a review of Resident 1's Physician Progress Notes, there were no Physician Progress Notes found related to Resident 1's hearing aid appointment visit on 7/18/2024. During a review of Resident 1's Physician Order dated 7/8/2024, timed at 10:56 a.m., indicated an order for a follow-up ENT appointment on 7/23/2024 at 10:20 a.m. to go over Resident 1's audiology (a branch of science dealing with hearing, balance, and related disorders) exam results. During a review of Resident 1's Nursing Progress Notes dated 7/23/2024, timed at 12:45 p.m., indicated, Resident 1 returned from the ENT appointment. During a review of Resident 1's Physician Progress Notes, there were no Physician Progress Notes found related to Resident 1's hearing aid appointment visit on 7/23/2024. During a concurrent interview and record review with Licensed Vocational Nurse 1 (LVN 1) on 7/29/2024 at 1:00 p.m., LVN 1 reviewed Resident 1's Physician's Orders related to the ENT and audiology appointments from 4/22/2024 to 7/29/2024. LVN 1 stated that there were no Physician Progress Notes found for the following appointment visits: 5/7/2024, 7/18/2024 and 7/23/2024. LVN 1 further stated that the facility received ENT consultation notes from the ENT clinic on the same day (7/29/2024), for the services provided on 5/7/2024, and 7/23/2024. LVN 1 stated that the clinic should sent the Physician's Progress Notes to the facility on the same day of the visit where medical care or services were provided to the resident. During an interview with the Director of Nursing (DON) on 7/29/2024 at 2:15 p.m., the DON reviewed the ENT Physician Progress Notes received for Resident 1 on 7/29/2024, for the ENT services provided on 5/7/2024, and 7/23/2024. The DON stated that the facility should have ensured receipt of the Physician's Progress Notes the same day of the appointment visit when the resident received the services or treatments. During a review of the facility's policy and procedure titled Physician Services, last revised on 2/2021, last reviewed on 7/16/2024, indicated, Physician orders and progress notes are maintained in accordance with current OBRA (stands for Omnibus Budget Reconciliation Act, also known as the Nursing Home Reform Act of 1987, setting federal standards of how care should be provided to residents) regulations and facility policy.

May 2024 12 deficiencies

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the window screen was affixed to the frame and did not have gaps or openings from top to bottom for one of 18 resident's room (Room A) investigated under physical environment. This deficient practice had the potential to result in insect infestation that could pose harm to the residents. Findings: During the initial facility tour and room observation on 5/28/2024 at 11:37 a.m., observed Room A occupied by three residents. Upon closer observation of the room environment, observed one panel of the window screen was not affixed on the window frame creating a gap or opening from top to bottom measuring half an inch. During a concurrent observation and interview on 5/29/2024 at 11:46 a.m., with the Assistant Director of Nursing (ADON), the ADON verified the observation by stating there was a gap on the window screen of Room A. The ADON stated staff frequently conduct room inspections to ensure the environment is safe for the residents. The ADON stated that they make sure rooms are clutter free and free from insect infestations. The ADON stated that if the screens are not tightly sealed to the frame or there are openings, it could pose a potential hazard to the occupants if insects can gain access to the inside of the rooms. The ADON stated that she will have maintenance fix the window screens. A review of the facility's policy and procedure, titled Maintenance Service, last reviewed on 10/17/2023, indicated, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a resident had a comprehensive care plan (a written document that summarizes a patient's needs, goals, and care/treatment) addressing the use of insulin (a hormone that lowers the level of glucose [sugar] in the blood) for one of one sampled resident (Resident 57) investigated for insulin use. This deficient practice had the potential to result in failure to deliver the necessary care and services. Findings: A review of Resident 57's admission Record indicated the facility initially admitted the resident on 10/27/2014 and readmitted the resident on 3/5/2024 with diagnoses that included muscle weakness, type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach). A review of Resident 57's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/14/2024, indicated the resident had the capacity to make self-understood and the capacity to understand others. The MDS indicated the resident is totally dependent on staff for activities of daily living (ADLs- activities related to personal care). A review of Resident 57's physician's orders indicated the following orders: - Insulin aspart (rapid-acting insulin) injection solution 100 unit/milliliter (U/ml- unit of measurement) inject as per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) before meals and at bedtime for hyperglycemia (high blood sugar), ordered 4/2/2024. - Insulin glargine solution 100 U/ml, inject nine (9) units subcutaneously at bedtime, ordered 3/5/2024. During a concurrent interview and record review on 5/29/2024 at 11:01 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 57's physician's orders and care plans dated 3/5/2024 to 5/29/2024. The ADON stated that Resident 57 is currently on insulin therapy for his diabetes mellitus diagnosis and stated Resident 57 did not have a care plan for insulin therapy. The ADON stated that for resident's on insulin therapy, there has to be a care plan identifying the resident's problem and risks, such as hypoglycemia (condition in which the body's blood sugar level goes below the standard range) and hyperglycemia. The ADON stated that a care plan for residents on insulin therapy would indicate the resident`s current condition, the goals and objectives and intervention to attain the stated goals and timeframe of when to evaluate if the care plan is effective or if the resident is progressing and meeting his treatment goals. A review of the facility's policy and procedure titled, The Resident Care Plan, last reviewed on 10/17/2023, indicated, The Resident Care Plan shall be implemented for each resident on admission and developed throughout the assessment process. Healthcare professionals involved in the care of the resident shall contribute to the resident's written care plan .

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure Licensed Vocational Nurse 4 (LVN 4) was competent in taking orthostatic blood pressure (taking a blood pressure [BP] lying down flat, sitting up, and standing up to ensure a resident does not have orthostatic hypotension [a form of low blood pressure that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting]) measurements for one of 37 sampled residents (Resident 158). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) of hypotension (low blood pressure). Findings: A review of Resident 158's admission Record indicated the facility admitted the resident on 5/4/2023 with diagnoses including schizophrenia (a serious mental health condition that can cause people to have abnormal interpretations of reality). A review of Resident 158's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/16/2024, indicated the resident had intact cognition (thought processes) and required setup or clean-up assistance from staff for most activities of daily living (ADLs - activities related to personal care). A review of Resident 158's physician's orders indicated the following: - Seroquel (antipsychotic medication- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) 200 milligrams (mg - unit of measurement) by mouth two times a day for schizophrenia manifested by paranoid feeling causing fear, ordered on 5/4/2023. - Monitor for orthostatic hypotension (a sudden drop in blood pressure that occurs when standing up from a sitting or lying position) (sitting position) every Monday, ordered on 5/5/2023. - Monitor for orthostatic hypotension (lying position) every Monday, ordered on 5/5/2023. A review of Resident 158's care plan (a written document that summarizes a patient's needs, goals, and care/treatment) for the use of Seroquel, initiated on 5/16/2023, indicated a goal to minimize the risk of adverse side effects of medication use daily. Among some of the interventions included to observe for side effects and document occurrence of side effects per policy: .orthostatic hypotension. A review of Resident 158's Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) dated 5/2024 indicated the following: - On 5/6/2024, Resident 158's blood pressure reading was 132/68 millimeters of mercury (mmHg - unit of measurement) in the lying position and 132/68 mmHg in the sitting position. - On 5/13/2024, Resident 158's blood pressure reading was 130/66 mmHg in the lying position and 130/66 mmHg in the sitting position. - On 5/20/2024, Resident 158's blood pressure reading was 132/78 mmHg in the lying position and 132/78 mmHg in the sitting position. - On 5/27/2024, Resident 158's blood pressure reading was 128/77 mmHg in the lying position and 128/77 mmHg in the sitting position. During a concurrent interview and record review on 5/29/2024 at 11:47 a.m., with LVN 4, reviewed Resident 158's MAR dated 5/2024. When asked how LVN 4 takes a resident's orthostatic blood pressure, LVN 4 stated he would take the resident's blood pressure while the resident was sitting down on the bed. When asked if he took the resident's blood pressure while lying down on the bed, LVN 4 stated no, he only took the resident's blood pressure in one position, the sitting position. LVN 4 stated those were his signatures on the MAR for 5/6/2024, 5/13/2024, 5/20/2024, and 5/27/2024 for Resident 158's orthostatic blood pressure readings. During an interview on 5/30/2024 at 2:44 p.m., with the Director of Nursing (DON), the DON stated the correct way to take a resident's orthostatic blood pressure was to first get a reading while the resident was lying down, wait 30 minutes, then take another measurement with the resident in a sitting position. The DON stated the two blood pressure readings should not be exactly the same. The DON stated she would expect her licensed nurses to know how to take an orthostatic blood pressure because she provided in-services (training intended for those actively engaged in a profession) about it when teaching about antipsychotic medications. The DON stated the resident can potentially experience adverse side effects of hypotension such as an increased risk for falls if the nurse does not take the resident's orthostatic blood pressure correctly. A review of the facility's policy and procedure titled, Staffing, Sufficient and Competent Nursing, last reviewed on 10/17/2023, indicated the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) .basic nursing skills.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure the Controlled Drug Record form (CDR- accountability record of medications that are considered to have a strong potential for abuse) reflected what was on the Medication Administration Record (MAR - report that serves as a legal record of the drugs administered to a resident by a health care professional) for one of three sampled residents (Residents 492). These deficient practices resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: A review of Resident 492's admission Record indicated the facility admitted the resident on 5/8/2024 with diagnoses including respiratory failure (condition in which not enough oxygen passes from your lungs into your blood). A review of Resident 492's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 5/21/2024, indicated the resident had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and was completely dependent (helper does all of the effort to complete the task) on a helper to roll left and right. A review of Resident 492's physician's orders, dated 5/8/2024, indicated an order for lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) oral tablet 0.5 milligram (mg, a unit of measurement) to be given via percutaneous endoscopic gastrostomy tube (PEG tube- a long-term feeding tube that is surgically inserted into the stomach through the abdominal wall) every eight (8) hours as needed for anxiety for 14 days for agitation leading to shortness of breath. During a concurrent interview and record review on 5/30/2024 at 11:48 a.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 492's CDR for lorazepam 0.5 mg and MAR dated 5/2024. LVN 1 stated the entries on the CDR for lorazepam 0.5 mg on 5/18/2024 at 1:01 a.m. and 5/19/2024 at 9:32 p.m., were not documented on the MAR. LVN 1 stated as soon as medications are given to residents, they should be documented on the MAR. LVN 1 further stated, the nurses would not know the last time the medication was administered unless the CDR was checked and if they failed to check the CDR and gave the medication, the resident might overdose. During a concurrent interview and record review on 5/30/2024 at 3:09 p.m., with the Director of Nursing (DON), reviewed Resident 492's CDR for lorazepam 05 mg and MAR dated 5/2024. The DON verified by stating that the licensed nurses documented the following: - Lorazepam 0.5 mg was documented on the CDR on 5/18/2024 at 1:01 a m. but was not documented on the MAR. - Lorazepam 0.5 mg was documented on the CDR on 5/19/2024 at 9:32 p.m. but was not documented on the MAR. The DON stated it was important for the CDR and the resident's MAR to match to allow the next nurse to know when the lorazepam was last given. The DON stated if the records were not reconciled, the nurses could give another dose, cause more side effects or overdose the resident. A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, dated 10/17/2023, indicated, The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 187) did not exceed more than 3,000 milligrams (mg, unit of measure) of acetaminophen (Tylenol, a medication used to treat pain and fever) per day per physician order. This deficient practice had the potential to cause toxic levels of acetaminophen to build up in the blood which can lead to nausea, vomiting, abdominal pain, and/or liver failure. Findings: A review of Resident 187's admission Record Face Sheet indicated the facility admitted the resident on 4/25/2024 with diagnoses including fracture (broken bone) of shaft of left tibia (lower leg) and multiple fractured ribs. A review of Resident 187's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/5/2024, indicated the resident is dependent on staff for toileting, bathing, and dressing. A review of Resident 187's History and Physical (H&P - a formal assessment of a patient and their problem), dated 5/14/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 187's physician's order indicated the following: - Tylenol extra strength 500 mg tablet, take two tablets by mouth two times per day for generalized body pain, order dated 4/26/2024 to 5/29/2024. Order indicated not to exceed 3,000 mg of acetaminophen per day. - Hydrocodone-acetaminophen 10 mg-325 mg tablet, take one tablet by mouth every four hours as needed for moderate pain, order dated 4/25/2024 to 5/13/2024. - Oxycodone-acetaminophen 5 mg-325 mg tablet, take one tablet by mouth every four hours as needed for severe pain 7-9/10, order dated 5/9/2024 to 5/29/2024. During a concurrent interview and record review on 5/28/2024 at 10:36 a.m., with Licensed Vocational Nurse (LVN) 1 and the Assistant Director of Nursing (ADON), reviewed Resident 187's Medication Administration Record (MAR) dated 5/2024. Resident 187's MAR indicated on 5/12/2024, Resident 187 was administered four acetaminophen 500 mg tablets, three hydrocodone-acetaminophen 10 mg - 325 mg tablets, and five oxycodone-acetaminophen 5 mg - 325 mg tablets. The total acetaminophen administered that day was 4,600 mgs. LVN 1 stated Resident 187 received over 3,000 mgs of acetaminophen on 5/12/2024. The ADON stated there is an order indicating Resident 187 should not receive over 3,000 mgs of acetaminophen per day. During a concurrent interview and record review on 5/20/2024 at 3:00 p.m., with the Director of Nursing (DON), reviewed Resident 187's MAR dated 5/2024. The DON stated the maximum amount of acetaminophen a resident should receive in a day is 3,000 mgs. The DON stated Resident 187 received over 3,000 mgs of acetaminophen on 5/12/2024. The DON stated an excess of acetaminophen can cause multiple side effects like a decrease in functioning and negatively affect the kidneys and liver. A review of the facility's policy and procedure titled, Medication Administration - General Guidelines, dated 4/2008, indicated medications should be administered in accordance with the physician's orders.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to properly store six boxes of Santyl ointment (medication used for removing damaged tissue or burned skin to allow for wound healing and growth of healthy skin) in the medication's room discontinued medication cabinet for one of three residents (Resident 57) when it was discontinued by the physician on 5/22/2024. The deficient practice had the potential to cause unintentional medication administration and a loss of control against drug loss, diversion, or theft. Findings: A review of Resident 57's admission Record indicated the facility admitted the resident on 3/5/2024 with diagnoses that included respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), tracheostomy (procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and cervical (the first seven bones of the spine composing the neck) spinal cord injury. A review of Resident 57's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 3/14/2024, indicated Resident 57 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 57 was dependent (helper does all the effort to complete the activity) in repositioning in bed and transferring to and from a bed to a chair. A review of Resident 57's physician's orders, dated 5/22/2024, indicated Santyl external ointment 250 unit/gram (U/gm, a unit of measurement) was discontinued on 5/22/2024 at 2:28 p.m. During an observation on 5/30/2024 at 12:01 p.m., with Registered Nurse 1 (RN 1), observed in Medication Room A, a cardboard box that contained Santyl ointment on a shelf against the wall. The box contained medication for three residents with six tubes of Collagenase (breaks down collagen [protein found in skin and connective tissue] in damaged tissue and helps healthy tissue grow) Santyl Ointment 250 units/gram for Resident 57 that were discontinued and unmarked with a discontinuation date. During an interview on 5/30/2024 at 12:45 p.m., with RN 1, RN 1 stated the order was discontinued by the physician and should have been placed in the locked discontinued medications cabinet and into the discontinued medications box labeled for liquids by nursing staff. RN 1 further stated the medication discontinuation cabinet is used to store all the medications that are discontinued or were from discharged residents to prevent it from accidentally being given to other residents. During an interview on 5/30/2024 at 3:03 p.m., with the Director of Nursing (DON), the DON stated when medications are discontinued the licensed nurse should write the discontinuation date on the medication then place it in the locked discontinued medications cabinet to allow proper medication disposition. The DON stated if the procedure is not followed, it can create a safety risk from hazardous waste, or the drug could be given to another resident. The DON further stated Resident 57's medications should have been put in the discontinued medication cabinet immediately after its discontinuation. A review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, dated 10/17/2023, indicated when a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose. The date the medication was discontinued shall be indicated on the medication container. Medications awaiting disposal or return are stored in a locked secure area designed for that purpose until destroyed.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure an eight-ounce glass of milk was not left at the resident's bedside for more than four (4) hours for one of three sampled residents (Resident 94). This deficient practice had the potential to result in food borne illness (when contaminated food is consumed which causes an infection resulting illness) upon ingestion of a spoiled milk. Findings: A review of Resident 94's admission Record indicated the facility originally admitted the resident on 9/3/2020 and readmitted the resident on 10/29/2023, with diagnoses including gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach), shortness of breath, and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 94's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/4/2024, indicated that the resident's cognitive (thought processes) skills for daily decision making was intact and the resident required supervision with oral hygiene, upper body dressing and personal hygiene. During a concurrent observation and interview on 5/28/2024 at 10:47 a.m., observed an eight-ounce glass of milk on Resident 94's bedside table. Resident 94 stated the eight-ounce glass of milk was from his breakfast tray. During a concurrent observation and interview on 5/28/2024 at 3:01 p.m., with Resident 94 and the Director of Nursing (DON), observed an eight-ounce glass of milk. Resident 94 stated that the milk at his bedside table was from his breakfast tray. The DON stated dairy products such as milk must be consumed within 30 minutes of delivery or the same time the meal is served. The DON stated that milk products, if not consumed within the timeframe as stated in the policy and federal guidelines, can potentially make the resident acquire food borne illnesses. The DON acknowledged Resident 94's statement that the glass of milk was from his breakfast tray. A review of the facility's policy and procedure titled, Handling of Potentially Hazardous Food, last revised on 2019, indicated, All potentially hazardous food (PHF) shall be cooked and handled in a safe and sanitary manner to protect residents and staff from food borne illness . A review of the US Department of Agriculture Food Safety and Inspection Service Guidelines, undated, indicated, Leaving food out too long at room temperature can cause bacteria to grow to dangerous levels that can cause illness. Bacteria grow most rapidly in the range of temperatures between 40 °F and 140 °F, doubling in number in as little as 20 minutes. This range of temperatures is often called the 'Danger Zone'.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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b. A review of Resident 179's admission Record indicated the facility admitted the resident on 3/9/2024 and readmitted the resident on 4/1/2024 with diagnoses of fracture (broken bone) of right femur (thighbone), fracture of left tibia (two bones between the knee and ankle), and fracture of right lower leg. A review of Resident 179's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/1/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 179's Order Summary Report, dated 4/25/2024, indicated an order for vancomycin (used to treat and prevent various bacterial infections) 1.25 gram (gm, a unit of measurement) intravenously (entering by way of a vein) every 12 hours for surgical infection. During a concurrent interview and record review on 5/30/2024 at 3:32 p.m., with the Director of Staff Development (DSD), reviewed the infection surveillance forms for the month of 4/2024. The DSD stated that the infection surveillance forms must be collected before starting an antibiotic. The DSD stated this is done to confirm the presence of a true infection, categorize the resident's symptoms, and determine the necessity of antibiotic treatment. The DSD stated the infection surveillance form could not be located for Resident 179. The DSD stated she will seek assistance from another nurse to locate this information. During a concurrent interview and record review on 5/30/2024 at 3:59 p.m., with the DSD and Licensed Vocational Nurse 3 (LVN 3), reviewed the infection surveillance forms for the month of 4/2024. LVN 3 stated they were unable to locate the infection surveillance form for Resident 179. LVN 3 emphasized the importance of completing the infection surveillance forms prior to antibiotic administration and following the McGeer criteria to ensure the necessity of treatment. LVN 3 explained that failure to do so could lead to antibiotic resistance and unnecessary antibiotic use. A review of the facility's policy and procedure titled, Antimicrobial Stewardship Program, last reviewed on 10/17/2023, indicated the facility to implement an Antimicrobial Stewardship program that focus on a coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of optimal antimicrobial drug regimen including dosing, duration of therapy and route of administration: to achieve best clinical outcomes related to antimicrobial use while minimizing the unintended consequences of the antimicrobial use and reducing treatment related cost. Based on interview and record review, the facility failed to implement its antibiotic stewardship program (a program to promote the appropriate use of antibiotics [medication used to treat bacterial infections] in effectively treating infections and to reduce negative side effects) by failing to complete an infection surveillance form (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) once signs and symptoms of an infection were identified and antibiotics were initiated for two of five sampled residents (Resident 178 and 179). This deficient practice had the potential for the residents to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections. Findings: a. A review of Resident 178's admission Record indicated the facility admitted the resident on 4/13/2024 and re-admitted the resident on 5/7/2024 with diagnoses that included acute respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body). A review of Resident 178's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/26/2024, indicated Resident 178 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 178 was dependent on staff for toileting, dressing, and personal hygiene. A review of Resident 178's physician's orders, dated 5/22/2024, indicated an order for ceftriaxone (an antibiotic medication) one gram (g, a unit of measurement), intravenously (to be given through a vein) every 24 hours for leukocytosis (increased white blood cells [blood cell that helps the body fight infections and other disease] that occurs during an infection) for seven days. A review of Resident 178's Change of Condition form (COC - a structured communication tool that can be used to share information about a resident's condition), dated 5/22/2024, indicated Resident 178 had labs results of an abnormal white blood cell count of 17.1 (WBC, normal reference range is 4,500 to 11,000 WBC per microliter [4.5 - 11 x 109/L]). Resident 178's COC indicated vital signs (clinical measurements that indicate the state of a patient's essential body functions) were normal and Resident 178 remains without any signs of distress (emotional, social, spiritual, or physical pain or suffering). A review of Resident 178's Laboratory Values, dated 5/21/2024, indicated Resident 178's WBC count was 17.1 WBC/microliter. During a concurrent interview and record review on 5/29/2024 at 2:47 p.m., with the Director of Staff Development (DSD) and the Infection Preventionist (IP), reviewed the infection surveillance forms for Resident 178. The IP stated once a resident is prescribed an antibiotic, an infection surveillance form should be created to ensure the McGeer's (a criteria of signs and symptoms that must be met to qualify an infection as being a true infection) criteria is met. The IP stated if the resident does not meet the criteria for the illness to be a bacterial infection, the resident's physician is notified, and the physician decides if they want to continue the medication or to discontinue it. The IP stated Resident 178 did not have an infection surveillance form regarding their lab values and antibiotic that was prescribed, but one should have been created. The IP stated it is important that each resident prescribed an antibiotic should have an infection surveillance form created so that a resident's physician can then be made aware if they do not meet the McGeer's criteria for infection. The IP stated this was important so that a resident is not prescribed an antibiotic unnecessarily because a resident could develop a resistance to this medication and not be effective in treating future infections. During an interview on 5/30/2024 at 2:38 p.m., with the Director of Nursing (DON), the DON stated licensed nurses should fill out a surveillance form when a resident is started on an antibiotic to ensure the resident is on the appropriate medication and is not an unnecessary medication. A review of the facility's policy and procedure titled, Antimicrobial Stewardship Program, last reviewed 10/17/2023, indicated the IP will be responsible for infection surveillance. The policy and procedure indicated the IP will collect and review: - Type of antibiotic ordered, route of administration, antibiotic costs. - Whether the order was made by phone, if attending physician or on-call doctor gave the order. - Whether a culture (a test to find germs that can cause an infection) was obtained before ordering the antibiotic. - Whether the antibiotic was changed during the course of treatment.

CONCERN (E)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected multiple residents

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2. A review of Resident 179's admission Record indicated the facility admitted the resident on 3/9/2024 and readmitted the resident on 4/1/2024 with diagnoses of fracture (broken bone) of right femur (thighbone), fracture of left tibia (two bones between the knee and ankle), and fracture of right lower leg. A review of Resident 179's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/1/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 179's Order Summary Report, dated 4/1/2024, indicated to give oxycodone hydrochloride (medication used to treat moderate to severe pain) tablet 7.5 milligram (mg- a unit of measurement) by mouth three times a day for severe pain. A review of Resident 179's Medication Administration Record (MAR- the report that serves as a legal record of the drugs administered to a resident of a facility by a health care professional) dated 5/2024, indicated Resident 179 did not receive her prescribed oxycodone 7.5 mg on the following dates and times: - 5/13/2024 at 10:00 a.m., 4:00 p.m., and 10:00 p.m. - 5/14/2024 at 10:00 a.m., 4:00 p.m., and 10:00 p.m. The MAR included a note indicating that the medication was awaiting supply. A review of Refill Request Form dated 5/11/2024 at 1:00 p.m., indicated Licensed Vocational Nurse 1 (LVN 1) requested to refill oxycodone. A review of Resident 179's care plan (a written document that summarizes a patient's needs, goals, and care/treatment) for potential for alteration in comfort/pain, initiated on 4/15/2024, indicated to administer medication as ordered. During a concurrent interview and record review on 5/30/2024 at 11:48 a.m., with Registered Nurse 2 (RN 2), reviewed Resident 179's MAR dated 5/2024. RN 2 stated Resident 179 did not receive oxycodone 7.5 mg on 5/13/2024 and 5/14/2024 due to unavailability. RN 2 stated the medication was still awaiting delivery from the pharmacy. RN 2 stated that in such situations, the charge nurse should contact the pharmacy for follow-up and utilize medication from the emergency kit (e-kit- basic emergency medical kit that includes common emergency drugs) if necessary. During a concurrent interview and record review on 5/30/2024, at 2:01 p.m., reviewed Resident 179's MAR dated 5/2024. LVN 1 stated that Resident 179's oxycodone 7.5 mg was not administered on 5/13/2024 due to unavailability. LVN 1 stated that in future instances of medication unavailability, LVN 1 will contact the pharmacy and obtain authorization from the pharmacist to utilize the e-kit. During an interview on 5/30/2024 at 2:59 p.m., with the Director of Nursing (DON), the DON stated that if the facility does not have the medication the staff should call the pharmacy to get an authorization to use the e-kit while waiting for the medication to be delivered. The DON stated Resident 179 could suffer from pain. A review of the facility's policy and procedure titled, Medication Ordering and Receiving from Pharmacy, last reviewed on 10/17/2023, indicated the ordered medication is obtained either from the emergency supply or from the provider pharmacy. Reorder medication five days in advance of need to assure an adequate supply is on hands. A review of the facility's policy and procedure titled, Pain management, last reviewed on 10/17/2023, indicated to provide guidelines for the consistent assessment, management, and documentation of pain of resident, in order to provide maximum comfort and quality of life. Effective pain control is an important part of a resident's treatment. Implement the medication regimen as ordered, carefully documenting the results of the interventions. Based on interview and record review, the facility failed to: 1. Ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering narcotic pain medication (also known as opioids, a class of drugs that treat moderate to severe pain) to one of 37 sampled residents (Resident 11). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). 2. Ensure one of one sampled resident (Resident 179), who was at risk for pain, received care and services in accordance with professional standards of practice by failing to provide pain medication as ordered by the physician. This deficient practice had the potential to result in Resident 179 experiencing unrelieved pain. Findings: 1. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 9/27/2017 and readmitted the resident on 12/28/2023 with diagnoses including fracture (broken bone) of the left femur (thigh bone). A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/16/2024, indicated the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities related to personal care). During a concurrent interview and record review on 5/30/2024 at 10:02 a.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 11's physician's orders and Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) dated 5/2024. MDS Nurse 1 stated for Resident 11's pain, the physician prescribed the following medications: - Acetaminophen (medication used to relieve mild pain or reduce fever) 325 milligrams (mg - unit of measurement) via gastrostomy tube (g-tube - an opening to the stomach from the abdominal wall made surgically for the introduction of food and medication) two times a day for generalized pain management and ADLs, ordered on 4/3/2024. - Hydrocodone-acetaminophen (medication used for moderate to severe pain) 10-325 mg via g-tube every eight (8) hours as needed for severe pain 7-9/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered on 5/14/2024. - Hydrocodone-acetaminophen 5-325 mg via g-tube every six (6) hours as needed for moderate pain, ordered on 5/12/2024. - Acetaminophen 325 mg two tablets via g-tube every 6 hours as needed for mild pain (1-3), ordered on 4/3/2024. MDS Nurse 1 stated Resident 11 received hydrocodone-acetaminophen 5-325 mg as needed on the following dates and times: - 5/12/204 at 9:58 a.m. and 4:34 p.m. - 5/13/2024 at 2:35 a.m. and 9:30 a.m. - 5/14/2024 at 1:00 a.m., 10:00 a.m., and 9:47 p.m. - 5/15/2024 at 7:19 a.m. - 5/16/2024 at 1:15 a.m., 8:20 a.m., and 7:08 p.m. - 5/17/2024 at 4:02 p.m. and 10:39 p.m. - 5/18/2024 at 8:20 a.m. - 5/19/2024 at 5:00 a.m., 11:30 a.m., and 10:00 p.m. - 5/20/2024 at 2:00 a.m. and 4:22 p.m. - 5/21/2024 at 1:06 a.m., 8:30 a.m., and 4:09 p.m. - 5/22/2024 at 12:01 a.m., 8:45 a.m., 5:58 p.m. - 5/23/2024 at 12:00 a.m., 9:30 a.m., and 3:36 p.m. - 5/24/2024 at 5:21 p.m. - 5/25/2024 at 8:28 a.m. and 7:00 p.m. - 5/26/2024 at 8:40 a.m. and 6:42 p.m. - 5/27/2024 at 2:00 a.m., 8:40 a.m., and 4:39 p.m. - 5/28/2024 at 3:11 a.m., 9:30 a.m., and 6:59 p.m. - 5/29/2024 at 5:00 a.m. and 8:38 p.m. - 5/30/2024 at 2:38 a.m. When asked what non-pharmacological interventions the nurses attempted prior to administering hydrocodone-acetaminophen 5-325 mg on the above dates, MDS Nurse 1 stated he could not find any documentation that indicated the nurses had attempted non-pharmacological interventions prior to administering the medication. A review of Resident 11's care plan (a written document that summarizes a patient's needs, goals, and care/treatment) for potential for alteration in comfort/pain related to left upper thigh pain, initiated on 5/8/2024, indicated a goal of reducing episodes of pain or discomfort through appropriate interventions daily until the next assessment. Among some of the interventions listed included to provide non-pharmacological interventions (positioning for comfort, hot pack, cold pack, massage, and distraction). During an interview on 5/30/2024 at 2:42 p.m., with the Director of Nursing (DON), the DON stated it was important to first try non-pharmacological interventions prior to administering as needed pain medication because the resident may not need the medication after all. The DON stated if narcotic pain medication is given before attempting non-pharmacological interventions first, then the resident is at increased risk of experiencing adverse side effects from the medication, such as respiratory decline or increased risk for falls. A review of the facility's policy and procedure titled, Pain Management, last reviewed on 10/17/2023, indicated that non-pharmacological interventions shall be utilized as part of the Pain Management Program. Physician orders are to be made for pharmacological and non-pharmacological interventions as needed. Non-pharmacological interventions may include, but are not limited to the following: Repositioning the resident; dimming lighting or maintaining a quiet environment; hot or cold applications; instruction in relaxation techniques; providing activities or distractions; providing music; and massaging the resident.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) to two of 37 sampled residents (Residents 11 and 166). This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention). Findings: a. A review of Resident 11's admission Record indicated the facility originally admitted the resident on 9/27/2017 and readmitted the resident on 12/28/2023 with diagnoses including anxiety disorder. A review of Resident 11's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/18/2024, indicated the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities related to personal care). During a concurrent interview and record review on 5/30/2024 at 9:48 a.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 11's physician's orders and Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a healthcare professional) dated 5/2024. MDS Nurse 1 stated Resident 11 had an order for lorazepam one (1) milligram (mg - unit of measurement) via gastrostomy tube (g-tube - an opening to the stomach from the abdominal wall made surgically for the introduction of food and medication) every six (6) hours as needed for anxiety manifested by hyperventilation (when someone breathes in more oxygen than their body needs) leading to shortness of breath, for 14 days, ordered on 5/26/2024. MDS Nurse 1 stated Resident 11 received lorazepam on 5/26/2024 at 4:44 p.m. and 11:55 p.m., 5/27/2024 at 8:30 a.m. and 6:10 p.m., 5/28/2024 at 8:33 a.m. and 11:59 p.m., 5/29/2024 at 11:54 p.m., and 5/30/2024 at 8:35 a.m. When asked what non-pharmacological interventions the nurses attempted prior to administering lorazepam to Resident 11, MDS Nurse 1 stated he could not find any documentation indicating the nurses had attempted non-pharmacological interventions prior to administering lorazepam. During an interview on 5/30/2024 at 2:42 p.m., with the Director of Nursing (DON), the DON stated it was important to first try non-pharmacological interventions prior to administering as needed psychotropic medications (medications capable of affecting the mind, emotions, and behavior) because the resident may not need the medication after all. The DON stated if lorazepam is given before attempting non-pharmacological interventions first, then the resident is at increased risk of experiencing adverse side effects from the medication, such as increased risk for falls. A review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed on 10/17/2023, indicated that non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. b. A review of Resident 166's admission Record indicated the facility admitted the resident on 1/12/2024 with diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). A review of Resident 166's MDS, dated [DATE], indicated the resident had severely impaired cognition and was dependent on staff for most ADLs. The MDS also indicated the resident received antianxiety medication. During a concurrent interview and record review on 5/30/2024 at 10:31 a.m., with MDS Nurse 1, reviewed Resident 166's physician's orders and MAR dated 5/2024. MDS Nurse 1 stated Resident 166 had a prior order for lorazepam 1 mg via g-tube every 6 hours as needed for anxiety manifested by restlessness leading to shortness of breath, for 14 days, ordered on 5/7/2024. MDS Nurse 1 stated Resident 166 received lorazepam on the following dates: 5/8/2024, 5/10/2024, 5/11/2024, 5/12/2024, and 5/14/2024 - 5/21/2024. When asked what non-pharmacological interventions the nurses attempted prior to administering lorazepam to Resident 166, MDS Nurse 1 stated he could not find any documentation indicating the nurses had attempted non-pharmacological interventions prior to administering lorazepam. During an interview on 5/30/2024 at 2:42 p.m., with the DON, the DON stated it was important to first try non-pharmacological interventions prior to administering as needed psychotropic medications because the resident may not need the medication after all. The DON stated if lorazepam is given before attempting non-pharmacological interventions first, then the resident is at increased risk of experiencing adverse side effects from the medication, such as increased risk for falls. A review of the facility's policy and procedure titled, Psychotropic Medication Use, last reviewed on 10/17/2023, indicated that non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.

MINOR (B)

Minor Issue - procedural, no safety impact

Comprehensive Assessments (Tag F0636)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a resident's admission Minimum Data Set (MDS - a standardized assessment and care screening tool) timely for one of 37 sampled residents (Resident 172). This deficient practice had the potential to delay care and services for the resident. Findings: A review of Resident 172's admission Record indicated the facility admitted the resident on 1/5/2024 with diagnoses including osteoarthritis (a chronic condition that occurs when flexible tissue at the ends of bones wears down) of the right hip and aftercare following joint replacement surgery (procedure in which a surgeon removes a damaged joint and replaces it with a new one). A review of Resident 172's admission MDS, dated [DATE], indicated the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities related to personal care). During a concurrent interview and record review on 5/29/2024 at 2:58 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 172's admission MDS dated [DATE]. MDS Nurse 1 stated that the MDS assessment was not completed until 1/26/2024, which was 21 days after Resident 172's admission date. MDS Nurse 1 stated that timely completion of the assessment was important because it affected the establishment of the resident's plan of care. During an interview on 5/30/2024 at 12:48 p.m., with MDS Nurse 1, when asked what policy he followed regarding the schedule for completing MDS assessments, MDS Nurse 1 stated the facility did not have a policy but that he followed the MDS Resident Assessment Instrument (RAI) Manual. During an interview on 5/30/2024 at 2:38 p.m., with the Director of Nursing (DON), the DON stated it was important to complete the resident's admission MDS timely because it allowed the facility to get a clearer picture of the resident's needs and plan of care. A review of the Centers for Medicare and Medicaid Services (CMS- a federal agency within the United States Department of Health and Human Services [HHS] that administers the Medicare program) RAI 3.0 Manual dated 10/2023, indicated that, for an admission MDS, the MDS completion date should be no later than the 14th calendar day of the resident's admission date.

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create and transmit a Discharge Minimum Data Set (MDS - a standardized assessment and care screening tool) upon a resident's discharge on [DATE] for one of 37 sampled residents (Resident 172). This deficient practice had the potential to delay care and services for the resident. Findings: A review of Resident 172's admission Record indicated the facility admitted the resident on 1/5/2024 with diagnoses including osteoarthritis (a chronic condition that occurs when flexible tissue at the ends of bones wears down) of the right hip and aftercare following joint replacement surgery (procedure in which a surgeon removes a damaged joint and replaces it with a new one). A review of Resident 172's MDS, dated [DATE], indicated the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities related to personal care). During a concurrent interview and record review on 5/29/2024 at 2:58 p.m., with Minimum Data Set Nurse 1 (MDS Nurse 1), reviewed Resident 172's MDS dated from 1/5/2024 to 2/2/2024. MDS Nurse 1 stated that Resident 172 was discharged from the facility on 1/19/2024. MDS Nurse 1 stated he just realized today that the resident did not have a Discharge MDS completed. MDS Nurse 1 stated the facility should have completed a Discharge MDS by 2/2/2024, within 14 days after the discharge date and should have transmitted the Discharge MDS to Centers for Medicare and Medicaid Services (CMS- a federal agency within the United States Department of Health and Human Services [HHS] that administers the Medicare program) within 14 days after the completion of the MDS. MDS Nurse 1 stated it was important to complete and transmit a Discharge MDS for the resident because it reflected the resident's status upon leaving the facility. MDS Nurse 1 stated the Discharge MDS showed if the resident improved or declined during their stay in the facility. During an interview on 5/30/2024 at 12:48 p.m., with MDS Nurse 1, when asked what policy he followed regarding the schedule for completing MDS assessments, MDS Nurse 1 stated the facility did not have a policy but that he followed the MDS Resident Assessment Instrument (RAI) Manual. During an interview on 5/30/2024 at 2:38 p.m., with the Director of Nursing (DON), the DON stated it was important to have a Discharge MDS upon a resident's discharge in order to accurately track the resident. The DON stated it also showed whether the resident improved or declined during their stay in the facility. A review of the CMS RAI 3.0 Manual, dated 10/2023, indicated that, for a Discharge MDS, the MDS assessment should have been completed no later than the discharge date + 14 calendar days and transmitted within 14 days after the MDS completion date.

May 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of six sampled residents (Resident 1), who sustained a fall on 5/8/2024. This deficient practice placed Resident 1 at risk for further falls and injuries. Findings: A review of Resident 1's admission Record indicated the facility originally admitted the resident on 9/27/2017 and readmitted on [DATE] with diagnoses that included osteoporosis (a health condition that weakens bones), dementia (the loss of cognitive [thinking, remembering and reasoning] functioning that it interferes with a person's daily life and activities), and respiratory failure (a condition that makes it difficult to breathe on your own) dependent on ventilator (a machine that helps you breathe). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/18/2024, indicated Resident 1's cognition (ability to think and make decisions) was intact. The MDS further indicated Resident 1 was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, shower, upper body dressing, lower body dressing and for mobility (movement) such as the ability to roll from lying on back to left and right side and return to lying on back on the bed. A review of Resident 1's Change in Condition (COC- when there is a sudden change in a resident ' s health) Interact Assessment Form dated 5/8/2024, timed at 5:41 a.m., indicated that on 5/8/2024 at 5:20 a.m., Resident 1 slid off the bed and fell onto the floor. The COC form further indicated that on 5/8/2024 at 5:20 a.m. Certified Nursing Assistant 1 (CNA 1) reported that while providing care to Resident 1 who was positioned on her (referring to Resident 1) right side, grabbed the bed side railings to move more. Resident 1 then lost her balance, rolled over and slid off onto the floor. A review of Resident 1's Care Plan titled Actual Fall dated 5/8/2024, last revised on 5/11/2024 indicated Resident 1 had an actual fall on 5/8/2024. The goal was to minimize risk of falls or injury through appropriate interventions. The interventions included to apply bed and wheelchair alarm to alert staff, provide low bed with floor mat and administer pain medication as ordered. There were no new interventions found to address minimizing the risk or preventing further recurrence of fall while providing care and services to Resident 1. During a concurrent interview and record review on 5/14/2024 at 1:14 p.m., with the Minimum Data Set Director (MDSD), the MDSD reviewed Resident 1's care plan titled Actual Fall dated 5/8/2024, last revised on 5/11/2024. The MDSD stated that the use of alarm device (such as bed and wheelchair alarm) will not reduce the risk of fall. The MDSD further stated that the floor mattress would be used to reduce the injuries if a resident falls. The MDSD stated the facility had not develop a comprehensive person-centered care plan to specifically address on how facility staff will reduce the risk for fall and prevent further falls and injury while providing the care and services to Resident 1. During a concurrent interview and record review on 5/14/2024 at 4:46 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's care plan titled Actual Fall dated 5/8/2024, last revised on 5/11/2024. The DON stated that the care plan developed for Resident 1 after the fall incident on 5/8/2024 did not include interventions on how the facility staff will prevent further falls or reduce the risk of Resident 1 sustaining another fall incident while facility staff provides care and service to Resident 1. A review of the facility's policy and procedure (P&P) titled, The Resident Care Plan, last reviewed on 10/17/2023, indicated, To provide an individualized nursing care plan and to promote continuity of resident care Care necessitated by the resident's individual needs.

Oct 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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update a comprehensive person-centered care plan (a plan for an individual ' s specific health needs and desired health outcomes) for one of five sampled residents (Resident 1), who had their code status (describes the type of resuscitation procedures [ the process of treating the lack of breathing or heartbeat of a seriously ill resident]) changed from Do Not attempt Resuscitation (DNR-instructs health care providers to not to do cardiopulmonary resuscitation [CPR- an emergency lifesaving procedure performed when the heart stops beating] if a patient's breathing stops or if the patient's heart stops beating) to Full Code (if a resident ' s heart stopped beating and/or they stopped breathing, all resuscitation procedures including CPR will be provided to keep the resident alive). This deficient practice had a potential for a resident and or resident ' s representative ' s wishes for medical treatment to be violated in case of an emergency, and or cause confusion with regards to the resident ' s plan of care. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses included cerebral ischemia (a brain injury that results from impaired blood flow to the brain and results in damage to brain tissue) and tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help a resident breathe). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated [DATE] indicated Resident 1 was able to rarely understand others and was able to rarely make-self understood. The MDS further indicated that Resident 1 needed total assistance from staff with activities of daily livings (ADLs - bed mobility, transfer, eating, toilet use, and personal hygiene). A review of Resident 1 ' s POLST signed on [DATE] by Family 1 (FM 1), indicated that Resident 1 ' s code status was DNR. The POLST further indicated that Resident 1 is to have Full Treatment ( primary goal of prolonging life by all medically effective means as long as the resident is found with a heartbeat and or is breathing) A review of Resident 1 ' s care plan for POLST dated [DATE], indicated, DNR, and one of approaches and plans was to notify the physician of any changes. A review of Resident 1 ' s Interdisciplinary Team (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting notes indicated That Resident 1 ' s family member (Family 1 [FM 1]) participated in the meetings; the following was also noted: 1. IDT Note [DATE]- Resident 1 is documented as a Full Code. 2. IDT Note [DATE]- Resident 1 is documented as a Full Code 3. IDT Note [DATE]- Resident 1 is documented as a Full Code 4. IDT Note [DATE]- Resident 1 is documented as a Full Code. During an interview with Family 1 (FM 1) on [DATE] at 11:19 a.m., FM 1 stated that Resident 1 ' s code status should be Full Code (unable to recall exact date). FM 1 stated he was confused when he received a call from the facility on [DATE] asking about clarification of Resident 1 ' s code status. During a concurrent interview and record review with MDS Coordinator (MDSC) on [DATE] at 2:53 p.m., MDSC reviewed Resident 1 ' s POLST form dated [DATE] and IDT meeting notes dated [DATE], [DATE], [DATE], and [DATE]. MDSC stated, when the facility has an IDT meeting with a resident or resident ' s family, the nurse who attends the meeting should check the resident ' s physical POLST form and clarify the code status if there is a discrepancy. MDSC stated that if there is a change in code status, the POLST form should be updated to reflect the change in code status. MDSC stated that Resident 1 ' s POLST was not updated to reflect the change in the resident ' s code status from DNR to Full Code after each of the IDT meetings. MDSC stated that Resident 1 ' s care plan for POLST dated [DATE] had not been updated to reflect Resident 1 ' s current code status of Full Code (if a resident ' s heart stopped beating and/or they stopped breathing, all resuscitation procedures including CPR will be provided to keep the resident alive). A review of the facility ' s policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised [DATE], indicated, 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.

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 F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the Physician Order for Life- Sustaining Treatment (POLST - a written medical that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of five sampled residents (Resident 1), when Resident 1 ' s code status (describes the type of resuscitation procedures [ the process of treating the lack of breathing or heartbeat of a seriously ill resident]), if any; a resident would like the health care team to conduct if a resident ' s heart stopped beating and/or stopped breathing) was changed from Do Not attempt Resuscitation (DNR-instructs health care providers to not to do cardiopulmonary resuscitation [CPR- an emergency lifesaving procedure performed when the heart stops beating] if a patient's breathing stops or if the patient's heart stops beating) to Full Code (if a resident ' s heart stopped beating and/or they stopped breathing, all resuscitation procedures including CPR will be provided to keep the resident alive). This deficient practice had a potential to cause conflict with the resident ' s or resident ' s representatives wishes regarding health care in the event of an emergency. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] with diagnoses included cerebral ischemia (a brain injury that results from impaired blood flow to the brain and results in damage to brain tissue) and tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe to help a resident breathe). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated [DATE] indicated Resident 1 was able to rarely understand others and was able to rarely make-self understood. The MDS further indicated that Resident 1 needed total assistance from staff with activities of daily livings (ADLs - bed mobility, transfer, eating, toilet use, and personal hygiene). A review of Resident 1 ' s POLST signed on [DATE] by Family 1 (FM 1), indicated that Resident 1 ' s code status was DNR. The POLST further indicated that Resident 1 is to have Full Treatment ( primary goal of prolonging life by all medically effective means as long as the resident is found with a heartbeat and or is breathing) A review of Resident 1 ' s care plan for POLST dated [DATE], indicated, DNR, and one of approaches and plans was to notify the physician of any changes. A review of Resident 1 ' s Interdisciplinary Team (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting notes indicated That Resident 1 ' s family member (Family 1 [FM 1]) participated in the meetings; the following was also noted: 1. IDT Note [DATE]- Resident 1 is documented as a Full Code. 2. IDT Note [DATE]- Resident 1 is documented as a Full Code 3. IDT Note [DATE]- Resident 1 is documented as a Full Code 4. IDT Note [DATE]- Resident 1 is documented as a Full Code. During an interview with Family 1 (FM 1) on [DATE] at 11:19 a.m., FM 1 stated that Resident 1 ' s code status should be Full Code (unable to recall exact date). FM 1 stated he was confused when he received a call from the facility on [DATE] asking about clarification of Resident 1 ' s code status. During a concurrent interview and record review with MDS Coordinator (MDSC) on [DATE] at 2:53 p.m., MDSC reviewed Resident 1 ' s POLST form dated [DATE], IDT meeting notes dated [DATE], [DATE], [DATE], and [DATE]; and Care Plan for POLST dated [DATE] were reviewed. MDSC stated, when the facility has an IDT meeting with a resident or resident ' s family, the nurse who attends the meeting should check the resident ' s physical POLST form and clarify the code status if there is a discrepancy. MDSC stated that if there is a change in code status, the POLST form should be updated to reflect the change in code status. MDSC stated that Resident 1 ' s POLST had not been updated since [DATE]. MDSC stated that Resident 1 ' s POLST was not updated to reflect the change in the resident ' s code status from DNR to Full Code after each of the IDT meetings. A review of the facility ' s policy and procedure (P&P) titled, POLST, reviewed on [DATE], indicated, This facility will provide residents with the POLST that is voluntary and include physician orders for life-sustaining treatment. This POLST will: Allow residents to have more control over their care, allow both the doctor and patient to specify the types of medical treatment that the patient wishes to receive at the end of life Be completed by a physician, nurse practitioner, or physician assistant, and the patient, or his/her legally recognized healthcare decision maker.

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 2) received oxygen as ordered by the physician. This deficient practice placed Resident 2 at risk of having oxygen toxicity (lung damage that happens from breathing in too much extra [supplemental] oxygen). Findings: A review of Resident 2's Face Sheet (admission Record) indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnoses of acute respiratory failure (when the respiratory system cannot provide oxygen to the body), chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), shortness of breath (difficulty breathing), and obstructive sleep apnea (sleep disorder in which a resident's breathing stops). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/21/2023, indicated Resident 2 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 2 required one-person, extensive assistance (resident involved in activity, staff provide weight-bearing support) with dressing. The MDS indicated Resident 2 had a diagnosis of COPD and required oxygen therapy. A review of Resident 2's Physician's Orders indicated the following: 1. Administer oxygen at 2 to 3 liters per minute (L/min- measurements of oxygen quantity) by nasal canula (a plastic tube to deliver supplemental oxygen to a person through their nose) every shift, dated 11/29/2022. 2. Monitor oxygen saturation [the amount of oxygen that is circulating in the blood, normal amount is usually 92% to 100%] every shift, dated 11/29/2022. 3. Bilevel Positive Airway Pressure (BiPAP, a machine normalizes breathing by delivering pressurized air) Administer oxygen at three (3) L/min; may titrate (increase) up to five (5) L/min for oxygen saturation less than 92 precent (%), at bedtime for sleep apnea, dated 11/30/2022. A review of Resident 2's Oxygen Care Plan, initiated 6/22/2020, indicated an intervention to provide oxygen as ordered. During an observation with Resident 2 on 6/12/2023 at 11:20 a.m., observed Resident 2 in her bed. Observed Resident 2's oxygen concentrator (a machine that delivers supplemental oxygen) with oxygen set at 4 L/min. During a concurrent observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 6/12/2023 at 11:25 a.m., observed Resident 2's oxygen concentrator. LVN 1 stated that Resident 2's oxygen concentrator was set at 4 L/min. LVN 1 then was observed checking Resident 2's oxygen saturation at 11:28 a.m. which was at 90%. During an interview with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that Resident 2's oxygen level may have been set higher than the ordered 3 L/min because she was on a BIPAP at night and facility staff might have forgotten to lower the oxygen level back down to three (3) L/min. LVN 2 stated she had not checked Resident 2's oxygen concentrator when she took the resident's vital signs earlier that morning at approximately 10:48 a.m. LVN 2 stated she should have checked the oxygen concentrator of Resident 2 to make sure the oxygen matched the physician's order. During an interview with the Director of Nurses (DON) at 6/23/2023 at 1:55 p.m., DON stated that Resident 2's oxygen level should be set at two (2) to three (3) L/min as that is what the physician had ordered. A review of the facility's policy and procedure titled, Oxygen Administration, reviewed 11/17/2022, indicated to administer oxygen as per physician's orders.

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility ' s policy on documentation was implemented when staff failed to sign and date one of three sampled resident ' s (Resident 1) admission Reassessment form on 3/31/2023.medical records. This deficient practice had the potential to result in confusion in the care and services for Resident 1, which could place the resident at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information. Findings: A review of Resident 1 ' s admission record indicated the facility admitted Resident 1 on 2/24/2023 with diagnoses that included fracture (broken bone) of left lower leg, sepsis (the body's extreme response to an infection), cellulitis (a common, potentially serious bacterial skin infection), history of falling, and adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function). A review of Resident 1 ' s Physician ' s Progress Note dated 2/24/2023 at 3:54 p.m., indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) dated 3/25/2023, indicated Resident 1 required extensive assistance with bed mobility, transfer, dressing, and personal hygiene. During an interview and concurrent record review with the Director of Nursing (D.O.N.) on 5/2/2023 at 3:30 p.m., the D.O.N reviewed Resident 1 ' s admission Reassessment dated [DATE], at 6:06 p.m. When asked who documented the admission Reassessment document, the D.O.N. was unable to answer. When asked if the document was completed, the D.O.N. stated that the document was not compete because the signature and the date of the staff who documented the reassessment were missing. When asked what the importance of a signature and date on a document was, the D.O.N. stated that a signature and date is important so that the facility will know who was the specific person who completed the document. The D.O.N. stated that documents should be signed and dated as soon as staff are done charting to ensure completion of a document. A review of the facility provided policy titled Documentation Principles, dated 1/2004, indicated all entries in the health record must be authenticated by the person making the entry with the date, signature, and title. The signature is to include first initial, full last name and title.

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 F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that three of three sampled licensed nurses (Licensed Vocational Nurse 1 [LVN 1], Licensed Vocational Nurse 2 [LVN 2], Licensed Vocational Nurse 3 [LVN 3]) were assessed for competencies and provided with competency tests upon hire. This deficient practice has the potential to result in facility staff not having the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely. Findings: During an interview with the Director of Nursing (DON) on 5/1/2023 at 3:15 p.m., DON stated that all newly hired licensed nurses are oriented prior to being allowed on the floor to provide resident care. The DON stated that all newly hired licensed nurses are given an orientation packet that is discussed by the DON, and a five (5) day on the floor orientation with a preceptor (experienced licensed clinicians who act as teachers for newly hired nurses). DON stated that during the five-day floor orientation period with the preceptor, the newly hired nurse is allowed to pass medication and provide resident care. When asked if newly hired licensed nurses have an orientation check list or a competency that is completed upon hire, the DON stated that the facility does not conduct competencies upon hire nor does the facility have an orientation checklist upon hire. When asked how the facility gauges if the newly hired licensed nurse is ready to work on their own in the facility, the DON stated that she would verbally ask if the newly hired nurse is ready and comfortable. DON stated that if the newly hired licensed nurse says they are ready and have no concerns or questions, the facility will then allow the newly hired licensed nurse to work on their own. During an interview and concurrent record review with the Director of Staff Development (DSD) on 5/2/2023 at 2:26 p.m., DSD reviewed the staff competency check list for LVN 1. The DSD stated that LVN 1 was hired on 5/7/2021. DSD stated that after viewing the competency check list for LVN 1, LVN 1 ' s dated competency check lists were on 5/18/2022, 5/20/2022, and 8/15/2022. During an interview and concurrent record review with the DSD on 5/2/2023 at 2:26 p.m., DSD. reviewed the staff competency check list for LVN 3. The DSD stated that LVN 3 was hired on 7/28/2022. DSD stated that after viewing the competency check list for LVN 3, LVN 3 ' s dated competency check list was on 10/17/2022. During an interview and concurrent record review with the DSD on 5/2/2023 at 2:26 p.m., DSD stated that LVN 2 was hired on 2/20/2023. The DSD confirmed there was no competency checklist found for LVN 2. During an interview with the DON on 5/2/2023 at 3:20 p.m., the DON stated that LVN 2 does not have a competency check list because LVN 2 was hired in February of 2023. DON stated that LVN 2 ' s competency check will not be scheduled until after LVN 2 is off probation which is three months after hire. During an interview with the Assistant Director of Nursing (ADON) on 5/2/2023 at 3:48 p.m., the ADON stated that it is the responsibility of the DON and ADON to conduct competencies for the licensed nurses. When asked how the competencies are given to the licensed nurses, the ADON stated that that the competency check list is more of a discussion with licensed nurses similar to an in-service where the DON or ADON will ask questions, discuss, and lecture on topics listed on the competency check list. The ADON stated they should have conducted the competency tests for licensed nurses upon hire and not three months or a year after hire. When asked what the purpose of competency tests are, the ADON stated that competency tests should be provided to the licensed nurses to ensure the licensed nurses know what they are doing. The ADON stated that the facility should be evaluating staff to ensure that licensed nurses are competent in providing safe care to residents. A review of the facility ' s assessment dated [DATE], under staff qualifications for patient care: c) Competency Tests for Nursing. A review of the facility ' s policy and procedure (P&P) titled Competency Assessments, undated, indicated employees will be assessed for competency upon hire and annually. Each department will have its own competency assessment form to be utilized for new employees during initial orientation. Competencies will be utilized to identify areas that need to be incorporated into the in-service education for each department.

Apr 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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure staff honored resident's rights when a resident requested to wear a family-provided pull up adult brief and insisted the resident wear a facility-provided adult brief for one of three sampled residents (Resident 1). This deficient practice resulted in not honoring the resident's right to choose and had the potential to affect the self-esteem, self-worth, and sense of independence for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility readmitted Resident 1 on 2/20/2023, with diagnoses that included metabolic encephalopathy (broad term for any brain disease that alters brain function or structure), difficulty in walking, other reduced mobility, muscle weakness, and need for assistance with personal care. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 2/27/2023, indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 1 required extensive assistance with dressing, toilet use, and personal hygiene. During an interview on 3/22/2023 at 2:00 p.m., with Resident 1, Resident 1 stated he no longer resides in the facility. Resident 1 stated while he was in the facility, his family provided him with pull up adult briefs to wear. Resident 1 was unable to recall the date, however stated there was an incident where Resident 1 requested assistance from Certified Nursing Assistant 1 (CNA 1) to assist him with putting on a family-provided pull up adult brief because he wanted to get ready for a visitor. CNA 1 did not assist him with putting on the pull up adult brief but insisted Resident 1 wear a facility-provided adult brief. During an interview on 3/23/2023 at 2:48 p.m., with the Director of Staff Development (DSD), the DSD confirmed she was aware of the incident that occurred with CNA 1 insisting Resident 1 wear a facility-provided adult brief rather than a family-provided pull up adult brief. The DSD stated CNA 1 was in-serviced and re-educated regarding respecting resident's choices. The DSD stated that all staff should respect residents' preferences and choices. The DSD stated staff should also honor the resident's right to choose. During an interview on 3/23/2023 at 3:31 p.m., with CNA 1, CNA 1 confirmed caring for Resident 1 during his stay in the facility. CNA 1 confirmed that there was an incident where Resident 1 asked for assistance with putting on Resident 1's family-provided pull up adult brief. CNA 1 stated she informed Resident 1 that he only had 1-2 pull up adult briefs left. CNA 1 stated she suggested that Resident 1 use the facility-provided adult brief instead of using his pull up adult brief. CNA 1 confirmed placing a facility-provided adult brief on Resident 1 even though Resident 1 requested for his pull up adult brief. CNA 1 stated she should have listened to Resident 1's request in assisting him with the pull up adult brief instead of placing the facility-provided adult brief on Resident 1. CNA 1 stated she thought it was in Resident 1's best interest because Resident 1 only had 1-2 pull up briefs left, and the facility had a lot of adult briefs in supply. During an interview on 3/23/2023 at 12:45 p.m., with the Administrator (ADM), the ADM stated CNA 1 should have honored Resident 1's preference. A review of the facility-provided policy and procedure titled Resident Rights, undated, indicated under Resident Rights: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident. Exercise of rights: The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

Apr 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified for one of three sampled resident (Resident 1), when Resident 1 had two episodes of restlessness on 2/27/2023 and 3/1/2023. This deficient practice may potentially result in the delay of obtaining appropriate instruction from the physician for proper management. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/16/2022 and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), seizures, and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). A review of Resident 1 ' s History and Physical (H&P) dated 1/27/2023, indicated, Resident 1 can make her needs known but cannot make medical decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/3/2023, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) status was moderately impaired. The MDS indicated Resident 1 needed extensive assistance from staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). During a concurrent interview and record review on 3/29/2023 at 2:56 p.m., with Minimum Data Set Coordinator (MDSC), Resident 1 ' s Care Plan (CP), regarding restlessness dated 2/27/2023 and 3/1/2023 was reviewed. The 2/27/2023 CP indicated; Resident 1 was observed trying to sit on the bed. The CP dated 3/1/2023 indicated Resident 1 was observed moving a lot in the bed. The CP indicated an intervention to notify physician and family of resident change of condition. MDSC stated restlessness is a change of condition and nurses should have documented a Change of Condition (COC-a form where licensed staff document a change in the resident's health or functioning) and called the doctor. During an interview on 3/29/2023 at 3:01 p.m., Medical Records Director (MRD) stated there was no COC documentation for restlessness in Resident 1 ' s medical record. During an interview on 3/31/2023 at 12:20 p.m., Sub Acute Coordinator (SAC) stated nurses failed to document a change of condition when Resident 1 was restless and moving in bed. SAC stated doctor was not notified of her behavior on 2/27/2023 and 3/1/3023. A review of facility ' s policy and procedure (P&P) titled Change of Condition (COC) reviewed on 11/17/2022, indicated that a change of condition is a sudden or marked difference in a resident ' s behavior or movement. The policy further indicated that upon change of condition for any reason, nursing staff members are to call the physician promptly, and then document the change of condition by completing a COC as indicated.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for two of three sampled residents (Resident 2 and Resident 3) who were identified as high fall risks. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 2 and Resident 3. Findings: a. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/8/2023, with diagnoses that included acute and chronic respiratory failure (condition in which not enough oxygen passes from your lungs into your blood), encounter for attention to tracheostomy (a tube inserted through a cut in the neck below the vocal cords to allow air to enter the lungs) muscle weakness, and dependance on respirator (ventilator- provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing insufficiently). A review of Resident 2's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 5/15/2023 indicated Resident 2's cognition (relating to the process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 2 had unclear speech, had the ability to make self-understood, and had the ability to understand others. The MDS indicated Resident 2 required extensive assistance with bed mobility, transfer, walk in room with two+ person assistance, and is totally dependent on staff with dressing, eating, toilet use, and personal hygiene. A review of Resident 2 ' s Care Plan titled, Superstar, initiated on 5/12/2023, indicated the resident is at risk for falls and/or injuries secondary to: balance deficit, cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life), poor safety awareness, spontaneous movement, and unsteady gait (a person's manner of walking). The Care Plan included an intervention to implement Super Star interventions. During a concurrent interview and record review on 5/17/2023 at 1:10 p.m., with Registered Nurse 2 (RN 2), reviewed Resident 2 ' s medical records. Reviewed Resident 2 ' s fall risk assessment dated [DATE] and RN 2 stated Resident 2 ' s fall risk assessment score was 18, indicating high risk for fall. When asked what interventions are provided for residents who are assessed to be a high fall risk, RN 2 stated that the facility will provide a low bed set to the lowest level, floor mats, call lights within reach, and super star signs (stars) above the residents ' head of bed, on residents ' wheelchairs and geriatric chairs (a large, padded chair that is designed to help individuals with limited mobility), at the entrance of residents ' door and at the door of residents ' bathroom. RN 2 stated stars are placed to make staff aware that a resident is a high risk for fall and so staff can check on the resident more often. During a concurrent observation and interview on 5/17/2023 at 2:12 p.m., with RN 2, in Resident 2 ' s room, observed no floor mats on both sides of Resident 2 ' s bed, no stars on Resident 2 ' s bathroom door, and no star on Resident 2 ' s geriatric chair. RN 2 stated Resident 2 should have floor mats placed because Resident 2 receives physical therapy at bedside and floor mats will help prevent injury if a fall incident were to occur. RN 2 continued to state stars are important to be placed on Resident 2 ' s geriatric chair and bathroom to alert staff that resident is a high risk for fall and will alert staff to supervise resident more. When asked who was responsible for implementing fall risk interventions, RN 2 stated all nursing staff are responsible. RN 2 stated staff can provide nursing interventions without a physician ' s order. During a concurrent interview and record review on 5/17/2023 at 3:32 p.m., with the Director of Nursing (DON), in the presence of the Administrator (ADM), reviewed the facility ' s policy titled Super Star Program- For Severely High-Risk Residents at Risk for Falls & Injuries, revised 4/2023. The DON was asked, based on the facility ' s policy, what interventions should Resident 2 have. The DON stated that because Resident 2 is at risk for fall, Resident 2 should have a night light, floor mats, actual star should be placed on the bathroom door and her geriatric chair. The DON continued to state these interventions should be placed to prevent injuries. When asked why these interventions were not in place, the DON stated that the interventions were not in place because Resident 2 does not get out of bed, and she always uses the call light. When asked how the DON will ensure that Resident 2 will always use her call light, the DON was unable to answer. When asked about floor mats, the DON stated Resident 2 does not require a floor mat because the resident does not try to get up. When the DON was informed that Resident 2 receives physical therapy, the DON then stated that floor mats should be placed at Resident 2 ' s bedside to decrease the potential for injuries. b. A review of Resident 3 ' s admission Record indicated Resident 3 was readmitted to the facility on [DATE], with diagnoses that included respiratory failure, encounter for attention to tracheostomy, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]), personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), and history of falling. A review of Resident 3's MDS dated [DATE] indicated Resident 3's cognition (relating to the process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 3 was totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 3 ' s Care Plan titled, Superstar, initiated on 3/31/2023, indicated the resident is at risk for falls and/or injuries secondary to: balance deficit, cognitive impairment, history of falls, poor safety awareness, unsteady gait, and epilepsy. The Care Plan included an intervention to implement Super Star interventions. A review of Resident 3 ' s Order Summary Report indicated monitor seizure activity evert shift, ordered on 5/23/2019. During a concurrent interview and record review on 5/17/2023 at 1:18 p.m., with RN 2, reviewed Resident 3 ' s medical records. Reviewed Resident 3 ' s fall risk assessment dated [DATE] and RN 2 stated that Resident 3 ' s fall risk assessment score was 22, indicating high risk for fall. During a concurrent observation and interview on 5/17/2023 at 2:15 p.m., with RN 2, in Resident 3 ' s room, observed Resident 3 in bed and with no floor mats placed on both sides of Resident 3 ' s bedside. When asked why Resident 3 does not have floor mats at his bedside, RN 2 stated Resident 3 does not need floor mats because he does not move. Asked RN 2 what interventions were in place for Resident 3 since he is a high fall risk, and RN 2 stated Resident 3 has his call light within reach and his bed in lowest position. During an interview on 5/17/2023 at 3:33 p.m., with the DON, in the presence of the ADM, the DON stated the fall risk preventions that are in place for Resident 3 are his call light within reach and his bed set at the lowest level. When asked if there were any additional interventions that should be in place for Resident 3, the DON stated no because he does not move. When asked about a floor mat, the DON stated that the floor mat is not necessary for Resident 3 because he does not move and has not exhibited any behaviors of restlessness, trying to get out of bed, or any movement. During a concurrent interview and record review on 5/17/2023 at 4:00 p.m., with the DON, reviewed Resident 3 ' s Order Summary Report. The DON stated that the Order Summary Report indicated to monitor seizure activity every shift. When asked about seizure movement, the DON stated that seizure movement is not movement, and it is different from trying to get out of bed. During a concurrent interview and record review on 5/17/2023 at 5:00 p.m., with the ADM, reviewed Resident 3 ' s Order Summary Report. The ADM stated that the Order Summary Report indicated to monitor seizure activity every shift. The ADM continued to state that because resident has seizures, Resident 3 should have a floor mat to protect him from potential injury. A review of the facility-provided policy and procedure titled Superstar Program- For Severely High Risk Residents at Risk for Falls & Injuries, revised 4/20/2023, indicated this special program is for residents who have a score of 18 or above on the Fall Risk Assessment and any of the following: 1. Noncompliant; 2. Very confused; 3. Family refuses use of restraints; 4. Is super independent and insists on helping self; 5. History of falls; 6. History of neurological conditions; e.g. Parkinsonism (A disorder of the central nervous system [made up of the brain and spinal cord] that affects movement, often including tremors]); 7. Spontaneous, unpredictable behavior/movement; 8. Short attention span; 9. New admission, toileting concerns, unfamiliar with facility or surroundings; 10. Refusal of most interventions; 11. Combative. The policy indicated procedure: 1. Discuss safety of room and replace furniture with plastic items and/or re-arrange furniture in room as needed to provide safer environment; 2. Low bed with mat and padding; 3. Thin floor mats at key locations; e.g bathroom, around bed, etc; 4. Night light; 5. Bathroom padding and toilet seat with handles and/or seat belt/walker for support; 6. Grab bars; 7. Non-skid foot wear as indicated, especially at night; 8. Locations of room close to nursing station for closer observation; 9. Helmets or caps to protect cranium (); 10. Rehab evaluation for safety needs for residents who score 18 or more on activities of daily living (ADL) needs provision of equipment based on assessed needs; 11. Padded underwear/knee pads as indicated; 12. Toileting plan on consistent basis; 13. In-service to staff on both Falling Star Program and Super Star Program; 14. Actual stars on bathroom doors, wheelchair, bed and/or special areas to identify high risk resident; 15. Tennis ball attached to call light as indicated; 16. Non-skid pads on wheelchair seat under cushion to prevent sliding as indicated; 17. Take photo of interventions; e.g., padded bathroom, furniture, grab bars or equipment, Super Star Program signage, helmet, low bed, mat, alarm, etc. and place in envelope in clinical record overflow. A review of the facility-provided policy and procedure titled The Resident Care Plan, undated, indicated healthcare professionals involved in the care of the resident shall contribute to the resident ' s written care plan .Professionals from each discipline write the portion of the care plan that pertains to their field, including their approach to the resident ' s current problem(s) .Care plans are considered comprehensive in nature, and should be reviewed in its entirety .The care plan generally includes: 1. Identification of medical, nursing, and psychosocial needs; 2. Goals stated in measurable/observable terms; 3. Approaches (staff action) to meet the above goals; 4. Discipline/staff responsible for approaches; 5. Reassessment and change as needed to reflect current status .It is the responsibility of the Director of Nursing to ensure that each professional involved in the care of the resident is aware of the written plan of care, including its location, the current problems of the resident, and the goals or objectives of the plan .It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1) was kept free from accidents and hazards by: 1. Failing to accurately assess Resident 1 ' s Fall Risk Assessment (FRA) upon readmission on [DATE]. The resident ' s history of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain) were not considered on the assessment. The facility identified Resident 1 as a low fall risk when the resident should have been identified as a high fall risk. 2. Failing to ensure that the facility conducted a Fall Risk Interdisciplinary Team (IDT-team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting for Resident 1 who was a high risk for falls. 3. Failing to ensure Resident 1 ' s care plan for restlessness (unable to stay still) as evidence by trying to sit on the bed initiated [DATE], and restlessness as evidence by Resident 1 hanging their feet on the bed initiated [DATE] had interventions to address safety concerns when the resident was found on two occasions to be sitting up in bed despite being identified as needing max assistance from two staff for mobility and transfer (moving from one place to another). 4. Failing to update the facility ' s policy and procedure (P&P) titled, Initial Fall Risk Assessment to reflect the current fall risk scoring system of the facility. Findings: 1. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on [DATE] and was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - inflammatory lung disease that causes obstructed airflow from the lungs), seizures, and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated [DATE], indicated the resident was able to make self understood and understands others. The MDS indicated Resident 1 required total assistance with two-person physical assist with bed mobility, transfer, and to walk in room. The MDS indicated Resident 1 ' s balance during transitions and walking was not steady and was only stabilized with staff assistance when moving from sitting to standing position, walking, and surface-to-surface transfer. A review of the General Acute Care Hospital 1 ' s (GACH 1) Discharge summary dated [DATE] indicated that Resident 1 had multiple episodes of seizures while in the emergency room (ER). A review of the GACH 1 ' s Discharge Instructions dated [DATE] indicated that Resident 1 ' s medical problems included a new onset seizure. A review of Resident 1 ' s Fall Risk Assessment (FRA) dated [DATE], indicated. that a total score of 18 or more would identify a resident as a high risk for fall. The FRA indicated that Resident 1 was scored a 16 by RN 1, identifying the resident as a low fall risk. Noted on the FRA under predisposing factors (conditions and activities that can lead to the development of falls), the diagnosis of seizure was not selected. Identification of a predisposing factor such as seizure would have accounted for four (4) additional points towards Resident 1 ' s total fall risk score. The FRA indicated that for any residents scoring 18 or more, the facility was to implement the following interventions: · Complete Fall Risk IDT · Initiate Falling Star/Super Star Care Plan · Complete Rehab Fall Risk Assessment · Assess for Environmental Hazards · Implement Useful Interventions A review of Resident 1 ' s Change of conditions (COC- a deterioration in health) dated [DATE], indicated, at 7:11 p.m., Resident 1 was found on the floor, parallel (lying in the same direction) to their bed. Resident 1 was facing upwards with the back of her head on the floor, and her upper back down to her thigh (upper leg) on the floormat. The COC further indicated that on the back of Resident 1 ' s head was a skin tear with minimal bleeding. The COC indicated that Resident 1 was found unresponsive with no pulse (heartbeat), CPR was initiated immediately and 911 was called at approximately 7:12 p.m. Paramedics arrived at 7:20 p.m., and CPR was continued. Resident 1 was pronounced dead at 7:46 p.m. On [DATE] at 1:13 p.m., during a concurrent interview and records review with the DON, DON reviewed Resident 1 ' s FRA dated [DATE]. DON stated that the assessment was done incorrectly because RN 1 failed to account of Resident 1 ' s diagnosis of seizures. DON stated that had RN 1 accounted for Resident 1 ' s diagnosis for seizures that would change the resident ' s total score from 16 to 20, and Resident 1 should have been identified as a high risk. On [DATE] at 3:11 p.m., during a concurrent interview and record review, the ADON reviewed Resident 1 ' s FRA dated [DATE]. ADON stated that the assessment was inaccurate because it did not reflect Resident 1 ' s diagnosis of seizure. ADON stated that the facility could have possibly tried additional interventions being that Resident 1 was a high fall risk. ADON stated interventions could have included things such as one to one care (one facility staff assigned to always remain with one resident), or an alarm device could have been utilized to alert staff if Resident 1 attempted to get out of bed. The ADON stated that because the FRA dated [DATE] was done incorrectly, the facility also failed to conduct the required Fall Risk IDT meeting. ADON stated that the facility did not do everything to prevent Resident 1 ' s fall on [DATE]. During a concurrent interview and record review on [DATE] at 9:23 a.m. with RN 1, Resident 1 ' s FRA dated [DATE] was reviewed. RN 1 stated that she did not include Resident 1 ' s diagnosis of seizure on the FRA. RN 1 stated that because she did not include Resident 1 ' s diagnosis of seizure, the resident was incorrectly identified as a low fall risk. RN 1 stated that had she correctly included Resident 1 ' s diagnosis of seizures, the resident would have been identified as a high risk for falls. RN 1 stated that the incorrect FRA dated [DATE] resulted in an inaccurate plan of care for Resident 1. RN 1 stated that had Resident 1 been correctly identified as a high fall risk, additional safety interventions could have been provided to the resident which included interventions such as conducting a Fall Risk IDT meeting. When RN 1 was asked if Resident 1 ' s fall on [DATE] was avoidable or unavoidable, RN 1 stated that the facility did not do everything to prevent the fall of Resident 1. A review of facility ' s policy and procedure titled, Initial Fall Risk Assessment, undated but reviewed on [DATE], indicated, A fall risk assessment will be completed within 72 hours for all new admissions and readmissions in order to prevent or reduce the episode of fall Each resident will be given a score, if the score is 18 or above, the resident will be considered as a high risk for fall and a plan of care will be established immediately for implementation of interventions to attempt prevention. 2. On [DATE] at 1:13 p.m., during a concurrent interview and record review with the DON, DON reviewed Resident 1 ' s FRA dated [DATE] completed by RN 1. DON stated that the FRA was done incorrectly because staff failed to account of Resident 1 ' s diagnosis of seizures. DON stated that had RN 1 accounted for Resident 1 ' s diagnosis for seizures that would change the resident ' s total score from 16 to 20, and Resident 1 would be identified as a high risk for falls. DON stated that for high fall risk residents, the facility should conduct a Fall Risk IDT meeting. After reviewing Resident 1 ' s medical records dated [DATE] to [DATE], DON stated that there was no Fall Risk IDT meeting held for Resident 1. DON stated that a Fall Risk IDT should have been done for Resident 1. On [DATE] at 3:11 p.m., during a concurrent interview and record review, the ADON reviewed Resident 1 ' s Fall Risk assessment dated [DATE]. ADON stated that the assessment was inaccurate because it did not reflect Resident 1 ' s diagnosis of seizure. The ADON stated that because the FRA dated [DATE] was done incorrectly, the facility failed to conduct the required Fall Risk IDT meeting for Resident 1. ADON stated that the facility did not do everything to prevent Resident 1 ' s fall on [DATE]. A review of facility ' s policy and procedure titled, Initial Fall Risk Assessment, undated but reviewed on [DATE], indicated, A fall risk assessment will be completed within 72 hours for all new admissions and readmissions in order to prevent or reduce the episode of fall Each resident will be given a score, if the score is 18 or above, the resident will be considered as a high risk for fall and a plan of care will be established immediately for implementation of interventions to attempt prevention. 3. During a record review of Resident 1 ' s Care Plan developed on [DATE], the plan indicated that Resident 1 had an episode of restlessness as evidence by trying to sit on the bed. During a record review of Resident 1 ' s Care Plan developed on [DATE], the plan indicated that Resident 1 had an episode of restlessness as evidence by Resident 1 placing her foot hanging on bed and further indicating that the resident moves a lot in bed. During a concurrent interview and record review on [DATE] at 2:56 p.m. with Minimum Data Set Coordinator (MDSC), MDSC reviewed Resident 1 ' s care plans for the two episodes of restlessness dated [DATE] and [DATE]. MDSC stated that after reviewing Resident 1 ' s care plans for the two episodes of restlessness dated [DATE] and [DATE], there were no safety interventions (a set of actions to reduce the risk of falls for all patients and focus on keeping the environment safe and comfortable) in the care plan for the resident ' s restlessness to prevent the resident from falling out of bed. The MDSC stated that after having reviewed the interventions listed in Resident 1 ' s care plans for the two episodes of restlessness dated [DATE] and [DATE], Resident 1 required an individualized care plan that included safety measures to reduce the risk for falls. On [DATE] at 3:11 p.m., during a concurrent interview and record review, the ADON reviewed Resident 1 ' s care plans for the two episodes of restlessness dated [DATE] and [DATE]. The ADON stated that Resident 1 ' s care plans for the two episodes of restlessness did not address fall risk or safety issues (a set of actions to reduce the risk of falls for all patients and focus on keeping the environment safe and comfortable). A review of facility ' s policy and procedure titled, The Resident Care Plan, undated, indicated that care plans are considered comprehensive in nature, and should be reviewed in its entirety. Problems, goals, and approaches can be addressed in more than one or different areas of the plan of care. 4. During a record review of the facility ' s policy and procedure titled Initial Fall Risk Assessment, undated, the policy indicated that each resident will be given a score based on the fall risk assessment. If the score is at least three (3) of five (5), the resident will be considered a moderate to high risk of fall and a plan of care will be established immediately for implementation of intervention to attempt prevention of fall. On [DATE] at 1:13 p.m., during a concurrent interview and records review with the DON, DON reviewed Resident 1 ' s FRA dated [DATE]. DON stated that the assessment was done incorrectly because RN 1 failed to account of Resident 1 ' s diagnosis of seizures. DON stated that had RN 1 accounted for Resident 1 ' s diagnosis for seizures that would change the resident ' s total score from 16 to 20, and Resident 1 should have been identified as a high risk. During a concurrent interview and record review on [DATE] at 1:13 p.m. with the DON, the facilities undated policy titled, Initial Fall Risk Assessment was reviewed. The DON stated that the facility did not update their policy for the initial fall risk assessment as the policy indicated the use of a different scoring criteria to identify high fall risk residents. DON stated that on the policy, a score of three out of five would indicate the resident was a high fall risk. DON stated that the facility had scored Resident 1 incorrectly with a score of 16 which had identified the resident as a low risk for falls. On [DATE] at 5:20 p.m., during an interview the DON, the DON was asked if the facility provided all the required services to Resident 1 in order to avoid the resident ' s fall incident on [DATE]. The DON did not answer to the question. On [DATE] at 10:51 a.m., during an interview with the ADM, the ADM was asked if the facility had provided all the necessary services and care to Resident 1 to have prevented the fall incident on [DATE]. The ADM stated that the facility provided services to the resident, however they were not enough. ADM stated that the provided services to Resident 1 were not adequate. ADM stated that the facility failed to provide some of the necessary services to avoid Resident 1 ' s fall on [DATE]. A review of facility ' s policy and procedure titled, Promoting Safety, Reducing Falls, reviewed on [DATE], indicated that if caregivers are to prevent the falls, they must first have a working knowledge of the key factors that determine which residents are most at risk.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) that was identified to have involuntary muscle movements of all extremities. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility readmitted Resident 1 on 12/12/2022, with diagnoses that included unspecified injury of head, laceration (a deep cut or tear in skin or flesh) without foreign body of other part of the head, anoxic brain damage (occurs when the brain is deprived of oxygen), mild cognitive (relating to the process of acquiring knowledge and understanding) impairment of uncertain or unknown etiology, personal history of traumatic brain injury (sudden injury that causes damage to the brain), and restlessness and agitation. A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 12/20/2322 indicated Resident 1's cognition was severely impaired. The MDS indicated Resident 1 was totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene. During an interview on 2/14/2023 at 12:30 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 is bed bound and he moves around a lot. LVN 1 stated Resident 1 throws his arms and legs around constantly. During a concurrent interview and record review on 2/14/2023 at 2:36 p.m., with the MDS Coordinator (MDSC), reviewed Resident 1 ' s medical record. The MDSC stated Resident 1 has involuntary movements of all his extremities. When asked if Resident 1 had a care plan for his involuntary movements, the MDSC stated he was unable to find a care plan specific to Resident 1 ' s involuntary movements of his extremities. The MDSC stated Resident 1 should have a care plan that is resident centered and specific to involuntary movements because the care plan will help staff provide proper interventions for the resident. A review of the facility-provided policy and procedure titled, The Resident Care Plan, undated, indicated healthcare professionals involved in the care of the resident shall contribute to the resident ' s care plan. Professionals from each discipline write the portion of the care plan that pertains to their field, including their approach to the resident ' s current problem(s) .Care plans are considered comprehensive in nature, and should be reviewed in its entirety .The care plan generally includes: 1. Identification of medical, nursing, and psychosocial needs; 2. Goals stated in measurable/observable terms; 3 Approaches (Staff action) to meet the above goals; 4. Discipline/staff responsible for approaches; 5. Reassessment and change as needed to reflect current status .It is the responsibility of the Director of Nursing to ensure that the professional involved in the care of the resident is aware of the written plan of care, including its location, the current problems of the resident, and the goals or objectives of the plan. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated for the presence of pressure ulcers (damage to the skin and underlying tissue because of prolonged pressure) on admission as per facility's policy. This deficient practice had the potential to delay necessary treatment and services to promote wound healing process. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/16/2022 with diagnoses including acute respiratory failure (a serious condition that makes it difficult to breathe on your own and develops when the lungs can't get enough oxygen into the blood) and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). A review of Resident 1's History and Physical exam, dated 12/19/2022, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 12/29/2022, indicated the resident was able to communicate their needs and required limited assistance with bed mobility and personal hygiene, and extensive assistance with dressing and toilet use. A review of Resident 1's admission Assessment (AA) dated 12/16/2022, indicated the resident's skin conditions were not assessed in the section of Skin Condition nor General Skin condition. A review of Resident 1's admission Reassessment (AR) dated 12/17/2022 (a day after admission), indicated the resident had suspected deep tissue injuries (SDTI - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) on the right ear, left ear, right heel, left heel, and sacrococcyx (the bottom area of the spine), and indicated the size and depth as follows: 1. Right ear: One centimeter (cm - units of measure) in length, two cm in width, and undetermined (not known) depth. 2. Left ear: One cm in length, one cm in width, and undetermined depth. 3. Right heel: Three cm in length, three cm in width, and undetermined depth. 4. Left heel: Three cm in length, three cm in width, and undetermined depth. 5. Sacrococcyx: Four cm in length, four cm in width, and undetermined depth. During a concurrent interview and record review on 1/25/2023 at 2:49 p.m., with Treatment Nurse 1 (TN 1 - licensed nurse focusing on wound treatments), reviewed Resident 1's AA dated 12/16/2022. TN 1 verified that the initial skin assessment was not done on the day of admission. TN 1 stated, the facility protocol was that the licensed nurse who admitted a new resident should assess the resident and document on the AA the first skin assessment upon arrival, if the TNs were not on duty. TN 1 stated, it was important to assess the resident's body conditions upon arrival at the facility to initiate the necessary treatments, if needed. During a concurrent interview and record review on 1/25/2023 at 3:30 p.m., with the Director of Nursing (DON), reviewed Resident 1's AA dated 12/16/2022 and the AR dated 12/17/2022. The DON verified that the licensed nurses did not perform the skin assessment when Resident 1 arrived at the facility on 12/16/2022. The DON stated, if the facility admitted the resident at the late evening and the treatment nurses were not available, the assigned license nurse for a new admission should assess the resident's body, document on the AA, and notify the physician, then start the necessary treatments as early as possible. The DON verified that the facility notified Resident 1's physician about the resident's skin conditions of SDTI on the right ear, left ear, right heel, left heel, and sacrococcyx and initiated wound treatments on 12/17/2022. A review of the facility's policy and procedures titled, Pressure Sore Management, undated, indicated, All available measures shall be taken to reduce skin breakdown and pressure sores On admission of Resident: The licensed nurse is to complete an initial admission assessment. This examination includes thorough body check of the resident. For Residents admitted with an Existing Pressure sore(s): A complete description of the pressure sore(s) shall be written in the comprehensive nursing assessment If the resident has no treatment orders for the pressure sore(s), an order is to be made. The name of the physician contacted and physician's response are to be noted in the resident's chart.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with the necessary behavioral health care services when the resident's psychological evaluation (a comprehensive evaluation focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) was not done timely as ordered by the physician. Resident 1 was ordered a psychological evaluation on 9/29/2022 and 11/14/2022, however, the evaluation was not done until 12/14/2022. This deficient practice had the potential to negatively affect the resident ' s psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being. Findings: A review of Resident 1 ' s admission Record indicated the resident was admitted to the facility on [DATE], and then readmitted on [DATE] with diagnoses including schizophrenia (a serious mental disorder that may interfere with a person ' s ability to think clearly, manage emotions, make decisions and relate to others) and anxiety disorder (a persistent feeling of anxiety or dread, which can interfere with daily life). A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and screening tool) dated 11/21/2022 indicated Resident 1 ' s cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) for daily decision making was severely impaired, and that the resident was totally dependent on staff with activities of daily living (ADL, such as bed mobility, dressing, eating, toilet use, and personal hygiene). A record review of Resident 1 ' s Census List dated 12/27/2022, indicated the followings: 1. Initial admission to the facility on 9/29/2022 and discharged to the General Acute Care Hospital (GACH) 10/23/2022. 2. readmitted to the facility on [DATE] and discharged to the GACH 10/31/2022. 3. readmitted to the facility on [DATE] and discharged to the GACH 11/9/20224. 4. readmitted to the facility on [DATE]. A record review of Resident 1 ' s Physician ' s Orders dated 9/29/2022, indicated psychological evaluation and follow up treatment as indicated. A record review of Resident 1 ' s Physician ' s Orders dated 11/14/2022, indicated psychiatrist consultation with treatment and follow up treatment as indicated. During a concurrent interview and record review on 12/27/2022 at 4:30 p.m., with the Director of Nursing (DON), Resident 1 ' s Gero-Psychiatry (study of mental illnesses and disorders affecting older adults) Initial Evaluation form dated 12/14/2022 was reviewed. DON stated that Resident 1 ' s first psychological evaluation was done on 12/14/2022. The DON stated that Resident 1 hospitalized several times and missed the Psychiatric Nurse Practitioner (Psych NP) ' s regular visits on a monthly basis, and the Psych NP would not visit the facility for only one patient ' s treatment. A review of the facility ' s Policy and Procedures (P&P) revised 3/2014, titled Behavioral Management Committee indicated, Psychiatric/Psychological referral will be made as indicated.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a resident's notice of proposed transfer and discharge was provided to the resident at least 30 days prior to discharge or as soon as practicable for one of three sampled residents. (Resident 1). Resident 1 was given the notice of discharge the same day of discharge 12/2/2022. This deficient practice resulted in Resident 1 ' s rights to be violated had the potential to deprive the resident with the right to be informed of their rights regarding transfer and discharge, which included the resident's right to file an appeal to the appropriate agency within 10 days of being notified of a proposed transfer and discharge. Findings: A review of Resident 1 ' s admission Record indicated the facility originally admitted the resident on 10/28/2022 with diagnoses including acute gastric ulcer (open sores that develop on the lining of the stomach) with perforation (complication of gastric ulcers is the lining of the stomach splitting open) and surgery to repair the perforation. A review of Resident 1 ' s History and Physical exam, dated 10/31/2022, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care-planning tool), dated 11/10/2022, indicated Resident 1 required limited assistance with bed mobility, transfer, dressing, and toilet use, and required supervision with walking in room, eating, and personal hygiene. A review of the Physician ' s Order for Resident 1, dated 11/30/2022, indicated to discharge the resident home Friday 12/02/2022 with Home Health for Registered Nurse (RN) and Physical Therapy evaluation for safety evaluation. A review of Resident 1 ' s Notice of Transfer/Discharge, dated 12/2/2022, indicated the date of the notification was dated 12/2/2022. On 1/3/2023 at 11:10 a.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent record review, ADON stated the Notice of Transfer/Discharge was given to Resident 1 on the day of discharge 12/2/2022. The ADON could not explain the lack of sufficient time of the notice of discharge. The facility provided policy and procedure titled Proposed Transfer and Discharge Notice, dated 1/2004 indicated a written notice is to be provided to the resident and, if known, a family member or resident ' s personal representative, of the reasons for the transfer or discharge as soon as practicable before the transfer or discharge takes place.

Nov 2022 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

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Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1), who required a knee immobilizer (removable devices that maintain stability of the knee) after a fracture (complete or partial break in a bone) of the right femur (thigh bone or upper hind limb). This deficient practice had the potential to delay healing and have complications from Resident 1's fracture. Findings: A review of Resident 1 ' s admission record indicated the facility admitted the resident on 6/13/2019, with diagnoses including fracture of right femur, congestive heart failure (condition in which the heart doesn't pump blood as well as it should), unspecified osteoarthritis (the most common form of arthritis (inflammation or swelling of one or more joints), Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), and unspecified dementia (A group of thinking and social symptoms that interferes with daily functioning). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/22/2021, indicated Resident 1's cognitive (relating to the process of acquiring knowledge and understanding) was severely impaired. Resident 1 was totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of the Physician ' s Order for Resident 1, dated 10/29/2022, timed at 6:30 p.m., indicated to apply a knee Immobilizer to the right lower extremity (RLE) always every shift. On 11/14/2022 at 11:26 a.m., during an interview with the Assistant Director of Nursing (ADON) and concurrent review of Resident 1 ' s record, the ADON was unable to find a care plan addressing Resident 1 ' s right knee immobilizer. The ADON stated a care plan is necessary for staff to provide the necessary intervention to Resident 1. A review of the facility provided policy and procedure titled The Resident Car Plan, undated, indicated healthcare professionals involved in the care of the resident shall contribute to the resident ' s care plan. Professionals from each discipline write the portion of the care plan that pertains to their field, including their approach to the resident ' s current problem(s). Care plans are considered comprehensive in nature and should be reviewed in its entirety. The care plan generally includes: 1. Identification of medical, nursing, and psychosocial needs; 2. Goals stated in measurable/observable terms; 3 Approaches (Staff action) to meet the above goals; 4. Discipline/staff responsible for approaches; 5. Reassessment and change as needed to reflect status. It is the responsibility of the Director of Nursing to ensure that the professional involved in the care of the resident is aware of the written plan of care, including its location, the current problems of the resident, and the goals or objectives of the plan. It is the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated.

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

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Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided to prevent the formation of and promote healing of pressure sores (areas of damaged skin caused by staying in one position for too long) for one of three sample residents (Resident 1). The facility did not ensure: a. Resident 1 ' s low air loss (LAL) mattresses (mattress designed to prevent and treat pressure sores by reducing pressure) was on the correct settings per manufacture ' s guidelines. b. Resident 1 ' s heel protectors (tool in the prevention, management, and treatment of heel pressure sores) were placed as ordered. These failures had the potential to result in delayed healing of pressure sores and placed Resident 1 at risk for developing or worsening pressure sores. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/13/2019, with diagnoses including fracture (break) of right femur (the long bone of the leg), congestive heart failure (condition in which the heart does not pump blood as well as it should), unspecified osteoarthritis (the most common form of arthritis (inflammation or swelling of one or more joints), Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), and unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/22/2021 indicated the resident's cognitive (relating to the process of acquiring knowledge and understanding) was severely impaired. Resident 1 was totally dependent on staff with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of the Physician ' s Order for Resident 1, dated 6/10/2021, indicated to use a LAL mattress for skin care and management. A review of the Physician ' s Order for Resident 1, dated 9/9/2021, indicated to apply to the resident heel protectors to both feet. During an observation on 11/8/2022 at 2:01 p.m., Resident 1 was in bed not wearing bilateral heel protectors. During an observation and concurrent interview Treatment Nurse 1 (TN 1) on 11/8/2022 at 2:47 p.m., Resident 1 was in bed on a LAL mattress. TN 1 stated that low air loss mattresses are adjusted based on resident ' s weight. TN 1 confirmed the setting on Resident 1 ' s LAL mattress was on #8. TN 1 stated the setting #8 was too firm for Resident 1 and the correct setting was on #4. On 11/9/2022 at 11:19 a.m., during an observation of Resident 1 in the presence of Registered Nurse 1 (RN 1), Resident 1 was in bed and not wearing bilateral heel protectors. RN 1 stated Resident 1 should be wearing heel protectors to help maintain Resident 1 ' s heels off pressure. A review of the facility provided manufacturer ' s guidance for the LAL mattress indicated: Select the appropriate therapy adjust level to prevent bottoming out (i.e., providing greater than one inch of air between the patient ' s sacral area/buttocks and the lower safety mattress): .2. Select the highest or most firm Therapy adjust setting. 3. Hand check: Place a hand with three (3) fingers (if head of bed at 30° or higher) or four (4) fingers (if head of bed lower that 30°) stacked vertically beneath the cell of the mattress and above the safety mattress directly between the lowest point of the patient ' s sacral area/buttocks. The smallest finger should be resting on the safety mattress. 4. Sequentially reduce the Therapy Adjust setting to the firmness level where the height of the three (3) or four (4) fingers can slide with minimal resistance between the patient ' s sacral area/buttocks and the lower safety mattress. This is the proper Therapy Adjust setting for the patient to assure proper inflation of the air cells and prevent bottoming out of the mattress. 5. Document the patient ' s Therapy Adjust setting for future reference and re-evaluate with the hand check as the patient ' s condition warrants. A review of the facility undated policy titled, Pressure-Reducing Mattresses, indicated to provide mattresses that will prevent and/or minimize pressure on the skin. A review of the facility provided policy titled Pressure Sore Management, undated, indicated all available measures shall be taken to reduce skin breakdown and pressure sores.

Nov 2021 11 deficiencies

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement the resident`s care plan (a care plan helps nurses and other care team members organize aspects of patient care according to a timeline) by not providing communication board or aid, for one of one sampled resident (Resident 125) investigated under the care area comprehensive care plans. This deficient practice had the potential to result in a failure in delivering necessary care and services to the resident. Findings: A review of Resident 125's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to, hypertension (high blood pressure), altered mental status (a general term used to describe various disorders of mental functioning ranging from slight confusion to coma), and hyperlipidemia (an abnormally high concentration of fats in the blood). A review of Resident 125's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/202/2021, indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making was severely impaired. The MDS also indicated that Resident 125 required extensive assistance for transfer, toilet use, personal hygiene, and bathing. On 11/08/2021 at 9:45 a.m., during an observation and interview with Resident 125, the resident responded when spoken to by gesturing and saying something in a language which was not in English. At the time of the observation, Certified Nurse Assistant 1 (CNA 1) entered the room. CNA 1, when asked, stated that the resident communicates with her thru hand gestures and CNA 1, after looking and sifting thru the resident`s bedside table and the resident`s immediate surrounding, stated that there was is no communication board in the resident`s language. On 11/15/2021 at 10:07 a.m., during an observation, interview, and record review, the Assistant Director of Nursing (ADON) stated Resident 125's care plan included an intervention to provide communication aid in resident`s preferred language. Accompanied by the ADON, a thorough observation (inspection) of the resident`s bedside table and surroundings indicated that there was no communication board or aid made available for the resident. According to the ADON, a communication board can help a resident communicate their specific needs and without it, the resident would feel that he/she cannot express what he/she needs to convey. A review of Resident 125`s care plan, initiated on 12/18/2020, indicated a goal for the resident to be able to relate to others effectively daily, and an intervention to provide resident with a communication board in his/her native language pointing to appropriate need. A review of the facility`s undated policy and procedure titled The Resident Care Plan, indicated that the care plan shall be implemented for each resident on admission and developed throughout the assessment process. A review of the facility`s undated policy and procedure titled Accommodation of Needs Related to Communication Deficits, indicated that communication needs will be identified and appropriate interventions, including care planning, will be developed in order to accommodate the needs of the resident.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor and document a skin discoloration to resident's right upper extremity and promptly notify the physician of the change of condition for one of one (Resident 175) resident reviewed. This deficient practice had the potential to result in a delay or lack of delivery of care and services to Resident 175. Findings: a. A review of Resident 175's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including cerebral infarction (refers to damage to tissues in the brain due to loss of oxygen to the area), contracture (abnormal shortening of muscle tissue) of the right hand, and history of falling. A review of Resident 175's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 09/09/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the resident was totally dependent on staff with activities of daily living (ADLs). During a concurrent observation and interview on 11/09/2021 at 11:17 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 175 in bed. The resident had skin discoloration to upper bilateral extremities. LVN 1 stated there is no documentation of the skin discoloration in the resident's progress notes and skin assessment notes. LVN 1 stated residents' skin condition should be assessed daily. The discoloration should be monitored because it could get worst, or it could lead to bleeding. If there is a change in the resident's skin condition, further assessment will be conducted by the Registered Nurse (RN), and the physician and the resident's party will be notified. During an interview on 11/12/2021 at 02:38 p.m., with the Director of Nursing (DON), the DON stated Resident 175's skin discoloration is being investigated, and the physician and the family has been notified of the change of condition. The DON stated skin checks are to be done during showers, daily and weekly. A review of the facility's policy and procedures titled, Change of Condition, last reviewed by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated all changes of condition in a resident shall be handled promptly, upon a change of condition for any reason, nursing staff members are to contact the physician promptly and documentation of change in condition shall be performed by the Licensed Nurse accordingly.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Resident 102's environment was free from accident hazards when not provided with a low bed and floor mats (a bedside cushion that minimizes the severity of injury if a resident fell from his/her bed), for one out of two sampled residents investigated for falls. This deficient practice had the potential to increase the risk for falls with injury for Resident 102. Findings: A review of Resident 102's admission Record indicated the resident was originally admitted , on 06/11/2010 and readmitted on [DATE], with diagnoses that included nontraumatic intracranial hemorrhage (bleeding inside the skull or brain), epilepsy (a neurological disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness), contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) on the right elbow, contracture on the right hand, contracture on the right ankle, contracture of muscles on multiple sites, and joint disorder. A review of Resident 102's Minimum Data Set (a standardized assessment and care screening tool), dated 09/10/2021, indicated the resident had severe impairment in cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of the Order Summary Report, dated 10/30/2021, indicated: 1. Resident 102 was to receive a floor mat to decrease potential injury, ordered on 02/28/2021. 2. Resident 102 was to receive a low bed to decrease potential injury, ordered on 02/28/2021. 3. Resident 102 was to be in super star program, ordered on 06/01/2020 A review of Resident 102's Fall Risk Assessment, dated 09/10/2021, indicated the resident received a score of 20. The form indicated that a total score of 18 or more represents high risk for falls. A review of Resident 102's super star care plan, initiated on 02/24/2018, indicated the resident had a history of falling and was at risk for injuries because of a balance deficit and poor safety awareness. The care plan's goal was for Resident 102 to reduce his risk of falls and injury through appropriate interventions. A review of Resident 102's care plan, revised on 06/09/2020, indicated the resident was to be on a low bed with floor mat in bed. The care plan's goal was to prevent and reduce incidents of injury/fall as well as for comfort of getting in and out of bed. A review of Resident 102's care plan, initiated on 02/24/2018, indicated the resident had an expected behavior of sometimes rolling from his bed to the floor mat and had a history of falls that placed him at risk for further falls. The care plan's goal was for the resident to minimize his risk of injury through appropriate interventions. During an observation, on 11/08/2021 at 8:56 a.m., Resident 102 was asleep in bed. The resident's bed was observed with no floor mats by the bed and was not in a low to the ground. During a concurrent observation and interview, on 11/08/2021 at 3:47 p.m., Certified Nursing Assistant 5 (CNA 5) verified that Resident 102's bed was not in a low to the ground and did not have floor mats. CNA 5 stated the resident's bed was in a high position because that was the resident's preference. CNA 5 also stated the resident was not at risk for falls because he was alert. During a concurrent interview and record review, on 11/10/2021 at 10:09 a.m., Minimum Data Set Nurse 1 (MDSN 1) stated Resident 102 was at high risk for falls. MDSN 1 stated the resident was at high risk for falls because he had weakness on one side of his body and multiple contractures. MDSN 1 stated the resident was not alert. MDSN 1 stated Resident 102 should have a low bed with floor mats. During an interview, on 11/15/2021 at 9:05 a.m., the Director of Staff Development (DSD) stated that residents were placed on the super star program when they have a history of falls. The DSD stated Resident 102 was to have floor mats and a low bed. During an interview, on 11/15/2021 at 9:14 a.m., the Director of Nursing (DON) stated that residents on the super star program should have safety devices such as a low bed and floor mats. A review of the facility's undated policy titled, Super Star Program - For Severely High-Risk Residents at Risk For Falls & Injuries, indicated to provide the resident with a low bed with mat and padding.

CONCERN (E)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for Resident 10 and Resident 14. This deficient practice had the potential to result in a delay in or lack of necessary care and services that can negatively affect the residents' comfort and well-being. Findings: a. A review of Resident 10's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke), vascular dementia (brain damage by multiple strokes), and heart failure (the heart is unable to provide adequate blood flow to other organs). A review of Resident 10's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 07/24/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the resident required extensive assistance of one person with transfer, toilet use, and bathing. A review of Resident 10's care plan initiated on 07/20/2021, indicated the resident had a history of fall and was at risk for further falls and/deficit, or injuries secondary to balance deficit, cognitive impairment, poor safety awareness, and unsteady gait. The interventions included to remind and encourage resident to call for help/assistance and to keep call light within easy reach. On 11/08/2021 at 09:39 a.m., during a concurrent observation and interview with Certified Nursing Assistant 4 (CNA 4), observed Resident 10 in bed with her eyes close. Resident 10's call light was observed on the floor. CNA 4 stated the call light should always be next to the resident. CNA 4 placed the call light next to the resident. On 11/12/2021 at 02:40 p.m., during an interview with the Director of Nursing (DON), the DON stated Resident 10 is at risk for fall and able to call staff for assistance. The DON stated the call light should be within the resident's reach. A review of facility policy and procedures titled, Call Lights, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated to assure residents receive prompt assistance, all staff shall know how to place the call light for a resident and how to use the call light system and ensure that the call light is within the resident's reach when the resident is in his/her room or when in the toilet. b. A review of Resident 14's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] and was most recently readmitted on [DATE], with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed), hypotension (abnormally low blood pressure), and history of falling. A review of Resident 14's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 07/24/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the resident required assistance of one person with activities of daily living. On 11/08/2021 at 09:17 a.m., during a concurrent observation and interview with Registered Nurse 2 (RN 2), observed Resident 14 in bed with her eyes close. The resident's call light cord was wedged between the side rail and the bed, with the call light button hanging from the bed. RN 3 stated the call light should be within the resident's reach. The CNAs should make sure to place the call light within residents' reach after the CNAs provide care and reposition the residents. On 11/09/2021 at 10:35 a.m., during an interview with the Infection Control Preventionist (IPN) (ICP), the IPN ICP stated the resident calls for assistance and uses the call light. A review of Resident 14's care plan initiated on 01/29/2018, indicated the resident was is at risk for falls/injury with interventions including placing items frequently used within her reach and placing the call light within easy reach. A review of facility policy and procedures titled, Call Lights, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated to assure residents receive prompt assistance, all staff shall know how to place the call light for a resident and how to use the call light system and ensure that the call light is within the resident's reach when the resident is in his/her room or when in the toilet.

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure documented evidence were in the residents' medical records indicating staff have informed and provided residents and/or their responsible party with written information regarding the right to formulate an advance directive (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three (Resident 14, 45, and 48) of 19 residents reviewed under the advance directive care area. This deficient practice violated residents' and/or their representatives' right to be fully informed of the option to formulate an advance directive and had the potential to cause conflict due to lack of communication regarding residents' wishes about their medical treatment. Findings: a. A review of Resident 14's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] and was most recently readmitted on [DATE], with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed), hypotension (abnormally low blood pressure), and history of falling. A review of Resident 14's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 07/24/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the resident required assistance of one person with activities of daily living. A review of Resident 14's History and Physical (H&P) dated 08/10/2021, indicated the resident does not have the capacity to make decisions. During a concurrent interview and record review, on 11/09/2021 at 10:43 a.m., with Infection Control Preventionist (IPN), Resident 14's Advanced Directive was reviewed. IPN stated the Advanced Directive and Acknowledgment form (document which indicates the acceptance of information regarding Advanced Directives was provided) was not in the resident's chart. During an interview with the Social Services Director (SSD) on 11/10/2021 at 09:36 a.m., the SSD stated that upon admission the residents and/or their responsible party are/is provided with an Advance Directive Acknowledgment form to complete and information on how to formulate Advance Directive is also provided if there is not on in place. The SSD stated the Advance Directive will give the facility information of the residents' choices regarding his or her care and treatment decisions and indicate if they have appointed someone else to make healthcare decisions for them. A review of facility policy and procedures titled, Advance Directive Acknowledgment last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated an Advance Directive acknowledgment will be provided to residents and/or responsible parties upon admission; they will be informed of the availability of options of medical care providers advance directive regarding the residents' health care decisions. b. A Resident 45's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including paraplegia (impairment in motor or sensory function of the lower extremities), pneumonia (infection that inflames air sacs in one or both lungs), and anemia (a condition in which the blood does not have enough healthy red blood cells). A review of Resident 45's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 08/17/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. A review of Resident 45's History and Physical (H&P) dated 08/10/2021, indicated the resident has the capacity to make decisions. During a concurrent interview and record review, on 11/09/2021 at 10:23 a.m., with Infection Control Preventionist (IPN) (ICP), Resident 45's Advanced Directive was reviewed. IPN ICP stated the Advanced Directive and Acknowledgment form (document which indicates the acceptance of information regarding Advanced Directives was provided) was not in the resident's chart. During an interview with the Social Services Director (SSD) on 11/10/2021 at 09:36 a.m., the SSD stated that upon admission the residents and/or their responsible party are/is provided with an Advance Directive Acknowledgment form to complete and information on how to formulate Advance Directive is also provided if there is not on in place. The SSD stated the Advance Directive will give the facility information of the residents' choices regarding his or her care and treatment decisions and indicate if they have appointed someone else to make healthcare decisions for them. A review of facility policy and procedures titled, Advance Directive Acknowledgment last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated an Advance Directive acknowledgment will be provided to residents and/or responsible parties upon admission; they will be informed of the availability of options of medical care providers advance directive regarding the residents' health care decisions. c. A review of Resident 48's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) and encephalopathy (a brain disease that alters brain function or structure). A review of Resident 48's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 08/17/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. A review of Resident 48's History and Physical (H&P) dated 08/12/2021, indicated the resident does not have the capacity to make decisions. During a record review of Resident 48's Advance Directive, the Advance Directive Acknowledgment form (document which indicates the acceptance of information regarding Advanced Directives was provided) was not in the resident's chart. During an interview with Social Services Director (SSD) on 11/12/2021 at 01:59 p.m., the SSD stated that upon admission the residents and/or their responsible party are/is provided with an Advance Directive Acknowledgment form to complete and information on how to formulate Advance Directive is also provided if there is not on in place. The SSD will follow-up with the resident's responsible if the resident does not have the capacity to make decisions or if the resident is non-verbal. A review of facility policy and procedures titled, Advance Directive Acknowledgment, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated an Advance Directive acknowledgment will be provided to residents and/or responsible parties upon admission; they will be informed of the availability of options of medical care providers advance directive regarding the residents' health care decisions.

CONCERN (E)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 83's admission Record indicated the resident was originally admitted to the facility, on 02/28/2018 and readmitted on [DATE], with diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), encounter for attention to gastrostomy, adult failure to thrive (a state of decline manifested by weight loss, decreased appetite, poor nutrition, and inactivity), and dysphagia (difficulty swallowing). A review of Resident 83's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 08/31/2021, indicated the resident was severely impaired in cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and was totally dependent on staff for transfers, dressing, eating, toilet use, and personal hygiene. A review of the Order Summary Report, dated 10/30/2021, indicated the following physician's orders: 1. Resident 83 was to receive enteral feed (a special liquid food mixture containing protein, carbohydrates, fats, vitamins and minerals, given through a tube into the stomach or small intestine) order every shift. G-tube feeding (GTF) of Jevity 1.5 at 65 cubic centimeters (cc/hour (hr) for 20 hours via pump to provide 1300 cc/1950 kilocalories (kcal-calories)/day. Turn pump on at 12 p.m. and off at 8 a.m. until total volume is infused. 2. Resident 83 was on aspiration (when food or liquid goes into the airway) precaution and to elevate head of bed (HOB) at least 30-45 degrees at all times during g-tube feeding. A review of Resident 83's care plan, initiated on 05/30/2019, indicated the resident was on g-tube feeding and was at risk for aspiration, dehydration, weight fluctuation, weight gain, weight loss, nausea and vomiting, abdominal distension (when the stomach is measurably swollen beyond its normal size), diarrhea, constipation, intolerance to feeding, and infection at the g-tube site related to dysphagia and failure to thrive. The care plan's goals indicated that the resident would minimize the risk of aspiration and feeding intolerance daily. The care plan's interventions were to keep the head of the bed (HOB) elevated. During an observation, on 11/08/2021 at 8:35 a.m., Resident 83 was awake in bed. The resident was observed receiving g-tube feeding with the bed was flat. During concurrent observation and interview, on 11/08/21 at 9:17 a.m., Registered Nurse 2 (RN 2) confirmed that the resident's bed was flat. RN 2 stated the head of the resident's bed should be up at least 30 degrees while the resident received g-tube feeding in order to prevent aspiration. During an interview, on 11/15/2021 at 9:01 a.m., the Director of Staff Development (DSD) stated the resident's head of the bed should be up at least 30 to 45 degrees to prevent aspiration. During an interview, on 11/15/2021 at 9:11 a.m., the Director of Nursing (DON) stated she taught the nurses that the resident's head of the bed should elevated to at least 30 to 45 degrees to prevent aspiration. A review of the facility's undated policy titled, Gravitational Enteral Feedings, indicated the head of the bed should be elevated at least 30 degrees during the feeding and for 30 to 60 minutes after the feeding to prevent aspiration. c. A review of Resident 16's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including cerebral infarction (stroke - brain lesion in which a cluster of brain cells die when they don't get enough blood) and dysphagia (difficulty in swallowing). A review of Resident 16's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 10/25/2021, indicated the resident was in a persistent vegetative state with no discernible consciousness. The MDS indicated the resident was totally dependent on staff with activities of daily living (ADLs). A review of Resident 16`s Order Summary Report indicated a physician`s order dated 10/20/2021, for Glucerna 1.2 (tube feeding formula) at 55 cubic centimeter per hour (cc/hr - units of measurement) via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration) feeding pump for 20 hours to provide 1100 cc/1,320 kilocalories per day (kcal/day). Turn off GT feeding at 8 a.m. and turn on at 12 p.m. until total volume is infused. On 11/09/2021 at 9:49 a.m., during a room observation, observed Resident 16 in bed with GT feeding pump off at that time. Upon closer inspection, the label in the formula bottle had all the information but the start time (time bottle was hung) only indicated 11-7. On 11/15/2021 at 10:51 a.m., during an interview and record review, the Assistant Director of Nursing (ADON) stated that the formula bottle should indicate what was the order, the date and the time when a new bottle was hung, and the nurse`s signature. According to the ADON, they need to write the specific when the formula bottle was hung so that they can check how much quantity has been infused. The ADON also stated, if time is not indicated, there is no way you can compute how many cc or milliliters (ml - unit of measurement) were infused on a certain time frame. A review of Glucerna 1.2 cal label, indicated that the following information should be written: 1. Patient 2. Room number 3. Date 4. Start a.m./p.m. 5. Rate ml/hr d. A review of Resident 69's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including anoxic brain damage (harm to the brain due to a lack of oxygen) and dysphagia (difficulty in swallowing). A review of Resident 69's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 08/28/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the resident was totally dependent on staff with activities of daily living (ADLs). A review of Resident 69`s Order Summary Report indicated a physician`s order dated 10/24/2021, for Jevity 1.2 cal (is fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) at 50 cubic centimeters per hour (cc/hr - unit of measurement) via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration) feeding pump for 20 hours to provide 1000 cc/1,200 kilocalories per day (kcal/day). Turn off GT feeding at 8 a.m. and turn on at 12 p.m. until total volume is infused. On 11/09/2021 at 9:43 a.m., during a room observation, observed Resident 16 in bed with GT feeding pump off at that time. Upon closer inspection, the label in the formula bottle had all the information but the start time (time bottle was hung) only indicated 11-7. On 11/12/2021 at 02:45 a.m., during an interview and record review, the Director of Nursing (DON) stated the bottle formula label should indicate the room number, name of the patient, date and time started, and the rate. The DON stated, the time has to be specific so you know when to change the formula bottle because they only have 48 hours or depending on the bottle. According to the DON, the formula bottle should also indicate what is the order and when was the bottle hung. The DON also stated, the time must be specific and writing 11-7, was not acceptable. A review of Jevity 1.2 cal label, indicated that the following information should be written: 1. Patient 2. Room number 3. Date 4. Start a.m./p.m. 5. Rate ml/hr A review of the facility-provided undated Jevity 1.2 cal Precautions indicated to follow directions for use provided by manufacturer of feeding sets. Unless a shorter hang time is specified by the set manufacturer, hang product for up to 48 hours after initial connection when clean technique and only one new set are used. Otherwise, hang for no more than 24 hours. Based on observation, interview, and record review, the facility failed to ensure four out of five sampled residents investigated for tube feeding received appropriate care and services by failing to: 1. Check the resident's gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration placement prior to administering medications to Resident 96. 2. Flush the GT before and after administering medications for Resident 96. 3. Elevate the resident's head of bed prior to administering medications for Resident 96. 4. Ensure Resident 83's head of the bed was elevated at least 30 degrees while the resident received gastrostomy tube feeding. 5. Indicate the hang time (time when feeding started) of the gastrostomy tube feeding nutrition formula for Residents 69 and 16. These deficient practices had the potential to cause complications, such as tube clogging and aspiration (breathing in of a foreign substance into the lungs) for Residents 96 and 83; and had the potential to result in inaccurate computation of the total formula infused for a certain number of hours that can lead to Residents 69 and 16 not meeting the amount required to meet their nutritional needs. Findings: a. A review of the admission Record (face sheet), indicated Resident 96 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions [sudden, violent, irregular movement of a limb or of the body], associated with abnormal electrical activity in the brain). A review of the History and Physical (H & P) dated 7/07/2021, indicated, Resident 96 was non-communicative, non-ambulatory, and was able to move left-side extremities. The H & P also indicated the resident was at high risk for aspiration (breathing foreign objects into the airway), infections, and sepsis (infection of the blood). A review of the Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 9/07/2021, indicated Resident 96 required extensive assistance from staff with bed mobility and dressing; and was totally dependent with transfer, locomotion on unit, eating, toilet use, personal use, and bathing. A review of Resident 96's Order Summary Report indicated the physician's orders as follows: 1. Amantadine hydrochloride (medication for uncontrolled muscle movements) syrup 50 milligrams/5 milliliters (mg/ml - unit of measurement), give 10 ml via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration); order date: 07/06/2021. 2. Amlodipine besylate (blood pressure medication) tablet (tab) 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 3. Dilantin suspension (medication to manage epilepsy) 125 mg/5 ml, give 35 ml via GT; order date: 08/12/2021. 4. Eliquis (anticoagulant - blood thinner) tablet 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 5. Levetiracetam (Keppra - medication to manage epilepsy) solution 500 mg/5ml, give 15 ml via GT; order date: 07/06/2021. 6. Tylenol (medication to manage generalized body pain) tablet 325 mg, give 2 tablets via GT; order date: 07/06/2021. On 11/08/2021, at 10:11 a.m., during medication administration observation for Resident 96 and a concurrent interview, observed the following medications given by Registered Nurse (RN 1): 1. Eliquis 2.5 mg 1 tab via GT 2. Amlodipine 2.5 mg 1 tab via GT 3. Amantadine 50mg/5ml, 10 ml via GT 4. Levetiracetam solution 100mg/ml, 15 ml via GT 5. Tylenol 325 mg 2 tabs via GT Observed RN 1 crushed Eliquis, amlodipine, and Tylenol all together and combined with all liquid medications (amantadine and levetiracetam) together and loaded in one syringe. When she passed (administered) the medications, RN 1 did not check the placement of GT and did not flush the GT before and after administering medications. Observed Resident 96 sliding down to the middle of the bed, so his position was not proper to receive any medications, because his head of bed was not elevated 30 to 45 degrees up; however, RN 1 did not reposition Resident 96 prior to administering medications. When asked, RN 1 she stated she should have separated each medicine in separate cups and crushed the medications one at a time due to possible interactions; changed the resident's position prior to administering medications; checked GT placement; and flushed GT before and after medication pass. RN 1 stated, she was too busy to follow all the procedures properly, because she still needed to pass nine more residents' medications. On 11/15/2021, at 2:30 p.m., during an interview with the Assistant Director of Nursing (ADON), she verbalized steps when passing (administering) medications via GT as follows: 1. Knock the door 2. Introduce self to the resident 3. Wash hands 4. Check/ask pain level and ask what kind of pain medication resident wants for the severity of pain 5. Measure vital signs prior to passing blood pressure pills 6. Check the arm band of resident 7. Pull the curtains for privacy 8. Put each medication in separate cups and crush individually 8. Check residual of GT 9. Flush GT with 30 mL of water first 10. Flush GT with 5 to 10 ml of water in between medications The ADON stated, she offers in-services to staff for competency (measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in order to perform occupational functions successfully) and do skills check (validation of skills). She added, if anyone does not follow, staff will be required more in- services. The ADON was asked how she checks skills and competencies. She stated, she would interview nurses and evaluate them. A review of the facility's undated policy and procedures, titled, Medication Administration via Gastrostomy or Nasogastric (supplying the stomach via the nose) Tube, indicated to check tube placement by inserting 10 cubic centimeters (cc) of air and listen with stethoscope for whoosh sound below xiphoid process (lowest segment of the breastbone). Aspirate for gastric contents for GT, reinserting gastric contents. Place medication in separate cups, and then place each medication in pill crusher pouch for crushing. Crushed medication may then be placed in a plastic cup with approximately 10 cc of water prior to placement of medications in cup. All medications will be administered appropriately and separately. Pour medication into syringe barrel 30 cc at a time and tilt the tube to allow air to escape as fluid flows downward; instillation may require actuating the syringe plunger (the part that moves up and down inside a syringe to push contents out of the syringe) to ensure that medications are instilled if gravity method is ineffective. Medications requiring crushing may be crushed and mixed with approximately 10 cc of water and administered via GT. Approximately 10 cc of water should be administered after each medication. Antihypertensive should be administered separately after apical pulse/blood pressure is taken. The enteral feeding (feeding tube) should be flushed with at least 30 cc of water before and after medications are administered.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 90's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including migraine (a medical condition which usually causes a pounding, throbbing headache on one side of the head), malignant neoplasm of breast (uncontrolled growth of abnormal cells in the breasts) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 90's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/02/2021 indicated the resident`s cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making were intact. The MDS indicated the resident required supervision with transfer, dressing, toilet use; and limited assistance with bathing. On 11/10/2021 09:27 a.m., during a medication pass observation with Licensed Vocational Nurse 5 (LVN 5) and concurrent record review, Resident 90`s due medications were prepared and during the preparation of the tramadol order, LVN 5 opened the binder containing the Antibiotic or Controlled Drug Record, which indicated that tramadol 50 milligrams (mg - unit of measurement) tablets were not initialed as given on 11/08/2021 and 11/09/2021. The bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover) containing the medication indicated that the number of tramadol in it was 20 tablets which corresponded to the number in the Antibiotic or Controlled Drug Record. Upon review with LVN 5, the Electronic Medication Administration Record (eMAR) eMAR for the month of November 2021, indicated that tramadol were initialed as administered. On 11/10/2021 at 10:15 a.m., during an interview and record review of the Antibiotic or Controlled Drug Record, with Infection Control Preventionist (IPN), and attested to by IPN that 11/08/2021 and 11/09/2021 doses were not signed out as given. According to the IPN, Resident 90 could have been in pain and left untreated. Per IPN, she cannot explain what had happened. A review of the facility`s undated policy and procedure, titled Med Pass, indicated in the basic procedure to prepare the medication correctly, administer the medication correctly, and chart the med pass correctly; a discrepancy in the med sheet is a discrepancy between the supply of a medication available and the amount of medication required by the resident`s chart. Discrepancies in the med sheet are to be handled accordingly: 1. Double-check the chart to be handled accordingly 2. Make appropriate correction to the med sheet or add a direction change sticker to the label. 3. Make appropriate correction to MD orders in chart and/or recap page, or write a clarification order. Based on observation, interview, and record review, the facility staff failed to: 1. Check the resident's arm band for Resident 96's identity 2. Check Resident 96's pulse and blood pressure prior to administering blood pressure medication 3. Elevate Resident 96's head of bed prior to administering medications via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration) 4. Check Resident 96's GT placement prior to administering medications 5. Flush Resident 96's GT before and after administering medications 6. Separately crush Resident 96's medications and not to combine and administer medications via GT 7. Ensure physician`s medication orders for tramadol (can treat moderate to severe pain) were administered on 11/08/2021 and 11/09/2021 for one of five sampled residents (Resident 90) investigated under the care area Pharmacy Services. These deficient practices had the potential to cause safety issue for Resident 96; and had the potential for a new onset or exacerbation of pain for Resident 90. Findings: a. A review of the admission Record (face sheet), indicated Resident 96 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions [sudden, violent, irregular movement of a limb or of the body], associated with abnormal electrical activity in the brain). A review of the History and Physical (H & P) dated 7/07/2021, indicated, Resident 96 was non-communicative, non-ambulatory, and was able to move left-side extremities. The H & P also indicated the resident was at high risk for aspiration (breathing foreign objects into the airway), infections, and sepsis (infection of the blood). A review of the Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 9/07/2021, indicated Resident 96 required extensive assistance from staff with bed mobility and dressing; and was totally dependent with transfer, locomotion on unit, eating, toilet use, personal use, and bathing. A review of Resident 96's the Physician's Order indicated as follows: 1. Amantadine hydrochloride (medication for uncontrolled muscle movements) syrup 50 milligrams/5 milliliters (mg/ml - unit of measurement), give 10 ml via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration); order date: 07/06/2021. 2. Amlodipine besylate (blood pressure medication) tablet (tab) 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 3. Dilantin suspension (medication to manage epilepsy) 125 mg/5 ml, give 35 ml via GT; order date: 08/12/2021. 4. Eliquis (anticoagulant - blood thinner) tablet 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 5. Levetiracetam (Keppra - medication to manage epilepsy) solution 500 mg/5ml, give 15 ml via GT; order date: 07/06/2021. 6. Tylenol (medication to manage generalized body pain) tablet 325 mg, give 2 tablets via GT; order date: 07/06/2021. On 11/08/2021, at 10:11 a.m., during medication administration observation for Resident 96 and a concurrent interview, observed the following medications given by Registered Nurse (RN 1): 1. Eliquis 2.5 mg 1 tab via GT 2. Amlodipine 2.5 mg 1 tab via GT 3. Amantadine 50mg/5ml, 10 ml via GT 4. Levetiracetam solution 100mg/ml, 15 ml via GT 5. Tylenol 325 mg 2 tabs via GT RN 1 stated there was only 5 ml in the Dilantin bottle. RN 1 further stated she needs to give 15 ml, and so she is going to open an emergency kit (back-up supplies of medications) and pass (administer) Dilantin. Observed RN 1 crush Eliquis, amlodipine, and Tylenol all together and combined with all liquid medications (amantadine and levetiracetam) together and loaded in one syringe. When she passed the medications, RN 1 did not: 1. Check Resident 96's identity band 2. Check pulse and blood pressure prior to administering amlodipine 3. Elevate the resident's head of bed prior to administering medications 4. Check the placement of GT prior to administering medications 5. Flush GT before and after administering medications Resident 96 slid down to the middle of the bed, so his position was not proper to receive any medications, because his head of bed was not elevated 30 to 45 degrees up; however, RN 1 did not reposition Resident 96 prior to administering medications. When asked, RN 1 stated she should have separated each medicine in separate cups and crushed the medications one at a time due to possible interactions; however, she was too busy to follow all the procedures properly, because she still needed to pass nine more residents' meds. It was 10:26 a.m. she stated, she is supposed to finish administering medication by 11:00 a.m., because she is allowed to pass medications one hour before and one hour after due/scheduled time. A review of Refill Requests Only Form indicated Dilantin was ordered on 11/08/2021. On 11/09/2021, at 11:45 a.m., at a concurrent record review and interview with RN 1, she stated, Dilantin was ordered yesterday and usually pharmacy delivers within five hours; however, when the medication cart was checked in the presence of RN 1, there was no new bottle of Dilantin stocked other than one empty bottle. She added, all licensed nurses were responsible for following up and should have been ordered when the bottle is half empty and should have administered Dilantin immediately since it is a significant medication to prevent seizure. A review of the facility's undated policy and procedures, titled Medication Administration via Gastrostomy or Nasogastric (supplying the stomach via the nose) Tube, indicated: 1. To pull cubicle curtains to maintain privacy 2. Ensure head of bed is elevated 30 to 45 degrees 3. Check tube placement by: a. inserting 10 cubic centimeters (cc) of air and listen with stethoscope for whoosh sound below xiphoid process (lowest segment of the breastbone). b. Aspirate for gastric contents for GT, reinserting gastric contents. 4. Place medication in separate cups, and then place each medication in pill crusher pouch for crushing. Crushed medication may then be placed pill crusher pouch for crushing. Crushed medication may then be placed in a plastic cup with plastic cup with approximately 10 cc of water prior to placement of medication in cup. 5. All medications will be administered separately. If using gastrostomy tube, pour medication into syringe barrel 20 cc at a time and tilt the tube to allow air to escape as fluid flows downward; instillation may require actuating the syringe plunger (the part that moves up and down inside a syringe to push contents out of the syringe) to medications are instilled if gravity method is ineffective. 6. The enteral feeding tube should be flushed with at least 30 cc of water before and after medications are administered. A review of the facility's policy & procedure dated 04/2008, and titled, Medication Ordering and Receiving from Pharmacy, indicated to reorder medication five days in advance of need to assure an adequate supply is on hand. Promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five percent (%). Ten medication administration errors out of 31 total opportunities (observations during medication pass) contributed to the overall medication error rate of 32.25% affecting two out of six residents (Resident 115 and 96) observed during medication administration. These deficient practices of ten medication administration errors had the potential for harm to Resident 115 and 96 due to potential adverse effects from drug-to-drug reactions when crushed medications are mixed together. Findings: a. A review of Resident 115's admission Record indicated that the resident was admitted to the facility on [DATE], with diagnoses including anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues), diabetes mellitus (DM- group of diseases that result in too much sugar in the blood), and benign prostatic hyperplasia (BPH-prostate gland enlargement). A review of Resident 115's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/16/2021 indicated that the resident`s cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was intact. The MDS indicated the resident required extensive assistance with transfer, dressing, toilet use, and bathing. On 11/10/2021 at 4:00 p.m., during a medication administration observation and an interview, during a continuing medication pass observation for multiple residents and when it was Resident 115's turn, observed Licensed Vocational Nurse 7 (LVN 7) reviewing the electronic chart and began preparation of the scheduled medications. The following medications were dispensed from the bubble pack (packaging in which medications are organized and sealed between a cardboard backing and clear plastic cover), individually crushed, placed in one cup, and mixed with apple sauce: 1. Metoprolol Tartrate tablet 50 milligrams (mg - unit of measurement) 1 tablet by mouth two times a day for high blood pressure 2. Metformin tablet 500 mg 1 tablet by mouth two times a day for DM 3. Acetaminophen tablet 500 mg two tablets by mouth two times a day for generalized body pain 4. Magnesium Oxide tablet 400 mg 1 tablet by mouth two times a day for supplement According to LVN 7, Resident 115 preferred to have his medications crushed and mixed together. Observed LVN 7 proceeded to administer the four medications that were mixed together. On 11/12/2021 at 8:24 a.m., during an interview after medication pass observation, Registered Nurse 3 (RN 3) stated Resident 115`s medications are to be administered crushed and mixed with apple sauce, and to be given separately. RN 3 explained further that he separates the medication because sometimes the resident will refuse some of the medications. RN 3 further stated, if medications were mixed together, it will not be possible to determine which medication is to be withheld (not to be administered). On 11/12/2021 at 11:12 a.m., during an interview and Resident 115`s record review, the Assistant Director of Nursing (ADON) stated that if a medication needs to be crushed, it has to be placed in a separate the medication cup. The ADON added that they will separate each medication because sometimes the resident does not want to take a particular medication; if the medications are crushed and mixed together, then the medications can no longer be distinguished and set apart. According to the ADON, any preference with regards to medications are care planned; if medications should be given together, it should be care planned. The ADON stated Resident 115`s care plans have not indicated this preference. A review of the facility's undated policy and procedures, titled, Med-Pass, indicated, prepare the medication correctly, administer the medication correctly, and chart the med pass correctly. b. A review of the admission Record (face sheet), indicated Resident 96 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions [sudden, violent, irregular movement of a limb or of the body], associated with abnormal electrical activity in the brain). A review of the History and Physical (H & P) dated 7/07/2021, indicated Resident 96 was non-communicative, non-ambulatory, and was able to move left-side extremities. The H & P also indicated the resident was at high risk for aspiration (breathing foreign objects into the airway), infections, and sepsis (infection of the blood). A review of the Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 9/07/2021, indicated Resident 96 required extensive assistance from staff with bed mobility and dressing; and was totally dependent with transfer, locomotion on unit, eating, toilet use, personal use, and bathing. A review of Resident 96's Physician's Order indicated as follows: 1. Amantadine hydrochloride (medication for uncontrolled muscle movements) syrup 50 milligrams/5 milliliters (mg/ml - unit of measurement), give 10 ml via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration); order date: 07/06/2021. 2. Amlodipine besylate (blood pressure medication) tablet (tab) 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 3. Dilantin suspension (medication to manage epilepsy) 125 mg/5 ml, give 35 ml via GT; order date: 08/12/2021. 4. Eliquis (anticoagulant - blood thinner) tablet 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 5. Levetiracetam (Keppra - medication to manage epilepsy) solution 500 mg/5ml, give 15 ml via GT; order date: 07/06/2021. 6. Tylenol (medication to manage generalized body pain) tablet 325 mg, give 2 tablets via GT; order date: 07/06/2021. On 11/08/2021, at 10:11 a.m., during medication administration observation for Resident 96 and a concurrent interview, observed the following medications given by Registered Nurse (RN 1): 1. Eliquis 2.5 mg 1 tab via GT 2. Amlodipine 2.5 mg 1 tab via GT 3. Amantadine 50mg/5ml, 10 ml via GT 4. Levetiracetam solution 100mg/ml, 15 ml via GT 5. Tylenol 325 mg 2 tabs via GT RN 1 stated there was only 5 ml in the Dilantin bottle. RN 1 further stated she needs to give 15 ml, and so she is going to open an emergency kit (back-up supplies of medications) and pass (administer) Dilantin. Observed RN 1 crush Eliquis, amlodipine, and Tylenol all together and combined with all liquid medications (amantadine and levetiracetam) together and loaded in one syringe. When she passed the medications, RN 1 did not check Resident 96's arm band (form of identification); did not check the placement of GT; and did not flush GT before and after med pass. Observed RN 1 push the plunger (the part that moves up and down inside a syringe to push contents out of the syringe) in less than two seconds and gave all medications together. When asked, RN 1 stated she should have separated each medicine in separate cups and crushed the medications one at a time due to possible interactions; however, she was too busy to follow all the procedures properly, because she still needed to pass nine more residents' meds. On 11/08/2021, at 11:45 a.m., during an interview with RN 1, she stated, she thought there was a dose of Dilantin in the emergency kit, but there was not, so she ordered the medication and was waiting for the medication to arrive. On 11/09/2021, at 11:45 a.m., during a concurrent observation, record review, and interview with the Registered Nurse 2 (RN 2), she stated, Dilantin was ordered yesterday and usually pharmacy delivers within five hours; however, when she checked Medication Cart 2A, there was no new bottle of Dilantin stocked other than empty bottle. RN 2 added, all licensed nurses were responsible for following-up and the medication should have been given since it is a significant medication. A review of the facility's undated policy and procedures, titled, Medication Administration Via Gastrostomy or Nasogastric (supplying the stomach via the nose), indicated, 1. To pull cubicle curtains to maintain privacy 2. Ensure head of bed is elevated 30 to 45 degrees 3. Check tube placement by: a) inserting 10 cubic centimeters (cc - unit of measurement) of air and listen with stethoscope for whoosh sound below xyphoid process. b) Aspirate for gastric contents for Gastrostomy tube, reinserting gastric contents. 4. Place medication in separate cups, and then place each medication in pill crusher pouch for crushing. Crushed medication may then be placed pill crusher pouch for crushing. Crushed medication may then be placed in a plastic cup with plastic cup with approximately 10 cc of water prior to placement of medication in cup. 5. All medications will be administered separately. If using gastrostomy tube, pour medication into syringe barrel 20 cc at a time and tilt the tube to allow air to escape as fluid flows downward; instillation may require actuating the syringe plunger to medications are instilled if gravity method is ineffective. 6. The enteral feeding tube should be flushed with at least 30 cc of water before and after medications are administered. The medication error rate was calculated as ten medication errors divided by 31 opportunities (observations during medication pass), multiplied by 100, which resulted in the medication error rate of 32.25%, exceeding the five percent threshold.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from potential significant medication errors for one out of three sampled residents (Residents 96) reviewed by failing to: 1. Follow the facility's policy and procedures in ensuring medications are crushed and administered separately during medication administration. Three medications were crushed all together and combined with two liquid medications during medication administration via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration). 2. Follow physician's order to administer Dilantin for epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions [sudden, violent, irregular movement of a limb or of the body], associated with abnormal electrical activity in the brain). The medication was omitted (not administered) for two days (on 11/08/2021 & 11/09/2021). This deficient practice had the potential to worsen epilepsy and can trigger seizure (uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body) activity. Findings: A review of the admission Record (face sheet), indicated Resident 96 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions [sudden, violent, irregular movement of a limb or of the body], associated with abnormal electrical activity in the brain). A review of the History and Physical (H & P) dated 7/07/2021, indicated, Resident 96 was non-communicative, non-ambulatory, and was able to move left-side extremities. The H & P also indicated the resident was at high risk for aspiration (breathing foreign objects into the airway), infections, and sepsis (infection of the blood). A review of the Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 9/07/2021, indicated Resident 96 required extensive assistance from staff with bed mobility and dressing; and was totally dependent with transfer, locomotion on unit, eating, toilet use, personal use, and bathing. A review of Resident 96's physician's orders indicated as follows: 1. Amantadine hydrochloride (medication for uncontrolled muscle movements) syrup 50 milligrams/5 milliliters (mg/ml - unit of measurement), give 10 ml via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration); order date: 07/06/2021. 2. Amlodipine besylate (blood pressure medication) tablet (tab) 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 3. Dilantin suspension (medication to manage epilepsy)125 mg/5 ml, give 35 ml via GT; order date: 08/12/2021. 4. Eliquis (anticoagulant - blood thinner) tablet 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 5. Levetiracetam (Keppra - medication to manage epilepsy) solution 500 mg/5ml, give 15 ml via GT; order date: 07/06/2021. 6. Tylenol (medication to manage generalized body pain) tablet 325 mg, give 2 tablets via GT; order date: 07/06/2021. On 11/08/2021, at 10:11 a.m., during medication administration observation for Resident 96 and a concurrent interview, observed the following medications given by Registered Nurse (RN 1): 1. Eliquis 2.5 mg 1 tab via GT 2. Amlodipine 2.5 mg 1 tab via GT 3. Amantadine 50mg/5ml, 10 ml via GT 4. Levetiracetam solution 100mg/ml, 15 ml via GT 5. Tylenol 325 mg 2 tabs via GT RN 1 stated there was only 5 ml in the Dilantin bottle. RN 1 further stated she needs to give 15 ml, and so she is going to open an emergency kit (back-up supplies of medications) and pass (administer) Dilantin. Observed RN 1 crush Eliquis, amlodipine, and Tylenol all together and combined with all liquid medications (amantadine and levetiracetam) together and loaded in one syringe. When she passed the medications, RN 1 did not check Resident 96's arm band (form of identification); did not check the placement of GT; and did not flush GT before and after med pass. Observed RN 1 push the plunger (the part that moves up and down inside a syringe to push contents out of the syringe) in less than two seconds and gave all medications together. When asked, RN 1 stated she should have separated each medicine in separate cups and crushed the medications one at a time due to possible interactions; however, she was too busy to follow all the procedures properly, because she still needed to pass nine more residents' meds. On 11/08/2021, at 11:45 a.m., during an interview with RN 1, she stated, she thought there was a dose of Dilantin in the emergency kit, but there was not, so she ordered the medication and was is waiting for the medication to arrive. On 11/09/2021, at 11:45 a.m., during a concurrent observation, record review, and interview with the Registered Nurse 2 (RN 2), she stated, Dilantin was ordered yesterday and usually pharmacy delivers within five hours; however, when she checked Medication Cart 2A, there was no new bottle of Dilantin stocked other than empty bottle. RN 2 added, all licensed nurses were responsible for following-up and the medication should have been given since it is a significant medication. A review of the facility's undated policy and procedures, titled, Medication Administration Via Gastrostomy or Nasogastric (supplying the stomach via the nose), indicated, 1. To pull cubicle curtains to maintain privacy 2. Ensure head of bed is elevated 30 to 45 degrees 3. Check tube placement by: a) inserting 10 cubic centimeters (cc - unit of measurement) of air and listen with stethoscope for whoosh sound below xyphoid process. b) Aspirate for gastric contents for Gastrostomy tube, reinserting gastric contents. 4. Place medication in separate cups, and then place each medication in pill crusher pouch for crushing. Crushed medication may then be placed pill crusher pouch for crushing. Crushed medication may then be placed in a plastic cup with plastic cup with approximately 10 cc of water prior to placement of medication in cup. 5. All medications will be administered separately. If using gastrostomy tube, pour medication into syringe barrel 20 cc at a time and tilt the tube to allow air to escape as fluid flows downward; instillation may require actuating the syringe plunger to medications are instilled if gravity method is ineffective. 6. The enteral feeding tube should be flushed with at least 30 cc of water before and after medications are administered. A review of the facility's policy and procedures, dated 04/2008, and titled, Medication Ordering and Receiving from Pharmacy, indicated to reorder medication five days in advance of need to assure an adequate supply is on hand. Promptly report discrepancies and omissions to the issuing pharmacy and the charge nurse/supervisor.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 287's medication, lorazepam solution (controlled medication [drugs with potential for abuse, with use potentially leading to psychological or physical dependence], used to treat anxiety) was stored in the refrigerator in the medication room. 2. Ensure Resident 9's hydromorphone (controlled medication [drugs with potential for abuse, with use potentially leading to psychological or physical dependence], used to treat moderate to severe pain) bubble (or blister pack -individually sealed compartments that hold medication) was kept intact. 3. Ensure unopened insulin (medication used to control high blood sugar) pens were stored in the refrigerator until removed for administration for Residents 7, 20 and 45. This deficient practice of failing to store medications appropriately according to the manufacturer's requirements and facility policy and procedure increased the risk of the facility's residents receiving medications which may have become ineffective or toxic resulting in a negative impact to their health and well-being. Findings: a. A review of Resident 287's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning) and myocardial infarction (a blockage of blood flow to the heart muscle). A review of Resident 287's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 10/05/2021 indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding for decision making). The MDS indicated the resident received anxiety medication during the look- back period (time frame for observation). A review of the Order Summary Report indicated an order dated 11/03/2021, for lorazepam solution 2 milligram (mg-unit of measurement)/milliliter (ml- unit of measurement), give 0.5 ml sublingually (under the tongue) every four hours as needed for inability to cope with activity of daily living causing stress for three months then reevaluate after three months for continuation of medication if necessary. A review Resident 287's Medication Administration Record (MAR) for November 2021 indicated the resident received lorazepam solution on 11/05/2021. During an observation (inspection) of Station 2 Medication Cart 2B and concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 11/10/2021 at 10:57 a.m., Resident 287's lorazepam solution was found stored in the medication cart at room temperature. The medication box had a sticker that indicated refrigerate. LVN 2 stated the medication should have been stored in the refrigerator. LVN 2 stated not storing the medication in the refrigerator could potentially affect the medication's effectiveness. A review of the facility document, Guide for Special Handling for Medications, dated 09/2019, indicated Ativan (lorazepam) intensol solution should be stored in the refrigerator and to be discarded after 90 days after opening. A review of the facility policy and procedures titled, Medication Storage in the Facility, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with thermometer to allow temperature monitoring. b. A review of Resident 9's admission Record (face sheet) indicated the resident was initially admitted to the facility on [DATE] and was recently readmitted from general acute care hospital (GACH) on 07/13/2021, with diagnoses including pain syndrome and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 9's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 10/23/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding for decision making) was intact. The MDS indicated the resident received opioid (controlled medication [medication used for moderate to severe pain]) during the look back period (time frame for observation). A review of the physician order dated 10/25/2021, indicated an order for hydromorphone hydrochloride tablet 2 milligrams (mg-unit of measurement), give 1 tablet by mouth as needed for breakthrough pain, severe pain at bedtime as needed. During an observation (inspection) of Station 2 Medication Cart 2B and concurrent interview with Licensed Vocational Nurse 2 (LVN 2) on 11/10/2021 at 11:08 a.m., observed Resident 9's hydromorphone medication in a 29-dose bubble pack (or blister pack - individually sealed compartments that hold medication) had 19 tablets left. One of the plastic bubble paper-backed foil was broken and was kept intact with three stickers that indicate Directions changed refer to chart. LVN 2 stated if a controlled medication was taken from the bubble pack and was not given to the resident, the medication should be wasted and witnessed by two licensed staff because the medication has been contaminated. A review of the facility policy and procedures titled, Controlled Medication, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated when a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to facility policy in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. c. During an observation (inspection) of Station 2 Medication Cart 2B on 11/10/2021 at 10:57 a.m., the following unopened insulin (medication used to control high blood sugar) pens were observed stored in the medication cart: 1. Resident 45's Admelog SoloStar (hormone that lowers the level of glucose in the blood by helping glucose enter the body's cells) 100 unit/milliliter (ml- unit of measurement) with quantity of 3 ml. The medication did not have a label with the date it was opened. The plastic bag that contained the medication had a sticker that indicated Refrigerate. 2. Resident's 20's Novolin N (hormone that lowers the level of glucose in the blood by helping glucose enter the body's cells) 100 unit /milliliter (ml- unit of measurement) with quantity of 3 ml. The medication did not have a label with the date it was opened. The plastic bag that contained the medication had a sticker that indicated Refrigerate. During an interview on 11/10/2021 at 11:13 a.m., Licensed Vocational Nurse 2 (LVN 2) stated the unopened insulin pens should have been refrigerated until removed for administration. A review of the facility policy and procedures titled, Medication Storage in the Facility, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with thermometer to allow temperature monitoring. d. During a concurrent inspection of Station 1 Medication Cart 1B and interview with Registered Nurse 1 (RN 1) on 11/12/2021 at 11:44 a.m., Resident 7's unopened Levemir Flex touch insulin (hormone that lowers the level of glucose in the blood by helping glucose enter the body's cells) pen was observed in the medication cart. The medication did not have a label with the date it was opened. The plastic bag that contained the medication had a sticker that indicated Refrigerate. RN 1 stated the unopened insulin pen should have been refrigerated until given to the resident. A review of the facility policy and procedures titled, Medication Storage in the Facility, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 36 degrees Fahrenheit and 46 degrees Fahrenheit are kept in a refrigerator with thermometer to allow temperature monitoring.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e. A review of Resident 172's admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included pneumonia (an infection of one or both lungs caused by bacteria, viruses, or fungi), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and shortness of breath. A review of Resident 172's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/08/2021, indicated the resident was severely impaired in cognitive (the mental action or processes of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making and was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. A review of Resident 172's Order Summary Report, dated 10/30/2021, indicated a physician's order, dated 07/06/2021, to administer oxygen (O2) inhalation at 2 to 3 liters (L)/minute (min) via nasal cannula (NC - a small flexible tube that contains two open prongs intended to sit just inside the nostrils) every shift for shortness of breath (SOB) related to chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). On 11/08/2021 at 8:35 a.m., during an observation, Resident 172 was asleep in bed. The resident's oxygen was on at 3 L/min via nasal cannula. Observed oxygen tubing touching the floor. On 11/08/2021 at 8:52 a.m., during a concurrent observation and interview, Minimum Data Set Nurse 2 (MDSN 2) confirmed that the resident's oxygen tubing was touching the floor and stated it was important for the oxygen tubing not to be on the floor for infection control. On 11/15/2021 at 9:08 a.m., during an interview, the Director of Staff Development (DSD) stated it was important to keep residents' oxygen tubing off the floor for infection control. On 11/15/2021 at 9:17 a.m., the Director of Nursing (DON) stated it was important to keep residents' oxygen tubing off the floor for infection control. A review of the facility's undated policy and procedure titled, Infection Control, indicated that Infection Control Program components will be utilized, such as prevention, which is the implementation of measures to prevent transmission of infectious agents and to reduce risks for device and procedure-related infections. Based on observation, interview and record review, the facility failed to: 1. Ensure a cup of milk that was dated from the previous day was discarded and not placed on Resident 43`s overbed table; 2. Ensure Licensed Vocational Nurse 5 (LVN 5) clean the mouthpiece after use of the Spiriva Respimat Aerosol Solution (used for the long-term, once-daily, maintenance treatment of bronchospasm [a tightening of the muscles that line the airways in your lungs]) for Resident 90; 3. Ensure infection control practices for coronavirus-19 infection (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) prevention by failing to monitor visitors' temperature when entering the facility; 4. Ensure hand washing was performed before and after administering medications according to the facility's policy for Resident 96; 5. Ensure a resident's oxygen tubing was kept off the floor while the resident received oxygen for one (Resident 172) out of four sampled residents investigated for infection control; 6. Ensure Respiratory Therapist 1 (RT 1) kept sterile 4x4 gauze sponges free from contamination while performing tracheostomy site care for Resident 48. These deficient practices had the potential for spread of infection to four (4) out of four residents investigated under the care area Infection Control, and to employees and visitors. a. Resident 43 had the potential of developing foodborne illnesses (infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) from contaminated milk, b. Resident 90 had the potential of being exposed to bacteria from dried saliva which can lead to infection; c. Resident 172 had the potential of acquiring infection thru a contaminated oxygen tubing; d. Resident 96 had the potential of acquiring infection from staff who did not do handwashing; e. Resident 48 had the potential of acquiring infection from contaminated sterile gauze. Findings: a. A review of Resident 43's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including muscle weakness, heart failure (develops when your heart doesn't pump enough blood for your body's needs), and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 43's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 8/12/2021 indicated the resident`s cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was severely impaired. The MDS indicated the resident required limited assistance with transfer, dressing, toilet use, and with bathing. On 11/08/2021 at 10:01 a.m., during an observation in resident's room visit, observed Resident 43 on her bed, sleeping. Observed on top of the overbed table were two eight-ounce plastic glasses containing milk. Observed that one of the plastic glasses had a sticker label dated 11/7/2021 and the other dated 11/08/2021. At the time of the observation, Certified Nurse Assistant (CNA 6) went into the room and when asked about the two plastic glasses of milk, CNA 6 responded that milk were served during breakfast and she will not leave the milk for that long if it was from yesterday. On 11/08/2021 at 10:15 a.m., during an observation and interview while in Resident 43`s room, Licensed Vocational 6 (LVN 6) entered the room and when asked about the milk labeled 11/7/2021, she stated that it was no longer safe for the resident to ingest the milk if it was served last night. According to LVN 6, ingesting of a contaminated milk can lead to foodborne illnesses (infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for the resident. A review of the facility`s undated policy and procedure, titled Handling of Potentially Hazardous Food (PHF), indicated that all potentially hazardous food shall be cooked and handled in a safe and sanitary manner to protect residents and staff from foodborne illness. The policy outlined a procedure that cold food can be held without temperature control for up to 6 hours if the following conditions are met: 1. Hold the food at 40 degrees F or below before removing from refrigeration. 2. Make sure food temperature does not exceed 70 degrees F while food is being served. Throw away any food that exceeds this temperature. 3. Discard food within 6 hours. b. A review of Resident 90's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses including migraine (a medical condition which usually causes a pounding, throbbing headache on one side of the head), malignant neoplasm of breast (a cancer uncontrolled growth of abnormal cells in the breasts) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). A review of Resident 90's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 9/02/2021 indicated the resident`s cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making were intact. The MDS indicated the resident required supervision with transfer, dressing, toilet use; and limited assistance with bathing. A review of Resident 90`s physician`s orders, included Spiriva Respimat Aerosol Solution (used for the long-term, once-daily, maintenance treatment of bronchospasm [a tightening of the muscles that line the airways in your lungs]) 2 puffs inhale orally (by mouth) one time a day related to COPD. On 11/10/2021 at 09:27 a.m., during a medication pass observation, observed Licensed Vocational 5 (LVN 5) administer Spiriva Respimat Aerosol Solution by oral puff inhalation as directed in the physician`s order. After the oral puff administration, LVN 5 replaced the Spiriva Respimat Aerosol Solution to its box without wiping the mouthpiece. LVN 5 stated that she never cleaned in the mouthpiece for the months that Resident 90 has been on this medication and that she is working on this section regularly. On 11/10/2021 at 10:15 a.m., during an observation and interview, while still observing LVN 5, Infection Control Preventionist (IPN) was in the vicinity and was requested to clarify if the Spiriva mouthpiece needed cleaning after use. According to IPN, they can clean the surrounding or the tip of the Spiriva mouthpiece to remove residual saliva as it is an infection control issue because the mouthpiece can harbor bacteria and can make the resident sick. A review of the facility-provided undated Spiriva Respimat Aerosol Solution manufacturer`s instruction, indicated to clean the mouthpiece, including the metal part inside the mouthpiece, with a damp cloth or tissue only, at least 1 time each week. f. A review of Resident 48's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood), encephalopathy (a brain disease that alters brain function or structure) and encounter for attention to tracheostomy (an opening created at the front of the neck so a tube can be inserted in the windpipe to help a person breathe). A review of Resident 48's Minimum Data Set (MDS-a standardized assessment and screening tool) dated 08/23/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDs indicated the resident was dependent on staff on most areas of activities of daily living. A review of Resident 48's care plan on respiratory care initiated on 08/11/2021, indicated interventions including check and secure trach ties every two hours and as needed (PRN) and tracheostomy site care daily and PRN. During a concurrent observation and interview on 11/10/2021 at 10:30 a.m., in Resident 48's room, observed Respiratory Therapist 1 (RT 1) performing tracheostomy (trach) site care to the resident. RT 1 donned (put on) clean gloves and opened the trach care tray and took the sterile 4x4 gauze sponges from the tray and placed them on top of the cleaning wipes package that was on the overbed table. RT 1 removed the soiled drainage gauze sponge from the trach stoma, washed hands and donned sterile gloves. RT 1 used the gauze sponges in cleaning the resident's trach site and as a dressing around the trach stoma. During the interview, RT 1 stated he should have not placed the sponges on top of the cleaning wipes package because the package is considered contaminated. RT 1 stated he should have observed sterile technique while performing trach site care to the resident. A review of the facility policy and procedure titled, Tracheostomy Site Care, last reviewed and approved by the facility's Quality Assessment/Assurance Committee on 02/22/2021, indicated tracheostomy care must be performed on tracheostomy patients every shift to ensure patency of the altered airway and minimize potential for infection, the procedures included preparing equipment, spreading out supplies on a sterile field. c. On 11/08/2021, at 7:30 a.m., during an observation, while entering the facility lobby, there was no one in the lobby screening for signs and symptoms of coronavirus-19 infection (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection). Employees were checking their own temperatures and entering entered their data in the Employee Log. The main entrance door remained open. On 11/08/2021, at 7:35 a.m., during an interview with Minimum Data Set Nurse 3 (MDSN 3), she stated the receptionist will be in soon and in the meantime, the facility keeps the gate or door locked. MDSN 3 further stated, when visitors try to come in before 8:00 am, they need to ring a bell, so someone at the Station One or the Registered Nurse (RN) supervisor will push the button to open the door. MDSN 3 was alerted that the door remained open this morning, so people were in and out without requesting or asking to open the door. On 11/08/2021, at 8:30 a.m, during an interview with the Receptionist, she stated she normally works from 8:00 a.m. to 11:30 a.m, to screen for COVID-19, after that someone else comes in and takes over. On 11/09/2021, at 9:32 a.m., during an interview, Infection Control Preventionist (IPN), stated that when anyone enters the facility, he or she checks own temperature and records on the log. When the receptionist comes in at 8:00 a.m., she would ask visitors to sign in, asks for COVID-19 vaccine record, and checks COVID-19 test result within the past 72 hours. If visitors are unavailable to show the proof of vaccine card or test result, the receptionist calls IPN and IPN runs rapid test on the spot. She added, no one can just walk in without being checked for COVID-19 signs and symptoms and questionnaires. IPN also stated they educate visitors on handwashing, mask wearing, and maintaining social distancing. IPN was reminded that no one was screening visitors for signs and symptoms of COVID-19 at 7:30 a.m. on 11/08/2021. A review of the facility's undated policy and procedures titled, COVID-19 Visitations, indicated the facility will ensure the health and safety of residents, visitors, and staff. Due to the facility's high-risk population, appropriate precautions will be initiated to help control and prevent the spread of the virus. Facilities shall conduct visitation through different means based on the facility's structure and resident's needs. The facility will attempt to follow visitations guidance to the best of its ability. The facility will actively screen and will restrict visitations by those who meet the following criteria: 1. Signs and symptoms of COVID-19, such as fever or chills, cough, shortness of breath, sore throat, headache, muscle or body ache, fatigue, new loss of taste or smell, congestion, nausea or vomiting, and/or diarrhea. 2. In the 14 days, has had contact with someone with a diagnosis of COVID-19, or under investigation for COVID-19, or are ill with respiratory illness. 3. Unvaccinated visitors returning from international trip are required to quarantine for 14 days. For those individuals that do not meet the above criteria, they may be allowed entry, but individuals may be required to use personal protective equipment. d. A review of the admission Record (face sheet), indicated Resident 96 was originally admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses that included cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions [sudden, violent, irregular movement of a limb or of the body], associated with abnormal electrical activity in the brain). A review of the History and Physical (H & P) dated 7/07/2021, indicated Resident 96 was non-communicative, non-ambulatory, and was able to move left-side extremities. The H & P also indicated the resident was at high risk for aspiration (breathing foreign objects into the airway), infections, and sepsis (infection of the blood). A review of the Minimum Data Set (MDS-a comprehensive assessment and screening tool) dated 9/07/2021, indicated Resident 96 required extensive assistance from staff with bed mobility and dressing; and was totally dependent with transfer, locomotion on unit, eating, toilet use, personal use, and bathing. A review of Resident 96's Physician's Order indicated as follows: 1. Amantadine hydrochloride (medication for uncontrolled muscle movements) syrup 50 milligrams/5 milliliters (mg/ml - unit of measurement), give 10 ml via gastrostomy tube (GT- a small tube surgically inserted through the abdomen wall and into the stomach for nutrition, medication, and fluid administration); order date: 07/06/2021. 2. Amlodipine besylate (blood pressure medication) tablet (tab) 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 3. Dilantin suspension (medication to manage epilepsy) 125 mg/5 ml, give 35 ml via GT; order date: 08/12/2021. 4. Eliquis (anticoagulant - blood thinner) tablet 2.5 mg, give 1 tablet via GT; order date: 07/06/2021. 5. Levetiracetam (Keppra - medication to manage epilepsy) solution 500 mg/5ml, give 15 ml via GT; order date: 07/06/2021. 6. Tylenol (medication to manage generalized body pain) tablet 325 mg, give 2 tablets via GT; order date: 07/06/2021. On 11/08/2021, at 10:11 a.m., during medication administration observation for Resident 96 and a concurrent interview, observed the following medications given by Registered Nurse (RN 1): 1. Eliquis 2.5 mg 1 tab via GT 2. Amlodipine 2.5 mg 1 tab via GT 3. Amantadine 50mg/5ml, 10 ml via GT 4. Levetiracetam solution 100mg/ml, 15 ml via GT 5. Tylenol 325 mg 2 tabs via GT Observed RN 1 crush Eliquis, amlodipine, and Tylenol all together and combined with all liquid medications (amantadine and levetiracetam) together and loaded in one syringe. When she passed the medications, she did not wash her hands before and after administering medications. When asked, RN 1 she stated she was too busy to follow all the procedures properly, because she still needed needs to pass nine more residents' meds A review of the facility's undated policy and procedures, titled, Hand Washing, indicated hand washing must be performed before and after direct care of individual patients.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• 30% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• 83 deficiencies on record. Higher than average. Multiple issues found across inspections.
• $20,102 in fines. Higher than 94% of California facilities, suggesting repeated compliance issues.
• Grade F (38/100). Below average facility with significant concerns.

Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is California Healthcare And Rehabilitation Center's CMS Rating?

CMS assigns CALIFORNIA HEALTHCARE AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is California Healthcare And Rehabilitation Center Staffed?

CMS rates CALIFORNIA HEALTHCARE AND REHABILITATION CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 30%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at California Healthcare And Rehabilitation Center?

State health inspectors documented 83 deficiencies at CALIFORNIA HEALTHCARE AND REHABILITATION CENTER during 2021 to 2025. These included: 81 with potential for harm and 2 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates California Healthcare And Rehabilitation Center?

CALIFORNIA HEALTHCARE AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LONGWOOD MANAGEMENT CORPORATION, a chain that manages multiple nursing homes. With 201 certified beds and approximately 192 residents (about 96% occupancy), it is a large facility located in VAN NUYS, California.

How Does California Healthcare And Rehabilitation Center Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, CALIFORNIA HEALTHCARE AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting California Healthcare And Rehabilitation Center?

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

Is California Healthcare And Rehabilitation Center Safe?

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

Do Nurses at California Healthcare And Rehabilitation Center Stick Around?

CALIFORNIA HEALTHCARE AND REHABILITATION CENTER has a staff turnover rate of 30%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was California Healthcare And Rehabilitation Center Ever Fined?

CALIFORNIA HEALTHCARE AND REHABILITATION CENTER has been fined $20,102 across 1 penalty action. This is below the California average of $33,280. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is California Healthcare And Rehabilitation Center on Any Federal Watch List?

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

Facility Details

Beds: 201
Avg. Residents: 192
Occupancy: 95.7%
Ownership: For profit - Corporation
Chain: LONGWOOD MANAGEMENT CORPORATION
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
83 Deficiencies: -10
Fines ($20,102): -2
Final Score: 38/100

Nearby Alternatives

MOUNT SAN ANTONIO GARDENS 5-star MONTECITO HEIGHTS HEALTHCARE &... 5-star MARYCREST MANOR 5-star

View all in VAN NUYS →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056149